Cause Of Blood Loss Research Articles

The Usefulness of Double-Balloon Enteroscopy in Patients with Gastrointestinal Bleeding of Obscure Origin

Background and Aim: Wireless capsule endoscopy permits examination of the entire small intestine, but it is limited in cases of gastrointestinal bleeding and lacks tissue sampling and therapeutic capabilities. Yamamoto et al. established a new double-balloon insertion method, which allows endoscopic scrutiny and intervention throughout the entire small bowel. The aim of this study was to evaluate the efficacy of double-balloon enteroscopy in patients with gastrointestinal bleeding of obscure origin. Methods: Between August 1, 2003, and July 31, 2004, 31 consecutive patients (18 males, 13 females; mean age 56.4 ± 3.2 years, range 9-80 years) with gastrointestinal bleeding of obscure origin were enrolled in this study, gave informed consent, and underwent double-balloon endoscopy for the following indications: (1) documented iron deficiency anemia (baseline hemoglobin □…10 g/dl or decrease in hemoglobin of ±2 g/dl over 2 or more months); (2) no site/cause of blood loss detected by upper endoscopy; (3) no site/cause of blood loss detected by lower endoscopy with examination of the terminal ileum. When a site/cause of blood loss was detected, biopsy specimens were obtained, and treatment was performed endoscopically as necessary. Results: No patient suffered procedure-related complications. Bleeding points were identified in 23 patients (74.2%). Twenty-one patients (91.3%) treated for an identified cause of blood loss showed no further bleeding during 8.5 ± 0.6 months of follow-up. Conclusions: Double-balloon enteroscopy is safe, easily performed, and permits observation and treatment of small bowel diseases. This method will allow detailed examination of the small bowel for diagnostic and therapeutic purposes without surgical laparotomy. Background and Aim: Wireless capsule endoscopy permits examination of the entire small intestine, but it is limited in cases of gastrointestinal bleeding and lacks tissue sampling and therapeutic capabilities. Yamamoto et al. established a new double-balloon insertion method, which allows endoscopic scrutiny and intervention throughout the entire small bowel. The aim of this study was to evaluate the efficacy of double-balloon enteroscopy in patients with gastrointestinal bleeding of obscure origin. Methods: Between August 1, 2003, and July 31, 2004, 31 consecutive patients (18 males, 13 females; mean age 56.4 ± 3.2 years, range 9-80 years) with gastrointestinal bleeding of obscure origin were enrolled in this study, gave informed consent, and underwent double-balloon endoscopy for the following indications: (1) documented iron deficiency anemia (baseline hemoglobin □…10 g/dl or decrease in hemoglobin of ±2 g/dl over 2 or more months); (2) no site/cause of blood loss detected by upper endoscopy; (3) no site/cause of blood loss detected by lower endoscopy with examination of the terminal ileum. When a site/cause of blood loss was detected, biopsy specimens were obtained, and treatment was performed endoscopically as necessary. Results: No patient suffered procedure-related complications. Bleeding points were identified in 23 patients (74.2%). Twenty-one patients (91.3%) treated for an identified cause of blood loss showed no further bleeding during 8.5 ± 0.6 months of follow-up. Conclusions: Double-balloon enteroscopy is safe, easily performed, and permits observation and treatment of small bowel diseases. This method will allow detailed examination of the small bowel for diagnostic and therapeutic purposes without surgical laparotomy.

A RETROSPECTIVE REVIEW OF CAPSULE ENTEROSCOPY AT ONE TERTIARY CARE INSTITUTION

Purpose: Capsule Enteroscopy (CE) is increasingly being utilized to diagnostically evaluate the small bowel but its efficacy is not completely well established. Methods: We reviewed the records of 100 patients who underwent CE and studied various parameters including demographics, indications, previous investigations, findings, recommendations, and complications. Results: Our patient population was 51% male and 49% female. The average age was 61 years (17–91). The weight range was 50–140 kg. Elevated BMI did not hinder any CE performance. The indications for the procedure were overt bleeding (47%), iron deficiency anemia with or without guaiac positive stool (41%), IBD (3%), and suspected small bowel tumor (9%). Investigations prior to CE included EGD (92%), colonoscopy (99%), push enteroscopy (41%), and SBFT (49%). Overall 85% of the CE's had an adequate preparation to allow necessary interpretation. The average gastric emptying time was 33 minutes and the average small bowel transit time was 221 minutes. There were 40 normal and 60 abnormal studies. After CE, 51% were suggested to have further endoscopic evaluation (76% were enteroscopies −8% of which were intraoperative). Of the 60 abnormal studies 42 revealed AVMs (6 actively bleeding and 36 non-bleeding), 11 polyps/tumors, 3 ulcers and 2 strictures. 67% of the patients with AVMs did not have prior endoscopy revealing AVMs. These AVM's were found in 49% of patients with overt bleeding, 41% with IDA and 17% incidentally in the remaining indications. 55% of studies done to evaluate for tumors/polyps were positive, while 2 were found in work-up of IDA. 80% of SBFT done prior to CE were reported as normal. Of these, 51% had abnormal findings on CE the most common of which are AVMs and polyps. 87% of the studies reached the cecum upon termination of the capsule's battery. Of the remaining 13 studies 69% had delayed transit. Laparotomy confirmed 2 small bowel masses (although the capsules passed spontaneously). Previously non-detected strictures resulted in 2 capsule impactions. One capsule was endoscopically retrieved, while the other required laparotomy. No patients had any acute obstructive symptoms. Conclusions: This study provides useful information regarding safety and utility of CE. In our population, 60% of patients were found to have some abnormality on capsule. Angiodysplasias were the most common cause of blood loss found. Our complication rate was 2%, but with no acute obstructions. In our experience, CE is more clinically useful than SBFT in evaluating the small bowel.

