Gastrointestinal Tract Bleeding Research Articles

Lower Gastrointestinal Bleeding

Bleeding from the lower part of the digestive system that appears as hematochezia (fresh blood, clot or cherry-coloured stool) or melena (dark-coloured tarry stool) is called lower gastrointestinal tract bleeding (lower GI bleeding) (or colonic bleeding). In the traditional definition, lower GI bleeding was generally classified as bleeding distal to the Treitz ligament (duodenojejunal junction) as the border. In the last decade, GI bleeding has adopted three categories in some recent publications: Upper, middle, and lower. According to this category, bleeding from a source between the Treitz ligament and the ileocecal valve is classified as middle GI bleeding, bleeding from the distal of the ileocecal valve is classified lower GI bleeding. Lower GI bleeding and hospitalization rates increase with ageing. Currently, physicians managing lower GI bleeding have many different diagnostics and therapeutic options ranging from colonoscopy and flexible sigmoidoscopy to radiographic interventions such as scintigraphy or angiography. Lower GI bleeding often stops spontaneously and less common than upper GI bleeding. Even though no modality has emerged as the gold standard in the treatment of lower GI bleeding, colonoscopy has several advantages and is generally considered as the preferred initial test in most of the cases.

Proton Pump Inhibitor Co-Therapy in Patients with Atrial Fibrillation Treated with Oral Anticoagulants and a Prior History of Upper Gastrointestinal Tract Bleeding.

The risk of gastrointestinal bleeding (GIB) can be mitigated by proton pump inhibitor (PPI) co-therapy in patients with atrial fibrillation (AF) treated with anticoagulants. We aimed to evaluate the effect of PPIs on the risk of GIB in Asian patients with AF, treated with oral anticoagulants (OACs), and with a prior history of upper GIB. Using a nationwide claims database, OAC-naïve patients with AF and a history of upper GIB before initiating OAC treatment between January 2010 and April 2018 were included. Patients were categorized into 10 groups according to the index OAC (warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban) and whether or not they received PPI co-therapy, and were followed up for incidence of major GIB. Among a total of 42,048 patients, 40% were prescribed PPIs as co-therapy with OACs. Over a median 0.6years (interquartile ranges 0.2-1.7years) of follow-up, rivaroxaban use without PPIs showed the highest crude incidence of major GIB (2.62 per 100 person-years), followed by the use of warfarin without a PPI (2.20 per 100 person-years). Compared to the patients without PPI use, PPI co-therapy was associated with a significantly lower risk of major GIB, by 40% and 36%, in the rivaroxaban and warfarin groups, respectively. In dabigatran, apixaban, and edoxaban users, PPI co-therapy did not show a significant reduction in the risk of major GIB. Among patients with AF receiving anticoagulant treatment and with a prior history of upper GIB, PPI co-therapy was associated with a significant reduction in the risk of major GIB in patients treated with rivaroxaban and warfarin.

Real-World Data on Characteristics and Management of Community Patients Receiving Anticoagulation Therapy Who Presented with Acute Bleeding to the Emergency Department at a Regional Australian Hospital: A Prospective Observational Study.

ObjectiveTo study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients’ characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management.MethodsA prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models.ResultsAmong the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition’s target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= −1.7, P=<.001), and with a shorter LoS (B= −4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy.ConclusionWarfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.

