Etiology Of Upper Gastrointestinal Bleeding Research Articles

Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report

BackgroundPrimary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate.Case presentationWe report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta.ConclusionsA timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

Should Vasoconstrictors be Considered in a Cirrhotic Patient with Acute Non-variceal Upper Gastrointestinal Bleeding?

Varices manifest as a major etiology of upper gastrointestinal bleeding in patients with chronic liver diseases, such as liver cirrhosis and hepatocellular carcinoma. By contrast, non-variceal upper gastrointestinal bleeding is rare. Pharmacological treatment differs between patients with variceal and non-variceal bleeding. Vasoconstrictors are recommended for the treatment of variceal bleeding, rather than non-variceal bleeding. In contrast, pump proton inhibitors are recommended for the treatment of non-variceal bleeding, rather than variceal bleeding. Herein, we present a case with liver cirrhosis and acute upper gastrointestinal bleeding who had a high risk of rebleeding (i.e., Child-Pugh class C, hepatocellular carcinoma, portal vein thrombosis, low albumin, and high international normalized ratio and D-dimer). As the source of bleeding was obscure, only terlipressin without pump proton inhibitors was initially administered. Acute bleeding episode was effectively controlled. After that, an elective endoscopic examination confirmed that the source of bleeding was attributed to peptic ulcer, rather than varices. Based on this preliminary case report, we further discussed the potential role of vasoconstrictors in a patient with cirrhosis with acute non-variceal upper gastrointestinal bleeding.

Clinical Vignettes/Case Reports - Biliary/Pancreas.

The differential diagnosis for patients presenting with concurrent cholecystitis and hematemesis is limited and includes cystic artery pseudoaneurysm and fistula between the cystic or hepatic arteries and gallbladder. Additionally, duodenal ulcer disease has been reported to cause both gastrointestinal bleeding and bilioenteric fistulas, though few cases have been reported of cholecystoduodenal fistula presenting with concurrent hematemesis, jaundice, and cholecystitis. An 84-year-old woman with diabetes, hyperlipidemia, and back pain on chronic NSAID therapy presented with hematemesis after a two-day history of post-prandial epigastric pain, vomiting, and fevers. Exam revealed jaundice and tenderness with guarding in the right upper quadrant of the abdomen. Shortly after presenting, she developed massive hematemesis and was intubated. Initial labs revealed a leukocytosis of 18, hemoglobin 6.9, AST 89, ALT 54, total bilirubin 5.8 (direct 4.9), and alkaline phosphatase 211. A CT scan revealed cholecystitis as well as gas in the gallbladder, cholelithiasis, and mild intrahepatic biliary dilatation. Subsequent angiography was negative for active extravasation, pseudoaneurysm, and arterial abnormalities. Upper endoscopy revealed a 15mm ulcer in the duodenal bulb with overlying clot. Removal of this clot revealed a defect, and injection of contrast under fluoroscopy demonstrated that the ulcer base extended into the gallbladder, confirming a cholecystoduodenal fistula. ERCP was performed revealing filling defects in the lower third of the common bile duct, and a biliary stent was placed. She improved clinically, with plans for future cholecystectomy and fistula repair. Amongst bilioenteric fistulas, cholecystoduodenal fistulas are most common, with choledochoduodenal fistulas comprising only one-fourth of cases. Up to 90% of bilioenteric fistulas result from cholelithiasis, while only 5% result from duodenal ulcer disease. The most common presentation is with cholangitis, though it occurs in less than 10% of patients; presentation with obstructive jaundice or gastrointestinal bleeding is exceedingly rare. Pneumobilia on imaging is a hint as to the diagnosis and is seen in 14-22% of cases. It is vital for clinicians to consider this diagnosis when such clinical signs are present, as complications from delay in diagnosis can be serious, and management differs from other etiologies of upper gastrointestinal bleeding and gallbladder disease.Figure: CT scan of the abdomen demonstrating gas in the gallbladder.Figure: Endoscopic appearance of the cholecystoduodenal fistula tract.Figure: ERCP revealing filling defects in the common bile duct.

