Interventional radiological treatment of gastrointestinal bleeding

Summary   Background: Gastrointestinal (GI) bleeding is divided into upper and lower GI bleeding. The most common reasons for upper GI bleeding are gastric and duodenal ulcers. Lower GI bleeding is located in the intestine below the ligament of Treitz. In this review article the possibilities for interventional radiological treatment of gastrointestinal bleeding will be discussed. Methods: Interventional treatment in form of embolization of arterial branches of the celiac trunc is indicated if endoscopic approaches fail to stop the bleeding. Localization and treatment of lower GI bleeding is more difficult and technically more demanding. Embolization of mesenteric branches may be effective to stop bleeding but carries the risk of inducing bowl ischemia. Sometimes surgical exploration can be necessary after embolization. However, especially in severe bleeding, embolization may help to stabilize the patient before major surgery. If the bleeding source can not be identified, intraarterial infusion of vasoactive drugs, like vasopressin, may be effective. Results: In upper GI bleeding, hemostasis can be achieved by transarterial embolization in up to 91 %. In lower GI bleeding the success rate is less well defined, since there are no larger series available in the current literature. In all embolization procedures, the risk of ischemic bowl damage has to be considered. This complication occurs more often in embolization after in lower GI bleeding. Conclusions: Transarterial embolization offers an efficient treatment of upper and lower GI bleeding. It should be used for upper GI bleeding when endoscopic hemostasis is not so successful. In lower GI bleeding transarterial embolization often has the character of a temporizing procedure before surgery.      

消化道出血患者药物治疗体会

目的：研究消化道出血患者的病因与药物治疗效果。方法回顾性分析2010年3月～2013年3月我院收治的消化道出血患者136例的临床资料。观察及分析患者的发病原因,以及泮托拉唑钠、奥曲肽与氨甲苯酸联合治疗的临床效果。结果136例患者的病因依次为消化性溃疡、急性胃黏膜病变、肝硬化食管静脉曲张破裂与胃癌。发病诱因为饮食不当、饮酒、药物、精神因素与劳累等因素。实施泮托拉唑钠、奥曲肽、氨甲苯酸联合治疗消化性溃疡的优良率为95.9%,治疗急性胃黏膜病变的优良率为93.3%,治疗肝硬化食管静脉曲张破裂的优良率为90.9%,治疗胃癌的优良率为100%。结论消化道出血疾病的病因是消化性溃疡,诱因常是口服刺激性的药物。采用泮托拉唑钠、奥曲肽、氨甲苯酸联合治疗消化道出血具有较高的应用价值,值得临床进一步推广应用。     

Endoscopic injection sclerotherapy in non-variceal upper gastrointestinal bleeding

Summary To date several agents have been used to achieve haemostasis in patients with non-variceal upper gastrointestinal bleeding using endoscopic sclerotherapy techniques. Polidocanol has been widely used but local complications have been reported after treatment. We have compared the efficacy and safety of thrombin and polidocanol in 82 consecutive patients with ongoing or recent bleeding from duodenal, gastric, or anastomotic ulcers. Primary control of haemostasis from spurting vessels was achieved in 90% of cases using polidocanol and in 86.6% using thrombin. Definitive haemostasis was obtained in 80% of patients in both groups. When a non-bleeding vessel was visible, injection of polidocanol or thrombin effectively prevented rebleeding in 90.9% and 85.7% of cases, respectively. When a non-bleeding sentinel clot was present, injection of polidocanol or thrombin provided definitive haemostasis in 100% and 92.8% of cases, respectively. No statistically significant difference was evident between the two agents. In the polidocanol group, one local haemorrhagic complication was noted. No general or local complications were recorded in the thrombin group.     

Laparoscopic-assisted resection of a bleeding gastrointestinal stromal tumor.

The authors report a case of a 29-year-old male patient with a severe lower gastrointestinal hemorrhage in whom a successful laparoscopic diagnosis and resection (assisted) of an ileal gastrointestinal stromal tumor (GIST) was performed. Laparoscopy can be very useful in the diagnosis and treatment of selected cases of lower gastrointestinal bleeding.     

兰索拉唑治疗消化道溃疡上消化道出血的综合治疗效果分析

目的：探讨兰索拉唑治疗消化道溃疡上消化道出血的临床效果。方法选取2011年7月～2014年4月我院治疗的98例消化道溃疡上消化道出血患者,随机分为两组,研究组49例,采用兰索拉唑治疗;对照组49例,采用法莫替丁治疗,两组患者在上述治疗基础上均口服阿莫西林胶囊及克拉霉素胶囊配合治疗,8周后进行疗效判断。结果研究组总有效率为93.88%,对照组为79.59%,研究组总有效率高于对照组,差异有统计学意义（P ＜0.05）。研究组 HP 根除率高于对照组,止血时间短于对照组,差异有统计学意义（P ＜0.05）。结论兰索拉唑治疗消化道溃疡上消化道出血可以提高治疗总有效率,提高 HP 根除率,减少止血时间,可以在临床推广应用。     

