Active Bleeding Research Articles

Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation.

Surgical evacuation of intracerebral hemorrhage (ICH) at early time points contributes to improved functional outcomes. However, ultra-early evacuation has been associated with postoperative rebleeding, a devastating complication that contributes to worse outcomes. Minimally invasive endoscopic techniques allow for intraoperative management of active bleeding, potentially allowing for safe and effective hemostasis at ultra-early time points. The authors proposed and prospectively assigned an intraoperative grading scale that quantified the severity of bleeding encountered intraoperatively. They hypothesized that ultra-early evacuation would correlate to increased intraoperative bleeding but not postoperative rebleeding or worse long-term clinical outcomes in a cohort of patients undergoing minimally invasive endoscopic evacuation. Patients presenting to a large healthcare system with spontaneous supratentorial ICH were triaged to a central hospital for potential surgical evacuation. Inclusion criteria for evacuation included age ≥ 18 years, premorbid mRS score ≤ 3, hematoma volume ≥ 15 mL, and presenting National Institutes of Health Stroke Scale score ≥ 6. A 5-point scale was developed and prospectively applied to grade the severity of bleeding encountered intraoperatively. A score of 1 indicated no active intraoperative bleeding. A score of 2 indicated minimal bleeding treated with irrigation alone. A score of 3 indicated bleeding that required cauterization to control. A score of 4 indicated bleeding that required irrigation or cauterization for at least 15 minutes to achieve hemostasis. A score of 5 indicated bleeding that required irrigation or cauterization for at least 1 hour. The authors evaluated 142 consecutive patients. The median bleeding score was 2 (IQR 2-4). Greater preoperative volume, concomitant intraventricular hemorrhage, and earlier time to evacuation were independently associated with increased bleeding score. Specifically, ultra-early evacuation within 5 hours was independently associated with a 2.4-point greater bleeding score as compared with evacuation thereafter (β = 2.41, 95% CI 1.44-3.38; p < 0.0001). Despite having higher intraoperative bleeding scores, patients undergoing ultra-early evacuation did not have an increased likelihood of postoperative rebleeding (14% vs 3%, p = 0.23), 30-day mortality (0% vs 6%, p = 0.99), or worse median 6-month mRS scores (4 [IQR 2-5] vs 4 [IQR 3-5], p = 0.51). Ultra-early evacuation within 5 hours of ictus is associated with increased intraoperative bleeding but not postoperative rebleeding or worse clinical outcomes. These findings suggest that the benefits of ultra-early evacuation can be explored without an increased risk of postoperative rebleeding when utilizing a minimally invasive endoscopic technique with good intraoperative visualization, active irrigation for targeted tamponade, and direct cauterization of bleeding vessels.

MÚLTIPLOS ABSCESSOS ESPLÊNICOS EM PACIENTE COM CIRROSE HEPÁTICA NO AMAZONAS

A 38-year-old male patient with a diagnosis of liver cirrhosis for 5 years, irregularly treated with lactulose and furosemide, presented with fever, confusion, fatigue, jaundice, and ventilator-dependent pleuritic pain when seeking medical attention. Upon examination, he was lucid but exhibited slowed thinking, a sleep-wake cycle inversion, and flapping. The physical examination revealed edema in the lower limbs, jaundice, and pain in the left subcostal region. Due to the presence of decompensated cirrhosis, monitoring and diagnostic investigation for possible etiologies were initiated. Laboratory tests, ECG, chest X-ray, and echocardiogram were performed. A computed tomography (CT) scan revealed splenomegaly with regular contours and heterogeneous attenuation coefficients, showing hypodense, non-enhancing collections occupying the entire upper half, as well as a left pleural effusion and signs of chronic liver disease and portal hypertension. A transverse incision was made, revealing splenomegaly with the presence of thick fluid collections in the upper pole of the spleen, consistent with a diagnosis of splenic abscess. The patient progressed to hypovolemic shock and underwent reoperation after 72 hours for active bleeding control. Ciprofloxacin and clindamycin were administered for 28 days. The patient improved well after discharge from the ICU, with clinical and laboratory improvement. Follow-up was conducted with amoxicillin 250 mg for two years, and he continues outpatient follow-up with a gastroenterologist. Splenic abscess (SA) usually arises from endocarditis or other forms of hematogenous transmission, such as pneumonias, gastrointestinal perforations, or arteriovenous malformations. Although not always present, risk factors for the development of endocarditis include immunosuppression, diabetes mellitus, trauma, or microorganisms. Diagnosis is based on clinical findings and imaging studies (ultrasound and CT). Treatment depends on the number, size, and location of the abscesses. Antibiotic therapy can drastically reduce mortality associated with this condition, and percutaneous drainage has been successful. However, in some cases, splenectomy is necessary. Splenic abscess is a rare condition, and its early diagnosis requires a high degree of suspicion, and there is still no best approach for treatment.