Upper Gastrointestinal Bleeding and the Importance of an Early Endoscopic Study for Diagnosis: A Retrospective Study

Objectives: Determine if the time of early endoscopy modifies the patients evolution and hospitalization stay in patients with upper gastrointestinal bleeding. Design: A retrospective and transversal study. Setting: Primary care Hospital, in Tegucigalpa, Honduras. Participants we review a total of 115 medical records with diagnosis of upper gastrointestinal bleeding who attended the Emergency unit of the Social Security Institute Hospital in Tegucigalpa MDC Period from January 1 to December 31 of 2011. Results: We registered 115 patients with diagnosis of upper gastrointestinal bleeding of whom 92.17% underwent upper endoscopy study. Early endoscopy was performed within 24 hours in 10.38% of patients, in this group the average hospitalization stay was 3.1 days. Early endoscopy within the first 24 hours significantly reduced (p=0.0001) hospitalization stay. The mean length of hospital stay was 4.74 days. The main etiology of upper gastrointestinal bleeding was non-variceal 64.1%. Peptic ulcer disease type Forrest III (clean base ulcer) was the most frequent in 77.78%. The mean hospitalization stay in patients with peptic ulcer disease type Forrest III was 4.6 days. No endoscopy study was performed in 9 patients of whom all died because of hemodynamic instability and lack of an emergency endoscopy unit in the hospital. Conclusion: Early endoscopy determines the patient’s evolution and hospitalization stay.

Clinical features and treatment of rare etiologies of upper gastrointestinal bleeding

Objective To explore the clinical features and treatment of upper gastrointestinal bleeding with rare etiologies. Methods A total of 45 cases with rare etiologies was selected from a group of 1200 patients with upper gastrointestinal bleeding admitted from January 2012 to December 2015. Results The incidence of gastric stromal tumor (24.4%) and Dieulafoy's lesion (20.0%) was the highest. Among rare etiologies of upper gastrointestinal bleeding were Mallory-Weiss syndrome (17.8%) and stomal ulcer and hemorrhage of efferent loops after subtotal gastrectomy (17.8%), as well as left-side portal hypertension (6.7%), liver cirrhosis complicated with variceal bleeding in the descending part of the duodenum (2.1%), esophageal hematoma (2.1%), esophageal mucosa avulsion (2.1%), P-J syndrome (2.1%), duodenal adenocarcinoma (2.1%), and cutaneous malignant melanoma with duodenal metastasis (2.1%). Conclusions Gastroscopy in early stages played a role in etiologies identification, while etiological treatments could substantially reduce recurrent bleeding rate, thus enhanced cure rate. Analysis on rare etiologies promoted the medical understanding, with clinical diagnosis and treatment improved. Key words: Gastrointestinal hemorrhage/ET/TH

Use of Antibiotics Among Patients With Cirrhosis and Upper Gastrointestinal Bleeding Is Associated With Reduced Mortality.

Prophylactic antibiotics are recommended for all patients with cirrhosis hospitalized for upper gastrointestinal bleeding (UGIB). We evaluated the association between use of antibiotics, outcomes of re-admissions, and mortality in these patients. We performed a retrospective study of 6451 patients with cirrhosis (mean age, 60.6 y) in the Veterans Affairs health care system hospitalized for UGIB from January 1, 2005, through December 31, 2013 (8655 hospitalizations). We collected information on patients' baseline features, hospitalizations, etiology of UGIB, antibiotics given, hospital re-admission within 30 days of discharge, and mortality. We defined timely administration of antibiotics as receipt from 8 hours before admission through 48 hours afterward. Timely administration of antibiotics occurred during 48.6% of admissions (n= 4210), increasing from 30.6% in 2005 to 58.1% in 2013. Independent predictors of antibiotic receipt included ascites, high model for end-stage liver disease score, esophageal variceal hemorrhage, and administration of octreotide or intravenous proton pump inhibitors. Variables associated with decreased odds of antibiotic provision included black race and nonalcoholic fatty liver disease. In multivariate analysis, timely administration of antibiotics was associated with a reduced 30-day mortality rate (adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.93; P= .012). In a study of patients with cirrhosis and UGIB in the VA health care system, timely administration of antibiotics was associated with a 30% reduction in 30-day mortality. The proportion of patients with cirrhosis and UGIB receiving timely antibiotics nearly doubled from 2005 to 2013, but many patients-particularly those with less-advanced cirrhosis-did not receive this intervention. Targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.

