Rare causes of gastrointestinal hemorrhage in infancy

Gastrointestinal hemorrhage in children is a critical condition that demands quick and effective management. The differential diagnosis of gastrointestinal hemorrhage is wide. Heterotopic pancreas is a rare congenital anomaly and usually discovered incidentally. It is generally asymptomatic, but symptoms may occur when complicated by inflammation, bleeding, obstruction or malign transformation. Heterotopic pancreas may present throughout the gastrointestinal tract, but it is most commonly found in the stomach, duodenum and proximal jejunum. Juvenile polyps are common during childhood and present most often with painless rectal hemorrhage. They remain the most common colonic polyps in children. Colonoscopic polypectomy is the most effective procedure in the treatment of juvenile polyps. In this study, we describe rare causes of gastrointestinal system hemorrhage in infancy and discuss some diagnostic and therapeutic approaches.     

Pulmonary arteriovenous malformation in children

Although pulmonary arteriovenous malformations (PAVM) are relatively rare in children, they are important in the differential diagnosis of common pulmonary problems, such as hypoxemia, hemoptysis and dyspnea on exertion. We report the cases of two PAVM patients with different presentations and describe the treatment strategies.     

Epicardial cysts: report of two rare cases

Epicardial cysts originating directly from the epicardium are seen very rarely. Complete surgical excision is recommended when these cysts are detected. If cysts compress surrounding vital structures, cardiopulmonary bypass (CPB) should also be considered. We report herein 2 cases of multiloculated epicardial cysts, both of which were successfully excised, 1 with CPB.     

Comparision of the effects of subtenon’s and subconjunctival anesthesia on retroorbital hemodynamics

The aim of the study was to compare retroorbital blood flow hemodynamics between subconjunctival and sub-Tenon’s anesthesia. This was a prospective, blinded study and included 80 cases. Patients were monitored and treated in the First Ophthalmology Clinic, Ataturk Training and Research Hospital, Turkey. Sub-Tenon’s anesthesia was performed in 42 cases, and subconjunctival anesthesia was performed in 38 cases. Color Doppler imaging to measure ocular blood flow parameters was performed preoperatively and 21 days after cataract operation in each case. Preoperative and postoperative values of resistivity and pulsatility indices in the ophthalmic, central retinal, and short posterior ciliary arteries were compared. Postoperative mean blood flow velocity measurements of ophthalmic artery were not statistically different between the subconjunctival anesthesia group and the sub-Tenon’s anesthesia group (49.63 ± 14.00 vs. 45.85 ± 13.41; P=0.389). Postoperative RI values were higher in the Subtenon’s anesthesia group than in the subconjunctival anesthesia group, but the difference between two groups was not statistically significant (0.81 ± 0.14 vs. 0.74 ± 0.08; P=0.079). The postoperative pulsatility index of the ophthalmic artery, RI of ophthalmic artery, pulsatility index of the central retinal artery, RI of the central retinal artery, and pulsatility index of the posterior ciliary arteries were not significantly different between the subconjunctival and sub-Tenon’s anesthesia groups. In conclusion, the study suggests that postoperative retroorbital blood flow hemodynamics are the same following sub-Tenon’s and subconjunctival anesthesia.     

Postoperative fluid management

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients' status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient's body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of overhydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient's actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient's specific condition.     

Imatinib mesylate-induced acute liver failure in a patient with gastrointestinal stromal tumors

Imatinib mesylate is a drug that has been approved for treatment of chronic myeloid leukemia, Philadelphia-positive acute lymphoblastic leukemia, and advanced gastrointestinal stromal tumors. Several cases of hepatotoxicity, including fatal liver failure, have been reported with the long-term use of imatinib mesylate. Generally hepatotoxicity resolves after discontinuation of imatinib. Despite discontinuation of imatinib, hepatotoxicity can be progressive. Steroid may be useful in these patients and should be started early. We report a 53-year-old woman with advanced gastrointestinal stromal tumors who developed hepatotoxicity while receiving imatinib and subsequently acute liver failure. Ten weeks after commencing imatinib treatment, hepatotoxicity was determined. Imatinib was immediately ceased. Subsequently, a week later hepatic encephalopathy, jaundice, and coagulopathy occurred. Prednisolone was commenced. Liver biopsy was performed five weeks after the determining of hepatotoxicity. Biopsy showed sinusoidal congestion, necrosis of hepatocytes, inflammation, and hepatocyte drop out around the hepatic venule consistent with drug toxicity. Her liver function tests normalized with a nine-week prednisolone treatment. The patient was discharged. Her liver enzymes remained in normal range following visits. In cases of imatinib-induced acute hepatitis, the administration of prednisolone may be useful in the resolution of the acute episode and allow the reintroduction of a drug without risking recurrence of hepatitis.