胃肠道血管畸形致消化道出血诊治体会

目的 总结血管畸形所致消化道出血的诊断及治疗经验。方法 回顾性分析我院1989-1999年间26例胃肠道血管畸形所致消化道出血的临床资料。结果 内镜血管畸形的检出率为42%，ECT消化道出血的检出率为55%，选择性动脉造影血管畸形的检出率为83%，剖腹探查血管畸形的检出率为100%，保守治疗1例，病变肠段手术切除14例，介入治疗4例，其余行扩张血管缝扎，胃十二指肠结扎术或硬化剂局部注射，效果良好，结论 怀疑血管畸形致胃肠道出血时，首选内镜检查，进一步检查可行ECT，选择性动脉造影是诊断血管畸形最有效的方法，必要时剖腹探查并可结合术中肠镜确诊，治疗以手术切除病灶最有效，辅以血管缝扎及介入治疗。     

Angiolipoma of the stomach as a cause of chronic upper gastrointestinal bleeding

Summary Angiolipomas are benign vascular fatty neoplasms, usually found in the subcutis of the trunk. Gastric angiolipomas have not been described. We report a gastric angiolipoma causing chronic gastrointestinal bleeding that did not respond to electrocoagulation and required surgical resection. Its classic endoscopic appearance is described. It may be managed endoscopically, utilizing either heater probe or laser photocoagulation and, therefore, should be recognized endoscopically prior to treatment.     

阿司匹林预防全髋或全膝置换术后深静脉血栓形成的循证医学进展

目的探讨阿司匹林预防全髋置换术（THA）或全膝置换术（TKA）后深静脉血栓形成（DVT）的循证医学研究证据。 方法检索英国国家医疗服务体系（National Health Service,NHS）数据库、研究转化临床实践（Turning Research into practice,TRIP）医学数据库、系统性评价Cochrane数据库、OVID、Web of science、MEDLINE以及EMBASE数据库2004年1月至2017年9月发表的关于阿司匹林预防THA或TKA术后DVT的随机对照研究（RCT）文章,评价临床疗效主要转归结果是任何形式的DVT,次要转归结果是伤口并发症（伤口延迟渗出、感染）。 结果共纳入14篇文章,其中5篇I级研究证据的文章,9篇Ⅲ级研究证据;证据级别高的1篇RCT文章研究结果显示：阿司匹林与低分子肝素相比,TKA术后DVT发生率差异无统计学意义;目前支持阿司匹林相较低分子肝素、华法林或者达比加群酯对THA或TKA术后DVT预防效果要差的证据尚不充分;与阿司匹林相比,利伐沙班可以使得TKA或THA术后的无症状DVT发生率下降,但是否能够预防有症状的DVT,目前证据尚且不足;与阿司匹林相比,THA或TKA术后使用达比加群酯和利伐沙班伤口并发症要更高。 结论目前临床研究证据表明,除了当前的利伐沙班及低分子肝素抗凝药物外,阿司匹林也许能成为THA或TKA术后DVT预防的另一选择。     

Lower gastrointestinal bleeding: a review

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.     

Upper gastrointestinal bleeding after hip and knee arthroplasty

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants increases the risk of upper gastrointestinal bleeding. This article assesses its incidence in patients undergoing hip and knee arthroplasty. A single-center, retrospective study was conducted on 100 consecutive hip and 100 consecutive knee arthroplasties performed at the Victoria Infirmary, Glasgow, between 1998 and 2000. Sixty-three percent of patients were women with a mean age of 74. Fifty-four percent of patients received NSAIDs and all patients received anticoagulants perioperatively. Four and a half percent of patients had upper gastrointestinal bleeding postoperatively. We believe that the incidence of upper gastrointestinal bleeding as a complication is underestimated and recommend gastro-protective agents in the perioperative period for patients on NSAIDs.     

Conversion of bilateral hip and knee ankylosis to total joint replacements

We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation.     

肝移植术后消化道出血的原因及处理

目的 探讨肝移植术后消化道出血的原因和处理方法.方法 对中山大学附属第一医院2000年1月至2006年12月施行的776例同种原位肝移植（OLT）患者的临床资料进行回顾性分析,总结原位肝移植术后消化道出血的诊治经验.结果 776例肝移植患者中共发生术后消化道出血18例（2.3%）.其中消化性溃疡出血8例（44.5%）,胃底食管静脉曲张急性出血3例（16.7%）,胃十二指肠炎出血3例（16.7%）,胆道出血3例（16.7%）,空肠憩室出血伴穿孔1例（5.6%）.分别采取积极的非手术治疗和经内镜直视下局部止血治疗、血管栓塞治疗和手术探查等措施,除死亡5例（27.8%）外,13例患者临床治愈,术后平均随访3.5年,除1例于术后2年死于移植肝癌复发外,其余均健康存活.结论 OLT术后可能出现不同部位的消化道出血,病死率较高：一旦发生,应尽快寻找出血部位并及时做出正确的治疗选择.     