Etiology of upper gastrointestinal bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria

Background: Upper gastrointestinal (GI) bleeding is a medical emergency that remains a common cause of morbidity and mortality worldwide. The aim of this study was to determine the common causes of upper GI bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria. Methods: Records of all patients referred with upper GI bleeding to the endoscopy unit of the University of Benin Teaching Hospital from February 2006 to January 2013 were reviewed. Relevant data and findings at diagnostic upper GI endoscopy were retrieved from the endoscopy register. Data obtained were analyzed using Statistical Package for Social Sciences version 15.0. Results: A total of 1084 patients had upper GI endoscopy during the study, of those 311 (28.7%) had upper GI bleeding. The mean age of patients with upper GI bleeding was 51.48 ± 17.5. Range was 14–90 years and the male: female ratio was 2.04:1. The most common cause of upper GI bleeding was peptic ulcer disease (PUD), found in 102 (32.8%) cases, followed by gastritis in 88 (28.3%) cases. Esophageal varices accounted for 47 (15.1%) cases whereas duodenitis was found in 16 (5.1%) cases. Carcinoma of the stomach occurred in 13 (4.2%) cases while 12 (3.9%) patients had esophagitis. Gastroesophageal reflux disease accounted for 11 (3.5%) cases whereas esophageal ulcers occurred in 3 (1.0%) cases. Carcinoma of the esophagus and esophageal candidiasis each constituted 2 (0.6%) cases. The cause of bleeding was not found in 15 (4.8%) patients. Conclusion: PUD is the most common cause of upper GI bleeding in patients undergoing endoscopy in the University of Benin Teaching Hospital, South-Southern Nigeria.

Upper Gastrointestinal Bleeding in Children: The Role of Helicobacter pylori Infection and Non-steroidal Anti-inflammatory Drug Use.

To study the role of non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection in the aetiology of upper gastrointestinal bleeding (UGIB) in children. One hundred and eighty-eight patients (82 girls, 106 boys; mean age 8.43 ± 5.24 years), admitted to the paediatric gastroenterology unit because of UGIB and who underwent endoscopic examination, were studied from their medical records, retrospectively. Upper gastrointestinal bleeding was observed in 188 (8.29%) of 2266 patients. The mucosal causes related to the oesophagus, stomach and duodenum were found at the rate of 37%, 58% and 24.5%, respectively with endoscopic examination. The location of bleeding could not be determined in 14.4% of the patients. History of drug intake before admitting to hospital was present in 40 patients (21.3%). When we examined these forty patients, 35% were on acetylsalicylic acid, 47.5% were on ibuprofen and 17.5% were on NSAIDs. Ibuprofen versus acetylsalicylic acid usage was found to be highly significant (p < 0.05) for UGIB. Helicobacter pylori was found in 20.7% of the patients. The relationship between H pylori and UGIB was not found statistically significant (p > 0.05). The relationship between drug intake and presence of H pylori infection was not found significant in our patients (p > 0.05). Ibuprofen and acetylsalicylic acid intake were found significant in the aetiology of UGIB in children. There was no significant connection with Helicobacter pylori infection in children with UGIB. We did not find a significant relationship with drug intake and H pylori infection.