Duodenal angiodysplasia: a case report

BackgroundAngiodysplasia (AD) is an abnormal, ectatic dilated, tortuous blood vessel that is found in the mucosa and the submucosa of the gastro-intestinal tract (GIT). While colonic angiodysplasia is a recognized finding of the lower intestinal tract in the elderly, small intestinal angiodysplasia is rare. However, it is an important reason of GIT bleeding so its detection and proper management can be a challenge. It should be considered among the differential diagnosis in the scenario of mild or intermittent GIT bleedings of obscure cause.Case presentationA 71-year-old woman was presented to our emergency department with hypovolemic shock due to lower GIT bleeding, and she was suffering of melena and severe anemia. The revision of past medical history revealed a history of hypertension, diabetes mellitus, and chronic renal disease. After stabilization, she underwent abdominal computed tomography (CT) which revealed a small abnormal vascular lesion along the anterior and posterior wall of the 2nd part of the duodenum. It appeared as blush of contrast in the arterial phase (representing dilated mucosal capillaries draining into tortuous submucosal vein) suggestive of vascular lesion (duodenal angiodysplasia). The patient was transferred to undergo an angiogram which confirmed the diagnosis of duodenal angiodysplasia. Super selective cannulation of the feeding artery was performed followed by post coiling angiogram which revealed successful embolization. No acute complications were encountered during or immediately after procedure.ConclusionAD is a rare but important cause that should be considered in the differential diagnosis of GIT bleeding especially in the older patients. It should be looked for in CT angiography done in such a clinical situation. Superselective coil embolization is a safe and effective technique to manage bowel AD.

Bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients: a hospital-based study

BackgroundThe presence of bacteremia as a complication of variceal bleeding in patients with liver cirrhosis had been investigated by many studies. The aim of this study was to assess the bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients. A cross-sectional study was conducted on 99 patients with chronic liver disease divided into three groups: group I included 35 patients presented with first attack of variceal bleeding, group II included 35 patients presented with recurrent attacks of variceal bleeding, and group III included 29 patients with no history of previous variceal bleeding as a control group. Routine laboratory tests were done, upper GI endoscopy, blood culture, and measurement of procalcitonin level in blood.ResultsPatients with recurrent variceal bleeding had statistically (p < 0.05) the highest percentage of positive blood culture followed by patients with first variceal bleeding and the control (60% vs 45.7% vs 24.1%) respectively. In addition to procalcitonin results, patients with recurrent variceal bleeding had statistically the highest values of PCT followed by patients with first variceal bleeding and the control (1.92 vs 0.325 vs 0.22 ng/ml) respectively. Multivariate regression analysis showed that procalcitonin and hemoglobin only was the significant predictors for variceal bleeding. Hemoglobin at cutoff value of ≤ 9.6 and procalcitonin (ng/dl) at cutoff value of > 1.76 is the most specific in predicting bleeding 86.21%, 86.21% (CI 95%) respectively.ConclusionBacteremia and procalcitonin are risk factor for variceal bleeding in cirrhotic patients. Procalcitonin can be used as easily measurable and surrogate biomarker for bacteremia and variceal bleeding.

Retrospective evaluation of patients with non-varicose upper gastrointestinal bleeding

Upper gastrointestinal tract (GIS) bleeding refers to any bleeding originates from the area from upper esophagus to the proximal of the treitz ligament. It has a wide range of clinical manifestations ranging from hypovolemic shock to death. Bleeding from peptic ulcer (PU) is one of the major cause of upper GIS bleeding. Despite improvements in therapeutic endoscopy and angiography, gastrointestinal bleeding is still an important source of morbidity and mortality. Although approximately 80-85% of upper GIS bleeding stops spontaneously, supportive treatment is required. In this study, we aimed to determine the clinical, laboratory and demographic characteristics of patients with upper GIS bleeding and their relationship with major scoring systems. Two hundred thirteen patients over 18 years old that were admitted to Canakkale Onsekiz Mart University Training and Research Hospital between January 2016 and March 2020 with a diagnosis of non-variceal GIS bleeding were retrospectively enrolled to this study. Age, gender, blood group, comorbid conditions, endoscopic findings, laboratory values and medications were recorded for each patient. Prognostic scorings were calculated for each patient. The mean age of patients was 68.67±14.8 years (Male/Female: 156/57). In overall, 90.7% of patients were discharged and 7.5% of patients were transferred to intensive care unit. The mortality rate was 1.8%. Endoscopic evaluation revealed that 31.9% of patients had duodenal ulcer and 19.2% of patients had gastric ulcer. Medical treatment was applied to 84.8% of patients and 13.4% of patients received endoscopic treatments. Length of stay was significantly correlated with Rockall and Glasgow Blatchford scores. This study revealed that age, comorbid conditions and prior drug history were related to predisposition to GIS bleeding. Early diagnosis and intervention might reduce the mortality in these patients. Despite early endoscopic interventions and the improvements in endoscopic techniques GIS bleeding still associated with increased rates of morbidity and mortality.