An uncommon cause of life-threatening gastrointestinal bleeding: 2 synchronous Dieulafoy lesions

Dieulafoy lesions are a rather uncommon cause of gastrointestinal bleeding that can be torrential and life-threatening. Extragastric location and pediatric cases are very rare. We report the first case of synchronous Dieulafoy lesions in the stomach and jejunum. This case is discussed in the light of the reported literature on this condition.     

The use of a gamma probe and radioactive technetium to identify obscure gastrointestinal bleeding

Lower gastrointestinal bleeding is a common cause of hospital admission. This bleeding is most often secondary to diverticuli, malignancy, or colitis. Rarely, the location of lower gastrointestinal bleeding cannot be identified after exhaustive efforts with endoscopy, angiography, and other modalities. To address this unique clinical situation, we present a modification of the technique for sentinel lymph node biopsy in which a gamma probe is used to identify the source of hemorrhage. This is completed intraoperatively after preoperative radioactive technetium sulfur colloid is injected at the time of angiography. This approach involves minimal risk and provides the surgeon with an improved ability to localize bleeding, as well as potentially minimize the extent of bowel resection.     

Cytomegalovirus colitis presenting as massive lower gastrointestinal bleeding in an immunocompetent patient

Cytomegalovirus infection is ubiquitous but often remains asymptomatic in affected patients. Symptomatic cytomegalovirus infection usually occurs in immunocompromised patients— patients who are infected with the Human Immunodeficiency Virus, have received organ transplantations, or are on immunosuppressive therapies. Cytomegalovirus colitis can present with abdominal pain, diarrhea and significant per rectal blood loss. It is a rare entity in immunocompetent patients and can often be missed unless one has a high index of suspicion. We describe a case of CMV colitis in a 78-year-old patient with no known risk factors for immunosuppression who was admitted for respiratory diseases and then subsequently developed transfusion dependent lower gastrointestinal bleeding. She ultimately required surgical resection of her colon. A literature review on CMV colitis, its myriad manifestations and therapeutic outcomes was conducted, with particular emphasis on its occurrence in immunocompetent patients.     

Incidence of tumoral pathology according to study using capsule endoscopy for patients with obscure gastrointestinal bleeding

Background Capsule endoscopy has involved a significant advance in techniques for imaging of the small bowel. Its most frequent indication is for studying patients with obscure gastrointestinal bleeding (OGIB). Small bowel tumors are infrequent, representing only 1% to 3% of all malignant gastrointestinal tumors. This study aimed to assess retrospectively the occurrence and characteristics of tumoral pathology diagnosed by means of capsule endoscopy in patients with OGIB. Methods A retrospective review analyzed the first 320 patients submitted to capsule endoscopy because of OGIB (166 with obscure overt bleeding and 154 with obscure occult bleeding) at a single center. The patients with a tumor diagnosis were analyzed in terms of incidence, characteristics, and treatment of OGIB pathology. Results Tumor incidence was of 7.18% (23/320), with 65.2% of the cases supported with histologic confirmation (15/23). Obscure overt bleeding was the most frequent form of presentation, with the jejunum as the most frequent location (65.2%). For 16 patients, an intervention was conducted with a healing intent. Capsule endoscopy allowed the diagnosis of two cecal adenocarcinomas missed by colonoscopy. Conclusions Small bowel tumors are not an infrequent cause of OGIB. Capsule endoscopy, even if it does not allow determination of the benign or malignant nature or the histologic type of the tumor, is a useful tool for the diagnosis and early management of these tumors.     

A prospective comparison of warfarin to aspirin for thromboprophylaxis in total hip and total knee arthroplasty

Current orthopedic practice requires consideration of contradictory recommendations regarding pulmonary embolism (PE) prevention among patients undergoing total hip arthroplasty (THA) and knee joint arthroplasty (TKA). A total of 696 consecutive patients underwent elective THA or TKA. Two hundred eighty-one patients received PE risk stratification per American Academy of Orthopaedic Surgeons guidelines. Of these patients, 152 standard-risk patients received aspirin, and 129 elevated-risk patients received warfarin. The comparator group of 415 patients received American College of Chest Physicians-recommended warfarin without PE risk stratification. Primary study outcomes were symptomatic PE, deep venous thrombosis, major bleeding, and death. The rate of symptomatic PE and venous thromboembolism among standard-risk group patients receiving aspirin was greater than the comparator group (4.6% vs 0.7% and 7.9% vs 1.2%, respectively). Most events (16/18) occurred among patients undergoing TKA. Patients with total joint arthroplasty at standard risk for PE receiving aspirin had a higher rate of symptomatic PE and venous thromboembolism than did patients receiving anticoagulation.