Treatment of Renal Capsule Lesion in a Transplanted Kidney: A Case Report and Literature Review

Expanded donor criteria have been established to reduce organ wastage, as various factors can lead the disposal of kidneys, such as anatomical abnormalities, traumatic injuries, and iatrogenic injuries during organ retrieval surgery. We report a case of kidney transplantation in which a capsular lesion was identi!ed and repaired during organ preparation (back table) and review of the literature regarding transplant kidney injuries. A diabetic and hypertensive 52-year-old patient with chronic kidney disease undergoing dialysis therapy for 2 years was admitted for a deceased donor kidney transplant. "e donor was a 35-year-old man with brain death secondary to traumatic brain injury in a car accident. During the kidney preparation on the back table, a capsular lesion was visualized on the upper pole of the right kidney. Continuous suture of the renal capsule was performed using a 3-0 CatGut suture to correct the defect and reconstruct the renal surface. After renal reperfusion, no active bleeding was observed from the sutured area. "e patient had a good postoperative course with no complications. "e main complications associated with capsular lesions and complete capsular denudation are bleeding and hematoma formation, as well as urinary and lymphatic extravasation through the exposed renal parenchyma. Treatment may involve direct cauterization using electrocautery or argon plasma, or the use of hemostatic agents. Successful repair of capsular lesions not only prevents complications such as bleeding during reperfusion and urinary !stulae but also plays a crucial role in expanding the pool of organs available for transplantation.

Management of a Rare Case of Superior Mesenteric Artery Aneurysm Associated with a Pancreatic Cyst Complicated by Acute Rupture: A Case Report and Review of Literature

Superior mesenteric artery aneurysms are a rare pathology, and rupture due to a pancreatic cyst in the context of alcohol-induced pancreatitis is an even rarer condition. The first line of treatment is usually an endovascular approach. We present the case of a 51-year-old male with alcohol-induced pancreatitis, diagnosed with a superior mesenteric artery aneurysm with active bleeding in close contact with a large pancreatic cyst. A covered stent was used to treat this condition. The patient developed hemorrhagic shock 12 h after the procedure and an urgent laparotomy was performed. A second rupture of the arterial wall at the distal end of the stent was observed and in order to obtain distal perfusion, first, an infrarenal aorta to superior mesenteric artery bypass distal to the rupture was performed in order to exclude the aneurysm. Secondly, a bypass originating from the distal end of the first bypass to the distal end of the superior mesenteric artery was performed. The patient had an uneventful recovery and was discharged after 10 days. We reviewed the literature regarding the incidence and the therapeutic management of superior mesenteric artery aneurysm complicated by pancreatic cyst. An advanced search on PubMed from 2004 to 2024 returned 194 results and after applying the inclusion–exclusion criteria, 11 publications were selected. Although the endovascular approach is usually the first line of treatment with obvious advantages for the patient, a patient-tailored approach should be made in such cases and surgery could be the first option, when considering that the mechanism of aneurysm rupture is due to erosion of the arterial wall by the pancreatic enzymes. Surgery has the advantage of cyst drainage and aneurysm exclusion and in our case proved lifesaving.

Management of anticoagulant-related soft tissue bleeding

Spontaneous, severe, and life-threatening soft tissue bleeding (STB) in patients taking anticoagulants is associated with high morbidity and mortality due to the substantial blood loss and nonspecific clinical symptoms. The optimal management of these predominantly older patients with multiple comorbidities has not yet been unanimously clarified. This work comprises aliterature search and analysis of the pertinent retrospective studies and case series. Structured diagnostic workup with contrast-enhanced computed tomography (CT) is essential for planning transarterial embolization (TAE). Contrast agent extravasation, the signal flare phenomenon, and the hematocrit effect are all indicative of active bleeding or an anticoagulant-related hematoma. For TAE, coils, particles, and liquid embolic agents can be used alone or in combination. Aback door/front door embolization should be strived for. Transarterial embolization is the method of choice for managing anticoagulant-related localized or diffuse spontaneous soft tissue bleeding in the context of hemodynamic stabilization of the patient.