The impact of COVID-19 pandemic on gastrointestinal diseases: a single-center cross-sectional study in central Greece.

BackgroundThe current COVID-19 pandemic induced a suppressive environment for healthcare professionals and patients, especially during the lockdown period. Except for the direct burden of the COVID-19, collateral damage has been identified concerning other diseases. The aim of this study was to evaluate the potential impact of the lockdown on the non-COVID-19 patients’ outcome in a tertiary gastroenterology department.MethodsPatients admitted to our department during the lockdown period (23 March- 4 May 2020) and during the respective previous year’s timeframe were recruited. Sex, age, comorbidities, presenting symptoms, final diagnosis, therapeutic management, duration of hospitalization, and outcome were evaluated. A direct comparison was performed to investigate the potential impact of the lockdown on the duration of hospitalization and the final outcome.ResultsA total of 161 patients were included to our analysis with 1:1 male:female ratio and mean age 70.86 years. Most of the cases experienced gastrointestinal tract bleeding, biliary stone disease manifestations, or gastrointestinal malignancy complications, and 85.1% were discharged. Fewer patients were hospitalized during the lockdown period (40%), whereas the duration of hospitalization was significantly longer (7.69±4.55 vs. 5.76±4.36 days). Binary logistic regression analysis and sensitivity analysis demonstrated that the quarantine was associated with increased prevalence of negative outcomes (odds ratio 5.21, 95% confidence interval 1.66-16.34; P=0.005), especially in cases with gastrointestinal malignancy and acute pancreatitis (P=0.045 and P=0.041, respectively).ConclusionThe increase in the negative outcomes of common gastrointestinal diseases and the duration of hospitalization during the lockdown raise reasonable concerns regarding healthcare policies against further outbreaks.

Unexpected Drop in Hemoglobin in a Patient After Undergoing Multiple Surgeries

A 71-year-old Black man presented to the emergency department with an upper gastrointestinal tract bleed. He presented with borderline shock prior to fluid resuscitation and transfusion of 4 units of packed red blood cells.

Re-audit of upper endoscopy in Assiut University Hospital

Background Audit is an attempt to improve the quality of medical care by measuring the performance in relation to desired standards, whereas re-audit demonstrates improvements that have been made. Patients and methods A prospective study was performed through a medical audit of 100 patients at the endoscopy unit of El-Rajhi Hospital University between January and December 2017. Revision of upper endoscopy, including indications, preparations, and complications, was done. Results The mean age was 59 years. The most frequent comorbidities were liver cirrhosis (70%) and diabetes mellitus (25%). All patients were indicated for endoscopy, as the majority (70%) of patients required urgent upper endoscopy secondary to upper gastrointestinal tract bleeding in contrast to the previous study as 4% of patients were not indicated. There was an increase in the percentage of complications in our study owing to the increased percentage of postband ulcers (92%) in comparison with the previous study (90%). Conclusion Improvement in our practice was noticed after recommendations of the previous audit regarding preparation and indications. It is important that a re-audit takes place following the implementation of changes.

The Congenital Absence of the Portal Vein

Congenital absence of the portal vein (CAPV) is a rare defect often accompanied by other abnormalities such as heart defect, skeletal anomalies and / or liver tumors [1]. We describe here a case of CAPV revealed by an upper gastrointestinal tract hemorrhage in a child aged 02 years and 8 months. The esogatro-duodenal fibroscopy revealed the presence of Esophageal varices grade II, abdominal ultrasound revealed a large liver with no visualization of the spleen. Subsequent abdominal computed tomography revealed the presence of a spleno-mesaraic trunk measuring 7 mm in anteroposterior diameter receiving the inferior and superior mesenteric vein and a small splenic vein draining by dilated peri-gastric and peri-esophageal leads. Associated with splenic hypoplasia and portal trunk atresia. The rest of the malformative assessment was negative