Nonvariceal upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastrointestinal bleeding and understand therapeutic modalities available in achieving hemostasis. This article summarizes guidelines in management of acute nonvariceal upper gastrointestinal bleeding and reviews recent advances in the field. Recent study showed that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days. Endoscopic therapy should be performed on actively bleeding ulcers and ulcers with visible vessel or adherent clot. An over-the-scope clip is a novel device that can be used to achieve hemostasis. It may be a useful tool for achieving hemostasis for patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy. Doppler ultrasound probe can evaluate arterial flow to the ulcer and identify ulcers that are at high risk of rebleeding. Upper gastrointestinal bleeding from peptic ulcer disease is not a new clinical problem. Yet, the approach to management continues to evolve with the accumulation of data and well designed studies on the subject.

AIMS 65 Scoring to Predict Clinical Outcomes in Upper Gastrointestinal Bleeding

Introduction: Upper gastrointestinal bleeding (UGIB) accounts for nearly 500,000 inpatient admissions annually in the United States and is associated with significant mortality and morbidity. Several risk stratification scores have been developed and validated to identify high risk patients. AIMS 65 is a simple bedside risk score used to predict in-hospital mortality in subjects with UGIB. The aim of this study was to assess if AIMS65 score can predict other clinical outcomes like transfusion requirements, re-bleeding and re-admission rates and length of stay. Methods: This is a retrospective study using data collected from a predominantly minority population. Subjects admitted with diagnosis of UGIB from January 2010 to January 2013 were identified by ICD-9 codes and subjects on anticoagulation were excluded. AIMS 65 score (includes albumin<3.0 g/dl, INR>1.5, mental status, systolic blood pressure 90 mm Hg or lower, age>65) and outcome data were studied using retrospective chart review. High risk was defined as AIMS 65 score > 3 and low risk was defined as AIMS 65 score < 2. Results: Two hundred one patients met the inclusion criteria with a mean age of 68.5 years. 54.7 % males and 45.9 % females. 187 had AIMS 65 score of <2 while 14 had a score of 3 or more. The average length of stay was 8.1 days for the entire study population. Subjects with score < 2 had a length of stay of 7.9 days versus 10.7 days for >3(p = 0.361). 110 (60%) patients in AIMS < 2 required blood transfusion versus 12 (86%) patients in AIMS 65 > 3 (p = 0.05). Rates of re bleeding were 18% and 7% in low risk and high risk group respectively (p = 0.3). Readmission rate within 30 days was 24% in low risk group and 23% in the high risk group (p = 0.98). Conclusion: AIMS 65 score appears to predict transfusion requirements in subjects with UGIB. AIMS 65 score did not appear to have a predictive value for length of stay, re-bleeding and readmission rates. A follow up study to consider the impact of AIMS 65 scoring based on the etiology of UGIB is planned.

Hemosuccus Pancreaticus: A Rare Cause Of GI Bleed

Introduction: Hemosuccus pancreaticus, a rare etiology of upper gastrointestinal bleeding, is bleeding from the papilla of Vater through the pancreatic duct into the duodenum. Case Report: A 64-year-old man with history of chronic pancreatitis presented with epigastric abdominal pain of 2 weeks’ duration. Patient underwent a CT scan, which showed partially occluding thrombus of the confluence of the superior mesenteric vein and splenic vein along with changes of chronic pancreatitis. Due to drop in hemoglobin while in hospital, patient underwent red cell tag study, which was positive for bleeding with activity at second portion of duodenum. Patient later underwent EGD showing periampullary area with oozing of blood without any definitive localized lesion. For further evaluation of periampullary area, he had EGD with side-viewing duodenoscope, which confirmed the finding of blood oozing from the ampula. Mesenteric angiogram showed a 1.9-cm splenic artery pseudoaneurysm and minimal intimal irregularity and active extravasation from the inferior pancreaticoduodenal artery. Patient had splenic artery aneurysm coiling, which took care of his gastrointestinal bleeding. Discussion: Hemosuccus pancreaticus is rare entity and often difficult to diagnose. Multiple etiologies can be considered as a culprit, with the most common one being arterial pseudoaneurysm formation secondary to chronic pancreatitis. In patient with known pancreatic disease who presents with upper GI bleeding and abdominal pain, upper endoscopy or appropriate radiological procedure can help to establish accurate diagnosis. Angiographic embolization and surgery are the options for the management and transcatheter intervention is the treatment of choice for the clinically stable patients. Additional innovative treatments have been discussed in literature, but more studies will be needed to confirm the safety and therapeutic effectiveness of those treatment options.