Hemorrhagic hepatic infarction in a pregnant woman with severe preeclampsia: A case report

Introduction and importance: Severe preeclampsia is a medical condition that affects women during the last two trimesters of pregnancy. Hemorrhagic hepatic infarction is a hepatic complication and is rarely encountered in women with severe preeclampsia. This case report aims to present the characteristics of hemorrhagic hepatic infarction in a pregnant woman with severe preeclampsia. Case presentation: A 27-year-old pregnant woman with a 30-week gestation of amenorrhea was admitted with a blood pressure of 160/100 millimeters of Mercury (mm Hg), headaches, dizziness and oedema in the lower limbs. Clinical discussion: These complaints with clinical and paraclinical examinations led to the diagnosis of severe preeclampsia and she underwent an emergency cesarean section but 6 hours later, she presented with hypovolemic shock and this led to a new surgery. A surgery which made it possible to develop or discover a diffuse hepatic infarction with hemorrhagic infiltration of the gallbladder and the falciform ligament without active bleeding in the liver. Emergency management of preeclampsia was adopted and the postoperative course was simple with a good clinical outcome when the patient was discharged. Conclusion: Severe preeclampsia and hemorrhagic hepatic infarction are complications of pregnancy which require emergency treatment and above all these medical conditions require the termination of the pregnancy.

Trans-arterial embolization for treatment of acute lower gastrointestinal bleeding-a multicenter analysis.

To assess the technical feasibility, safety, and clinical success rate of trans-arterial embolization (TAE) as an emergency treatment for acute lower gastrointestinal bleeding (LGIB). Consecutive patients who received urgent TAE due to active LGIB at five academic centers in Germany were retrospectively analyzed. LGIB was confirmed and localized using contrast-enhanced computed tomography (CT) or endoscopy. Outcome parameters including technical and clinical success rates as well as ischemia-related adverse events were analyzed. Furthermore, treatment-related variables that may affect technical and clinical success were analyzed using a regression model. One hundred and forty-one patients were included. TAE was performed in 91% (128/141) of patients. In 81% (114/141) of patients, TAE was performed due to active bleeding visible at angiography, the remaining 10% (14/141) underwent empiric embolization based on pre-interventional imaging. In 9% (13/141) of patients, no TAE was performed. Microcoils were the most used embolic 48.5% (62/128), followed by glue 23.5% (30/128) and Microparticles (8%; 10/128). In the case of bleeding visible in angiography, the technical success rate was 100% (114/114); the clinical success rate was 93.6% (120/128). Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% (18/128) of all patients after embolization. Thirty-day mortality was 14% (21/141). Regression analysis revealed no significant correlations but a statistical trend toward a higher incidence of bowel resection when glue was used (p = 0.090) and toward a higher 30-day mortality when an unselective embolization was performed (p = 0.057). TAE for LGIB has a high technical and clinical success rate. Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% of patients without identifying a significant correlation to the embolization technique or an embolic. Question Is trans-arterial embolization (TAE) viable as an emergency treatment for acute lower gastrointestinal bleeding (LGIB)? Findings TAE demonstrated a 100% technical and 93.6% clinical success rate in treating acute LGIB, with severe ischemia-related adverse events occurring in 14% of patients. Clinical relevance TAE is highly effective and has an acceptable complication rate in treating lower gastrointestinal bleeding, emphasizing the need for a direct head-to-head comparison between endovascular and endoscopic therapy.

Clinical management of active bleeding: what the emergency radiologist needs to know.

Active bleeding is a clinical emergency that often requires swift action driven by efficient communication. Extravasation of intravenous (IV) contrast on computed tomography (CT) is a hallmark of active hemorrhage. This can be seen on exams performed for a variety of indications and can occur anywhere in the body. As both traumatic and non-traumatic etiologies of significant blood loss are clinical emergencies, exams demonstrating active bleeding are often performed in emergency departments and read by emergency radiologists. Prompt communication of these findings to the appropriate emergency medicine and surgical providers is crucial. Although many types of active hemorrhage can be managed by interventional radiology techniques, endoscopic and surgical management or clinical observation may be appropriate in certain cases. To facilitate optimal care, it is important for emergency radiologists to understand the scope of indications for embolization of bleeding by interventional radiologists (IR) and when an IR consultation is warranted. Similarly, timely comprehensive diagnostic radiology reporting including pertinent positive and negative findings tailored for IR colleagues can expedite the appropriate intervention.