Tranexamic acid for upper gastrointestinal bleeding

Background. In patients with trauma and significant bleeding or risk of significant bleeding it is advised to administer tranexamic acid (TXA) intravenously as early as possible at a loading dose of 1 g for 10 minutes, followed by 1 g for 8 hours. The effectiveness of TXA has been proven in various pathological conditions in large trials. TXA has been shown to reduce the need for blood transfusions.&#x0D; Objective. To describe the use of TXA for upper gastrointestinal tract (GIT) bleeding.&#x0D; Materials and methods. Analysis of literature sources on this topic.&#x0D; Results and discussion. The mechanism of TXA action is to inhibit plasminogen activation and reduce fibrin degradation, however, its features are not clear. With the use of TXA, the strength of the blood clot and its resistance to lysis increases. The use of TXA in gastrointestinal bleeding was analyzed in the Cochrane Review (2012) of seven randomized controlled trials involving 1,654 patients. TXA was compared with placebo, lansoprazole or cimetidine. There was a lower mortality in the TXA group, however, after taking into account possible bias, this trend did not persist. A randomized placebo-controlled study of HALT-IT included 12,009 patients with gastrointestinal bleeding who were prescribed TXA (loading dose of 1+3 g for 24 hours) or placebo. The primary endpoint was death from bleeding within 5 days. There were no differences in mortality or re-bleeding. The TXA group had a higher frequency of deep vein thrombosis and pulmonary embolism. One of the reasons for the lack of benefits of TXA in gastrointestinal bleeding is that the onset of such bleeding is difficult to detect immediately, and to achieve the effect of TXA as early as possible administration is necessary. In this case, &gt;80 % of patients sought medical help &gt;3 hours after the onset of bleeding. In addition, in 50 % of patients, the bleeding was due to esophageal varices due to liver disease. It is known that most coagulation factors are synthesized in the liver, so liver failure is a common cause of coagulopathies. When the liver is affected, the levels of vitamin-K-dependent procoagulants (coagulation factors II, VII, IX and X), coagulation factor V, as well as anticoagulants (proteins C and S, antithrombin) decrease. Levels of fibrinogen and acute phase proteins remain normal or increase. In case of liver failure, hyperfibrinolysis occurs and at the same time the risk of thrombosis increases significantly. In such patients there is a decrease in hemostatic blood reserve. In general, contraindications to the use of TXA include severe renal failure, seizures, disseminated intravascular coagulation without bleeding, arterial or venous thromboembolism, active bleeding from the upper urinary tract.&#x0D; Conclusions. 1. TXA is effective for most types of bleedings, however, there are some exceptions. 2. One should remember the side effects of TXA and follow the recommended method of administration. 3. TXA is not suitable for the treatment of gastrointestinal bleeding.

S0533 Evaluating the Yield of EGD Performed as Clearance for TEE at Quaternary Referral Center and County Hospital

INTRODUCTION: Hoarseness, sore throat, odynophagia, and dysphagia are the most common complications following transesophageal echocardiography (TEE), but gastrointestinal (GI) tract perforation and bleeding have also been reported. Therefore, endoscopic evaluation prior to TEE is sometimes requested, particularly in those with history of GI disease and those with ongoing GI complaints. However, there are no published guidelines and very limited studies that offer insight on when an esophagogastroduodenoscopy (EGD) is needed before TEE. METHODS: This is a multi-site retrospective chart review of patients undergoing EGD prior to TEE. CPT codes were used to identify patients who underwent EGD prior to TEE from 10/1/2010 to 10/1/2019 at a quaternary referral center and a large urban county hospital. Medical records for patients ≥ 18 years of age were queried for demographic information along with the indications and findings from EGD and TEE. The presence of cirrhosis and its associated complications were documented along with MELD and Child-Pugh (CPT) score. The patients were classified based on whether the EGD was done as clearance for TEE and those who had diagnostic EGD within one year prior to TEE. RESULTS: In the year prior to the TEE, 26.6% of the EGDs done at the county hospital and 45.7% at the quaternary referral center were requested for clearance and Table 1 shows the differences in demographics and medical history between the two groups at each site. Patients requiring clearance EGD at the referral center, were more likely to be female with a history of cirrhosis, variceal bleed, and/or CPT score (P = 0.04, 0.0012, 0.0012, and 0.0013, respectively). This difference was not seen at the county hospital. The time lapse between EGD and TEE was shorter in the clearance group at both hospitals. Figure 1 shows the most common indications for EGD at each hospital which were not significantly different between groups (P = 0.134 and 0.23). None of the patients who underwent EGD clearance for TEE had endoscopic findings that precluded TEE.Table 1Figure 1CONCLUSION: EGD prior to TEE is more likely to be requested at a large referral hospital in patients with history of cirrhosis and variceal bleeding with an advanced CPT score. Due to the retrospective nature of this study, it is possible that we did not capture a small number of patients that underwent clearance EGD, but did not undergo TEE. Nonetheless, the results of this study do not show that EGD prior to TEE changes management.