UGI Bleeding in the AIDS Patient: Not Your Usual Ulcer

Introduction: Gastrointestinal Kaposi’s sarcoma (KS) is an entity that is often missed as a possible etiology of upper gastrointestinal bleeding in immunocompromised patients. We present a case of upper gastrointestinal tract bleeding from Kaposi’s sarcoma lesions in the stomach. Case Report: A 45-year-old man with Hx of AIDS (CD4 9) on HAART, ESRD on dialysis, HTN, CHF, chronic HBV, left internal jugular vein thrombus on warfarin, presented with altered mental status. A month prior to presentation, he was evaluated for chronic diarrhea and colonoscopy at that time was grossly normal with normal mucosal biopsies. On admission, the patient’s labs were significant for leukocytosis with bandemia and INR of 5.1. The patient was started on broad spectrum antibiotics. CT showed circumferential thickening of the whole colon, compatible with pancolitis. C difficile GDH antigen was positive and he was started on metronidazole. Subsequently, he developed melena with dark red clots, worsening mental status, and sepsis. Hb dropped from 9 gm on admission to 3.6 gm. EGD was performed and showed serpiginous, bulging, erythematous lesions of varying size/shape throughout the entire stomach. The lesions were friable and oozing moderate amounts of blood. Multiple biopsies were taken. Pathology showed mild chronic inflammation, negative for intestinal metaplasia or H. pylori, and no evidence of Kaposi’s sarcoma. Due to strong suspicion for KS, repeat EGD with deeper biopsies was performed. The clinical case was discussed with pathology department, and at this time, biopsies revealed Kaposi’s sarcoma with small focus of abnormal endothelial lined spaces with atypical endothelial cells positive for HHV8, indicative of KS. Upon second review, analysis of the previous pathology specimens also revealed KS due to a strong suspicion. Discussion: Kaposi’s sarcoma is the most common tumor among HIV infected individuals. The HIVinduced damage of the mucosa-associated immune system (decreased CD4cells in lamina propria) leads to more opportunistic infections and the development of malignant tumors. Although most cases of gastrointestinal KS are asymptomatic, advanced lesions may occasionally result in severe and life-threatening hemorrhage. Due to tumor growth in the submucosa, biopsies are diagnostic less than 25% of the time. In the setting of strong clinical suspicion for Kaposi’s, this case illustrates that multiple biopsies and deeper biopsies may be needed to establish the diagnosis, as well as the importance of discussing the clinical suspicion of a lesion with the pathology team. KS should always be considered as a strong differential diagnosis in the lesions of the gastrointestinal tract in an immunocompromised host.