Demand Ischemia due to Gastrointestinal Bleeding Secondary to Ticagrelor

Ticagrelor, an orally consumed antiplatelet medication, acts as an antagonist on the P2Y12 receptor preventing adenosine diphosphate-induced platelet aggregation. Gastrointestinal bleeding triggered by ticagrelor can lead to demand ischemia, as the demand for oxygen by the tissues surpasses the oxygen supply available following acute blood loss. A male patient in his 80s had his antiplatelet medication switched from clopidogrel to ticagrelor following a cardiac stent. He presented to the emergency department a few months later due to black stools and fatigue. The patient had a critically elevated initial troponin level of 780 ng/L which increased to 892 ng/L two hours later. Hemoglobin was low at 8.5 g/dL. The patient suspended usage of ticagrelor and switched back to clopidogrel. Three weeks later, he had an endoscopy, which demonstrated no active bleeding sources.

Preemptive Transjugular Intrahepatic Portosystemic Shunt in Variceal Bleeding: A Real-World Study in a Tertiary Hospital

Introduction: Several studies have highlighted the potential benefits of early prophylactic transjugular intrahepatic portosystemic shunt (preemptive TIPS) placement in reducing morbidity and mortality following variceal bleeding (VB). Baveno VII recommends its placement less than 72 h after VB (Child-Pugh class C <14 or class B >7 plus active bleeding). This study aimed to evaluate the effectiveness of preemptive TIPS compared to a control group in a referral center. Methods: The control group included cirrhotic patients with VB and Child-Pugh class C or B with active bleeding, retrospectively selected between 2016 and 2022 and divided into 2 subgroups: those that never underwent TIPS placement during the course of their illness (subgroup A) and those submitted to TIPS placement due to rebleeding (subgroup B). Additionally, patients who received preemptive TIPS placement between August 2022 and January 2024 were prospectively included into the preemptive transjugular intrahepatic portosystemic shunt (pTIPS) group. Results: A total of 47 patients were included, 19 (40.4%) in the pTIPS group and 28 (59.6%) in control group (17 in subgroup A). There were no differences in baseline characteristics between the groups, except hepatic encephalopathy that was significantly higher in the control group when compared to the pTIPS group: 19 (67.9%) versus 6 (31.6%), p = 0.014. Early rebleeding rates were significantly lower in the pTIPS group: 1 (5.3%) versus 13 (46.4%) (p = 0.002). There were no significant differences in 6-week survival between the groups: 25 (89.3%) versus 17 (89.5%), p = 0.683. Regarding hepatic encephalopathy, no significant differences were observed between the control and the pTIPS group: 6 (21.4%) versus 4 (21.1%), p = 0.632, even when comparing subgroup A (4, 23.5%) with the pTIPS group (p = 0.432). Conclusion: This real-world study highlights the potential benefits of preemptive TIPS placement in reducing early relapse of VB, thereby lowering morbidity and complications. The findings advocate for the proactive incorporation of preemptive TIPS into clinical practice to optimize patient outcomes following VB.

Effect of cardiopulmonary resuscitation on perfusion in a porcine model of severe hemorrhagic shock.

Pulseless electrical activity from hemorrhagic shock has not been shown to benefit from cardiopulmonary resuscitation (CPR). Using a porcine model, our objective was to determine the effects of CPR on brain and skin oxygenation as a measure of perfusion in the setting of severe hemorrhagic shock. Adult swine randomized to non-CPR and CPR were anesthetized. Tissue oxygen sensors were inserted into the parietal cerebral parenchyma and skin. Controlled hemorrhagic shock with mean arterial pressure (MAP) <30 mm Hg was achieved and allowed to persist for 10 minutes. Animals were randomized to either receive automated CPR or no treatment. They were then autotransfused with sufficient blood to achieve MAP >60 mm Hg. Measurements were obtained before, during, and after shock state. Outcomes were modeled using mixed-effects lognormal models. A total of 12 swine were used, and the results were analyzed (non-CPR, n = 5; CPR, n = 7). One animal in the CPR group died during shock. One cerebral probe sensor malfunctioned, and these data were excluded. Baseline characteristics were similar between groups. MAP during shock was similar between groups; however, the CPR group had significantly higher systolic blood pressure (62.8 vs. 48.8 mm Hg, p = 0.010) and lower diastolic blood pressure (12.8 vs. 27.8 mm Hg, p < 0.001). Both cerebral (pBO2) and skin oxygenation (TcO2) dropped significantly as a result of shock. The CPR group had lower overall measures of tissue perfusion during shock, but only TcO2 at the shoulder was significantly lower during shock (11.5 vs. 21.1 mm Hg, p = 0.027) and recovery (33.3 vs. 62 mm Hg, p = 0.033). Our model showed that adding CPR during hemorrhagic shock did not improve end-organ oxygenation/perfusion, but did significantly diminish skin perfusion. This experiment corroborates existing literature on the potential detrimental effects of CPR during hemorrhagic pulseless electrical activity, but further work is needed to confirm this observation.