Endoscopic management of early GI tract bleeding in a group of bariatric patients undergoing a fast track protocol.

IntroductionEnhanced recovery after bariatric surgery (ERABS) and other fast track protocols are currently being implemented in bariatric surgery. This approach has several benefits. However, early complications may occur and require urgent re-hospitalization and management. Gastrointestinal (GI) bleeding following bariatric surgery remains one of the most serious complications requiring endoscopic treatment.AimTo evaluate the potential influence of early endoscopic intervention on bariatric patients’ management.Material and methodsA clinical database was searched for patients undergoing endoscopic treatment because of GI tract bleeding following bariatric surgery under the ERABS protocol. 14 out of 1431 patients operated on were identified and their data were extracted for the purposes of this study. Patients readmitted to the hospital due to developing GI tract bleeding (group 2) were compared with patients undergoing endoscopic intervention during the initial stay (group 1), for the same purpose.ResultsWe found no statistically significant differences in hemoglobin level or length of hospital stay before endoscopy between groups. Based on the analyzed data, the percentage of GI bleeding in patients operated on under the ERABS protocol in our center is 0.97% (n = 14). The rate of early (up to 30 days) readmissions due to GI tract bleeding is 0.4% (n = 5) with an overall early readmission rate of 0.91% (n = 13) in the study period since the ERABS protocol was implemented.ConclusionsLong-term effects (% total weight loss, %TWL) of bariatric surgery do not depend on the need of early endoscopic intervention and rehospitalization. Endoscopic intervention is a safe treatment modality, not associated with risk of reoperation or complications.

Neuropatía óptica asociada con lesión de Dieulafoy

Objetivo: describir el caso de un paciente del Hospital de San José de Bogotá con hemorragia del tracto digestivo superior secundaria a lesión de Dieulafoy, que presentó cuadro compatible con neuropatía óptica anterior isquémica no arterítica (NOIANA). Se hace una revisión narrativa y búsqueda sistemática de la literatura para determinar las características clínicas, demográficas, tratamiento y pronóstico visual de los pacientes con NOIANA. Materiales y métodos: reporte de caso, revisión narrativa y búsqueda sistemática de la literatura en las bases de datos Medline (vía Ovid) y Embase de NOIANA secundaria a hipovolemia. Se analizaron las variables sociodemográficas, clínicas, diagnóstico, condiciones asociadas, tratamiento y pronóstico visual. El análisis estadístico se realizó mediante frecuencias absolutas y relativas. Resultados: la mejoría de agudeza visual final en los pacientes que presentaron un episodio de NOIANA es incierta. En 42% hubo algún tipo de mejoría de la agudeza visual, independiente del tratamiento recibido. Menos del 50% de los casos clínicos reportados incluidos en este estudio que recibieron tratamiento con corticoides intravenosos mejoraron la visión. Discusión: la NOIANA por choque hipovolémico es una entidad infrecuente y poco reportada que puede generar cambios irreversibles en la agudeza visual, por lo que es importante sospecharla y detectarla para dar un manejo oportuno. Este caso de NOIANA es uno de los pocos descritos como secundarios a hemorragia digestiva y el primero asociado con lesión de Dieulafoy.