Bleeding Serpiginous Lesions in the Upper Gastrointestinal Tract: A Diagnostic Challenge

Introduction: Gastrointestinal Kaposi's Sarcoma (KS) is an entity that is often missed as a possibly etiology of upper gastrointestinal bleeding in immunocompromised patients. We present a case of upper gastrointestinal tract bleeding from Kaposi's sarcoma lesions in the stomach. Case: A 45-year-old man with Hx of AIDS on HAART, ESRD on dialysis, HTN, CHF, chronic HBV, left internal jugular vein thrombus on warfarin presented with altered mental status. A month prior to presentation, he was evaluated for chronic diarrhea and colonoscopy at that time was grossly normal with normal mucosal biopsies. On admission, patient's labs were significant for leukocytosis with bandemia and INR of 5.1. The patient was started on broad spectrum anti-biotics. CT showed circumferential thickening of the whole colon, compatible with pancolitis. C. difficile GDH antigen was positive and he was started on metronidazole. Subsequently he developed melena with dark red clots, worsening mental status and sepsis. Hb dropped from 9 gm on admission to 3.6 gm. EGD was performed and showed serpiginous, bulging, erythematous lesions of varying size/shape throughout the entire stomach. The lesions were friable and oozing blood. Multiple biopsies were taken. Pathology showed mild chronic inflammation, negative for intestinal metaplasia or H. pylori, and no evidence of Kaposi's Sarcoma. Due to strong suspicion for KS and as the lesions were submucosal, repeat EGD with deeper biopsies was performed. The clinical case was discussed with pathology department and at this time biopsies revealed Kaposi's Sarcoma with small focus of abnormal endothelial lined spaces with atypical endothelial cells positive for HHV8, indicative of KS. Review of previous pathology specimens also revealed KS due to a strong suspicion. Discussion: Kaposi's Sarcoma is the most common tumor among HIV-infected individuals. The HIV induced damage of the mucosa associated immune system (decreased CD4 cells in lamina propria) leads to more opportunistic infections, and the development of malignant tumors. Although most cases of gastrointestinal KS are asymptomatic, advanced lesions may occasionally result in severe and life threatening hemorrhage. Due to tumor growth in the submucosa, biopsies are diagnostic in less than 25% of the time. In the setting of strong clinical suspicion for Kaposi's, this case illustrates that multiple biopsies and deeper biopsies may be needed to establish the diagnosis, as well as the importance of discussing the clinical suspicion of a lesion with the pathology team. Conclusion: KS should always be considered as a strong differential diagnosis in the lesions of the gastrointestinal tract in an immunocompromised host.

OC-142 Hemospray for non-variceal upper gastrointestinal bleeding: results of the seal dataset (survey to evaluate the application of hemospray in the luminal tract)

IntroductionHemospray is an endoscopic haemostatic agent licensed for use in non-variceal upper gastrointestinal bleeding (UGIB). It has been shown to be effective in achieving haemostasis in bleeding peptic ulcers in...

ACR Appropriateness Criteria® on Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is a significant cause of morbidity and mortality, affecting 36 to 48 per 100,000 persons annually. Aggressive resuscitation and upper endoscopy remain the cornerstones of therapy; however, in cases refractory to endoscopic diagnosis and management, radiology plays an increasingly vital and often lifesaving role, thanks to improvements in both imaging and interventional techniques. The various etiologies of upper gastrointestinal bleeding are discussed along with specific management recommendations based on an extensive literature review of current radiographic methods.

Potentially lethal enteric bleeding in the ED

Spontaneous or primary aortoduodenal fistula (PADF) is an uncommon etiology of upper gastrointestinal bleeding and may potentially cause sudden and unexpected death. Early diagnosis of this disease is difficult, and the mortality rate was reported near 100% when surgery is delayed. The emergency physician (EP) plays a major role in the early diagnosis of aortoduodenal fistula. A PADF should be included in the differential diagnosis when EPs treated emergency department patients with gastrointestinal bleeding, especially those in combination with known abdominal aortic aneurysm or palpable pulsating abdominal mass. Besides, abdominal computed tomography should be considered in patients with recurrent large amount of gastrointestinal bleeding without significant endoscopic findings. Prompt diagnosis and surgical intervention may preserve the life of these patients.