Spontaneous esophageal submucosal hematoma.

A 57-year-old woman presented to our hospital with chest distension, sore throat and back discomfort beginning the previous day after taking 5 panax notoginseng capsules. She had a history of hypertension for more than 2 years. Physical examination was unremarkable. Blood tests revealed results: A red blood cell count of4.27T/L, a platelet count of 296G/L, a hemoglobin count of 130 g/L (130-175 g/L), and a D-dimer count of0.252 mg/L. Endoscopy showed a longitudinal dark red submucosal hematoma (SH) extending from 20 cm down to 36 cm, with no active bleeding. The next day an enhanced CT of the chest showed uneven thickening of esophageal wall suggestive of intramural esophageal hematoma. A second endoscopy was performed 6 days later, and it showed an esophageal ulcer where the hematoma had been seen at the previous part. The patient was treated with a proton pump inhibitor (PPI) and nutritional support while oral intake was completely prohibited. Her symptoms gradually improved and disappeared. She was discharged one week after the second Upper GI endoscopy when she was able to eat liquid diet. After discharge, she continued the PPI and Kang Fuxin for 2 months. During the 4-month follow up, the symptoms did not recur.

Contrast-enhanced computed tomography assisted diagnosis of bleeding caused by colonic angiodysplasia: A case report.

Angiodysplasia (AD) in the gastrointestinal tract is a degenerative vascular condition characterized by vascular dilation, tortuosity, and arteriovenous connections within the mucosal and submucosal layers. AD is a significant cause of lower gastrointestinal bleeding in the elderly, often presenting as chronic, intermittent hemorrhage. The research challenge lies in the potential for multiple and minute AD lesions to be missed during endoscopy, which may lead to post-hemostatic rebleeding. An 82-year-old female with a history of coronary artery disease treated with aspirin, presenting with recurrent melena and anemia. The patient exhibited a suboptimal response to blood transfusions and octreotide therapy. After excluding tumorous bleeding in the initial contrast-enhanced computed tomography (CECT), we suspect vascular bleeding as the most probable etiology. The initial colonoscopy was unsuccessful due to the occurrence of ventricular tachycardia. Considering the patient's advanced age, cardiac dysfunction, and frailty, a repeat CECT were conducted during episodes of suspected active bleeding. Vascular dilatation within the colonic hepatic flexure wall was visualized during the venous phase, accompanied by contrast agent extravasation into the intestinal lumen. The subsequent urgent colonoscopy and pathological specimens from surgical resection supported the diagnosis of colonic AD. After the surgery, the patient did not experience melena thereafter. We highlight that CECT for diagnosing AD-related bleeding offers higher safety and convenience, potentially superior to digital subtraction angiography, particularly in critically ill elderly patients.

Jejunal Dieulafoy's lesion - An exceptionally rare and challenging culprit of gastrointestinal bleeding.

A 78-year-old male presented to the emergency department with melena. He was hemodynamically stable but displayed a hemoglobin level of 5.8g/dL necessitating blood transfusion. Initial esophagogastroduodenoscopy and colonoscopy failed to identify a bleeding source, prompting a capsule endoscopy that revealed an active bleeding site in the jejunum. A single-balloon enteroscopy identified an aberrant vessel in the mid-jejunum protruding through a 3mm mucosal defect, devoid of surrounding inflammation, consistent with a Dieulafoy's lesion, in which two through-the-scope clips were applied. Despite this, ongoing melena and decreasing hemoglobin levels in the subsequent days led to a second single-balloon enteroscopy, which confirmed continued bleeding. Definitive hemostasis was achieved through diluted adrenaline injection, four additional through-the-scope clips, and polidocanol sclerotherapy. Jejunal Dieulafoy's lesion is extremely rare and presents notable diagnostic and therapeutic challenges. Ávila et al. recently reported a case where, despite capsule endoscopy identifying the bleeding site, single-balloon enteroscopy failed to confirm the diagnosis, leading to the use of motorized enteroscopy with argon and metallic clip treatment. Similarly, our experience highlights the diagnostic value of capsule endoscopy and the crucial role of device-assisted enteroscopy in a multimodal therapeutic approach, which was essential for achieving successful hemostasis.