The Impact of Novel Anticoagulants on the Upper Gastrointestinal Tract Mucosa.

Background and objectives: Although treatment with novel oral non-vitamin K antagonist 3anticoagulants (NOACs) is associated with an overall decrease in hemorrhagic complications compared to warfarin, the incidence of gastrointestinal bleeding remains contradictory. Materials and Methods: After the exclusion of patients with pre-existing pathological lesions in the upper gastrointestinal tract (GIT) on esophageal-gastroduodenoscopy (EGD) at entry, a cohort of 80 patients (mean age of 74.8 ± 2.0 years) was randomly divided into four equivalent groups, treated with dabigatran, rivaroxaban, apixaban, or warfarin. Patients were prospectively followed up for three months of treatment, with a focus on anamnestic and endoscopic signs of bleeding. In addition, bleeding risk factors were evaluated. Results: In none of the patients treated with warfarin or NOACs was any serious or clinically significant bleeding recorded within the follow-up period. The incidence of clinical bleeding and endoscopically detected bleeding in the upper GT after three months of treatment was not statistically different among groups (χ2 = 2.8458; p = 0.41608). The presence of Helicobacter pylori (HP) was a risk factor for upper GIT bleeding (p < 0.05), while the use of proton pump inhibitors (PPIs) was a protective factor (p = 0.206; Spearman’s correlation coefficient = 0.205). We did not record any post-biopsy continued bleeding. Conclusions: No significant GIT bleeding was found in any of the treatment groups, so we consider it beneficial to perform routine EGD before the initiation of any anticoagulant therapy in patients with an increased risk of upper GIT bleeding. Detection and eradication of HP as well as preventive PPI treatment may mitigate the occurrence of endoscopic bleeding. Endoscopic biopsy during the NOAC treatment is safe.

Left-Sided Portal Hypertension: A Case Series

Left-sided portal hypertension is rarely found, but this condition may cause gastrointestinal tract bleeding and can be life-threatening. The exact incidence of left-sided portal hypertension is unknown as it is rarely found, approximately 1-5%, and most cases were misdiagnosed. We reported 3 cases of left-sided portal hypertension in male patient aged 34 years old, female patient aged 29 years old, and female patient aged 35 years old. Most diagnosis was made based on the clinical findings by excluding the diagnosis of cirrhotic portal hypertension. Splenic vein angiography remains the gold standard in diagnosing left sided portal hypertension. Left-sided portal hypertension is difficult to differentiate from cirrhotic portal hypertension because in these both abnormalities, varices can be present. Left-sided portal hypertension can be considered as a diagnosis in patient with upper gastrointestinal tract bleeding due to oesophageal varices, gastric varices, or portal hypertension gastropathy, accompanied with hypersplenism without the presence of hepatic abnormality or cirrhosis.

Clinical profile and colonoscopic findings in patients with lower gastrointestinal haemorrhage: a descriptive cross-sectional study

Background: Most of the bleeding in the lower gastrointestinal tract are usually located in the rectum, colon and terminal ileum. Colonoscopy is an invasive procedure used for both diagnostic and therapeutic purposes for detection of lower gastrointestinal (GI) tract pathologies and haemorrhage.&#x0D; Aims and Objective: The purpose of the study was to understand the clinical profile and colonoscopic findings in patients with lower gastrointestinal haemorrhage.&#x0D; Materials and Methods: Seventy-two patients presenting with lower GI haemorrhage were included in the study. All patients underwent colonoscopy after achieving hemodynamic stability and bowel preparation. Clinical profile and colonoscopic findings were studied.&#x0D; Results: The common aetiologies of lower GI haemorrhage were haemorrhoids followed by nonspecific colitis, colorectal polyp and carcinoma of colon. Rectum followed by sigmoid harbored majority of pathologies that presented with lower GI haemorrhage.&#x0D; Conclusions: The diagnosis of the pathological lesion and management of underlying cause not only prevents another episode of lower GI haemorrhage but also help in reducing morbidity and mortality. Colonoscopy or at least sigmoidoscopy is strongly recommended for evaluation, diagnosis and management of lower GI haemorrhage.