Gastrointestinal Tract Bleeding in Intellectually Disabled Adults

Gastrointestinal (GI) tract bleeding in intellectually disabled (ID) individuals presents peculiar diagnostic and management difficulties. This study details the experience of a tertiary referral teaching hospital in Central Saudi Arabia in the management of GI bleeding necessitating admission in ID adults. Prospective collection of data was taken on consecutive ID adults admitted for GI bleeding from January 2000 through December 2004. Demographic details, clinical presentation, diagnosis, associated physical and neurologic disabilities, etiology of bleeding and treatment outcome were analyzed. Thirty-nine ID adults accounted for 44 admissions during the period under review. Twenty-six (66.7%) patients were admitted with upper, and 13 (33.3%) for lower GI bleeding. Reflux esophagitis (57.7%) remained the most common cause of upper GI bleeding. Five out of 26 patients with upper and 6 of 13 with lower GI bleeding needed operative treatment. Various congenital anomalies or malformations were observed frequently associated with lower GI bleeding. Bleeding GERD remained the most common etiology of upper GI bleeding necessitating admission. Endoscopy is the mainstay in diagnosis and initial management of ID patients. Continued surveillance endoscopy is recommended for early diagnosis of Barrett changes. Bleeding from developmental malformations may have association with intellectual disability.

Management of acute upper gastrointestinal bleeding

Upper gastrointestinal bleeding in the pediatric population is a sign that warrants further investigation. Diagnostic evaluation should start with a thorough physical examination and medical history. Depending on the severity of bleeding resuscitative therapy is initiated and further diagnostic studies are performed. Etiology of upper gastrointestinal bleeding is broad and includes mucosal and vascular disorders. Endoscopy is an invaluable technique allowing for both diagnosis and specific therapy. Most commonly used endoscopic methods include coagulation therapy, injection therapy, and ligation techniques. These methods require state-of-the-art equipment and a considerable level of expertise to achieve best possible outcome of this potentially life-threatening condition.

Importância da hemorragia digestiva nos doentes com insuficiência renal crónica em hemodiálise.

Gastrointestinal Bleeding (GIB) is a complication in patients with Chronic Renal Failure (CRF) on regular hemodialysis (HD). To analyse the importance of GIB we studied, retrospectively, the causes of hospitalization in 301 patients, all on HD in the same Unit in January 1990. The average age was 57.4 +/- 14.2 years (17 to 87), time on HD 58.3 +/- 44.9 months, male = 166, female = 135. Of a total of 169 hospitalizations, the infectious disease were the most frequent cause with 37 admissions (21.9%), followed by gastrointestinal diseases with 34 admissions (21.1%). Of these, 23 (13.6%) were due to GIB (Upper GIB = 19, Lower GIB = 4). The etiologies of Upper GIB were: Peptic Ulcer = 9, erosive Gastritis/Duodenitis = 7. Angiodysplasia = 1, Mallory Weiss = 1 and unknown = 1. The etiologies of Lower GIB were: Angiodysplasia of the colon = 3, Cancer of the colon = 1. Non-steroid anti-inflammatory drugs (NSAID) had a positive correlation (p less than 0.01) with Upper GIB due to erosive Gastritis/Duodenitis. Surgery was necessary in a 8 cases of GIB, 7 of them due to Peptic Ulcer. GIB is an important cause of morbidity in patients with CRF on HD. Peptic Ulcer and erosive Gastritis/Duodenitis were the most frequent causes of GIB in the population studied. Angiodysplasia of the colon was the most important cause of Lower GIB. NSAID appear to be a risk factor for GIB from erosive Gastritis and or Duodenitis.

2 - Severe Upper Gastrointestinal Bleeding: Part I: Causes, Pathogenesis and Methods of Diagnosis

Upper gastrointestinal bleeding is a common gastrointestinal emergency associated with significant socioeconomic impact, morbidity and mortality. The aetiology of upper gastrointestinal bleeding has been reviewed, including the pathophysiological mechanisms of acid peptic and gastric mucosal disease. The initial diagnosis and therapeutic approach to the bleeding patient has been outlined.