Extracorporeal Carbon Dioxide Removal Instead of Mechanical Ventilation in a Patient with Respiratory Distress and Acute Kidney Failure, with Active Bleeding Using Regional Anticoagulation

Extracorporeal Carbon Dioxide Removal Instead of Mechanical Ventilation in a Patient with Respiratory Distress and Acute Kidney Failure, with Active Bleeding Using Regional Anticoagulation

Outcome of Negative Computed Tomographic Angiography in the Management of Gastrointestinal Bleeding at a Tertiary Centre: A Cross-sectional Study

INTRODUCTION: Acute gastrointestinal bleeding is a common gastrointestinal emergency. Only limited studies are available regarding the clinical outcomes after computed tomographic angiography (CTA) mesentery showed negative for active bleed. This study aims to determine the clinical outcome of negative mesentery CTA in patients with clinically active acute gastrointestinal (GI) bleeding. MATERIAL AND METHODS: A cross-sectional study with a universal sampling method was used. Patients who underwent CTA to detect gastrointestinal bleeding in the National University Hospital of Malaysia from December 2015 until March 2021 were retrospectively analysed. The outcome of each patient, risk of re-bleeding, and 30-days mortality rate were evaluated and assessed. RESULTS: In total, 280 CTAs were performed on 232 patients, with 186 of them showing negative results on their first initial CTA. 40.8% (76/186) of those with negative initial CTA had recurrent bleeding and 73.6% (56/76) of them required active intervention. We found that the risk of re-bleeding is lower in the upper gastrointestinal group compared to the lower gastrointestinal group (OR=1.5, 95% CI: 0.877- 2.852, p: 0.128). The overall 30 days mortality rate after the first negative CTA was 23.1% (43/186). Among those patients who experienced re-bleeding, 32.8% (25/76) died within 30 days, with 18.4% (14/76) succumbing to massive bleeding. CONCLUSION: From our analysis, it can be concluded that a clinically active GI bleeding with negative mesentery CTA has a 40.8% chance to re-bleed with 23.1% 30-day mortality rate. Close observation and follow-up

The Effectiveness of Medical Preparation for Endoscopy of Obese Patients with Active Gastrointestinal Ulcer Bleeding

The Effectiveness of Medical Preparation for Endoscopy of Obese Patients with Active Gastrointestinal Ulcer Bleeding

An alternative method for comparing hemorrhagic activity of snake venoms following one of the 3R's principles

Venom-induced hemorrhage analysis usually is performed by Minimum Hemorrhagic Dose (MHD), however a similar method can be used to compare venoms with fewer laboratory animals. Our work compared the MHD of five different venoms, with the size of hemorrhagic spot, finding good correlations in the results. Considering the 3Rs principle, we propose the use of the hemorrhagic spot method to compare hemorrhagic activity of snake venoms, rather than using the MHD method, since the first one needs 5 times less animals than the other.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.

Rectus Abdominis Sheath Hematoma Following Cesarean Section: A Case Series

This case series describes two patients who underwent Cesarean section complicated by a rectus abdominis sheath hematoma that did not immediately resolve following exploratory laparotomy. One of the patients required an additional procedure by interventional radiology. Both patients had similar presentations. Both were noted to have symptomatic anemia on postoperative day 1 with an acute drop in hemoglobin. This was accompanied by severe abdominal pain and distension on physical exam. Computerized tomography (CT) abdomen/pelvis demonstrated evidence of active bleeding within the anterior abdominal wall musculature. Due to increasing concern for intrabdominal hemorrhage in the setting of an acute abdominal exam, the decision was made to proceed with an exploratory laparotomy. A substantial amount of blood was evacuated from the abdomen with greater than 1500 cc of estimated blood loss in both cases. A Jackson-Pratt drain was placed and had increased output immediately postoperatively. Both patients received blood products. One developed a consumptive coagulopathy. Interventional Radiology was consulted following exploratory laparotomy to consider intravascular embolization of the inferior epigastric arteries, which was eventually performed in one of the cases. The patients were discharged on hospital day 5 in good condition. Rectus abdominis sheath hematomas are a rare complication that can lead to significant postpartum hemorrhage. Prompt recognition and management is vital to avoid significant morbidity and mortality. Algorithms exist to guide treatment and standardize patient care. Despite using sound clinical judgment in line with existing algorithms, both patients had delayed resolution of their bleeding following initial management, requiring additional intervention.