Idiopathic Intrahepatic Artery Aneurysm Presenting as Acute Hemorrhagic Cholecystitis

Intrahepatic artery aneurysm or pseudoaneurysm is an unusual condition encountered clinically that accounts for a very small part of all visceral artery aneurysm cases. True incidence of primary or spontaneous intrahepatic artery aneurysm is difficult to be verified and has been rarely reported. For intrahepatic artery aneurysm/pseudoaneurysm, the diagnosis and management are challenging owing to the lower incidence and occult or various presentations. Due to the insidious course, patients with such aneurysms often have a higher risk of rupture, sometimes causing a catastrophic bleeding situation. Herein, we present a case of a 20-year-old woman with idiopathic left intrahepatic artery aneurysm with initial presentation mimicking acute hemorrhagic cholecystitis. Following laparoscopic cholecystectomy, intermittent upper gastrointestinal bleeding occurred. At the second radiologic study, left lateral-superior subsegmental hepatic artery aneurysm was detected. After endovascular treatment, the patient recovered without complications. To avoid delayed diagnosis, we suggest that hepatic artery aneurysm/pseudoaneurysm should always be considered when there is no usual cause of upper gastrointestinal tract bleeding.

Rivaroxaban versus warfarin in Chinese elder diabetic patients with non-valvular atrial fibrillation: A retrospective study on the effectiveness and associated risks (EAR) analysis

Purpose: To evaluate the effectiveness and associated risks of rivaroxaban against warfarin in Chinese elderly diabetic patients with non-valvular atrial fibrillation.Methods: Data regarding demographical characteristics, clinical conditions, ischemic stroke, intracranial bleeding, gastrointestinal tract bleeding, myocardial infractions, hip/pelvic fracture, asthma, breast/prostate cancer, and death during 3-years of treatment of 584 Chinese diabetic patients with confirmed non-valvular atrial fibrillation who were placed on rivaroxaban (RX Cohort, n = 201) or warfarin (WF Cohort, n = 383) were collected from hospital records and analyzed. Multivariate analysis was performed for the prediction of the incidence of the treatment-emergent event(s).Results: During the 3-year treatment period, higher numbers of patients were reported for intracranial bleeding (p = 0.042), ischemic stroke (p = 0.042), gastrointestinal bleeding (p = 0.0006), hip/pelvic fracture (p = 0.042), and asthma (p = 0.0007) in WF cohort than RX cohort. Also, higher mortality was reported in WF cohort than for RX cohort (24 vs. 4, p = 0.024). Female sex (p = 0.031), age (p = 0.035), and comorbidities (p = 0.021) were associated with incidence of treatment-emergent event(s).Conclusion: With rivaroxaban, a significant and safe risk-reduction of thromboembolic events are found in elderly diabetic patients with non-valvular atrial fibrillation.&#x0D; Keywords: Anticoagulant, Diabetes, Non-valvular atrial fibrillation, Rivaroxaban, Warfarin

Cápsula endoscópica para el diagnóstico de metástasis de melanoma en intestino delgado, reporte de dos casos y revisión de la literatura

Malignant melanoma is the neoplasm that most frequently produces metastasis at the gastrointestinal tract. Metastatic lesions can be found in the small bowel in 50 to 60% of the necropsies of patients who die due to malignant melanoma; however, the diagnosis of metastasis in vivo is achieved in less than 10% of patients with this clinical entity. The capsule endoscopy is considered an excellent non-invasive diagnostic method for the evaluation of the small bowel in this group of patients. All patients with melanoma history and gastrointestinal tract hemorrhage, iron deficiency anemia, abdominal pain and / or unexplained weight loss should perform an capsule endoscopy to rule out small bowel involvement. We present two patients with cutaneous melanoma with apparent remission who develop iron-deficiency anemia, without a history of evident gastrointestinal bleeding with negative endoscopic examinations and capsule endoscopy findings of intestinal metastasis due to melanoma.