Review article: The advent of capsule endoscopy--a not-so-futuristic approach to obscure gastrointestinal bleeding.

Capsule endoscopy is a new, wireless, endoscopic examination of the small intestine. To date, two small clinical trials have been reported utilizing capsule endoscopy in patients with obscure gastrointestinal bleeding, and have shown its superiority to push enteroscopy in diagnosing the cause of blood loss. No outcome studies have been reported. This paper proposes a change in practice guidelines for obscure bleeding. It is our opinion that, in the future, with the advent of wireless capsule endoscopy, the evaluation of patients with obscure gastrointestinal bleeding will be very different from the practice of medicine today. We believe that capsule endoscopy will become the first-line method for the evaluation of patients with obscure bleeding, once upper endoscopy and colonoscopy have been shown to be negative. In patients with active bleeding, capsule endoscopy will confirm the small bowel as the site of bleeding, providing a location, or, if the study is negative for the small intestine, may indicate that the bleeding is either colonic or gastric in origin. In a patient with active bleeding within the small intestine, the capsule will guide further evaluation and therapy. A patient with a small bowel tumour detected by capsule endoscopy will proceed directly to laparoscopic surgery. If the site of bleeding is identified in the proximal small bowel and there is no mass, push enteroscopy will be used to re-identify the site and cauterize it. A distal small bowel site will require surgical intervention, coupled with intra-operative enteroscopy. Should the patient be too sick to undergo surgery, medical therapy utilizing hormonal agents will be considered. A colonic site will be evaluated by colonoscopy. In patients with a more occult or intermittent type of bleeding and in those whose upper endoscopies and colonoscopies are negative, capsule endoscopy will be used similarly to identify a bleeding lesion and thereby direct subsequent testing or treatment.

Screening for iron deficiency.

1. Ann Chen Wu, MD* 2. Leann Lesperance, MD, PhD* 3. Henry Bernstein, DO*† 1. *Pediatric Health Associates, Hunnewell Ground Children’s Hospital 2. †Associate Professor of Pediatrics, Harvard Medical School, Boston, MA After completing this article, readers should be able to: 1. Determine the most common cause of iron deficiency in the United States. 2. Describe the pathogenesis of iron deficiency. 3. List populations at high risk for iron deficiency. 4. Outline the common signs and symptoms of iron deficiency. 5. Specify the American Academy of Pediatrics recommendations for screening for iron deficiency. In the March and April issues of Pediatrics in Review, we published a two-part article on managing anemia in a pediatric office practice. This article expands on the various tests for iron deficiency, including some relatively new ones. These articles should be read as complementary.—RJH Iron deficiency is the most common nutritional deficiency in the world, responsible for a staggering amount of ill health, lost productivity, and premature death. Although its prevalence in the United States has declined since the late 1960s, iron deficiency with or without anemia still is seen frequently in infants, toddlers, adolescent females, and women of childbearing age. In fact, iron deficiency anemia remains the most common hematologic disease of infants and children. Anemia is defined as a low hemoglobin (Hgb) concentration or red blood cell (RBC) mass compared with age-specific norms. Anemia may be caused by decreased RBC production, increased RBC destruction, or blood loss. Based on the size of the RBC, hematologists categorize anemia as macrocytic, normocytic, or microcytic. Iron is found in different compartments within the body. Total body iron (measured by ferritin), transport iron (measured by transferrin saturation), serum iron, and other hematologic and biochemical markers are used to describe the degrees of iron deficiency. Iron depletion refers to the earliest stage of diminishing iron stores in the setting of insufficient iron supply. Iron deficiency (without anemia) develops as these iron stores are depleted further and begin to impair Hgb synthesis. Finally, iron deficiency anemia results …

Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms

Background The standard evaluation of a patient with iron deficiency anemia includes a complete evaluation of the gastrointestinal tract to identify a source of bleeding. However, even after a careful examination, many patients remain without a diagnosis. Because iron deficiency anemia results from iron loss or defective absorption, we sought to determine the prevalence of potential gastrointestinal sources for iron deficiency anemia in patients without gastrointestinal symptoms. Methods Over a 10-month period, 668 outpatients were referred to the University Hematology Department with iron deficiency anemia, defined by a hemoglobin concentration less than 14 g/dL (less than 12 g/dL in women), mean corpuscular volume less than 80 fL, and ferritin level less than 30 μg/L. After excluding patients with obvious causes of blood loss, inadequate diet, chronic diseases, or malignancies, there were 81 eligible patients, 10 of whom refused investigation. The remaining 71 patients (51 women, median age 59 years) underwent colonoscopy, as well as gastroscopy with gastric (antrum and body) and duodenal biopsies. Results A likely cause of iron deficiency anemia was detected in 60 patients (85%). Diseases associated with bleeding were found in 26 patients (37%), including colon cancer (10 patients), gastric cancer (2), peptic ulcer (7), hiatal hernia with linear erosions (5), colonic vascular ectasia (3), colonic polyps (2), and Crohn’s disease (1). Causes not associated with bleeding were found in 36 patients (51%), including 19 with atrophic gastritis, 4 with celiac disease, and 13 with Helicobacter pylori gastritis. Six (8%) patients had coincident gastrointestinal findings, and 11 (15%) had no cause identified. Patients with an identified nonbleeding-associated cause were younger than those with a bleeding-associated cause (median, 56 vs 70 years; P = 0.001) and included 59% of women (n = 30) versus 30% of men (n = 6) ( P = 0.04). Hemoglobin level was not related to the site and severity of disease. Conclusion Gastrointestinal diseases that do not usually cause bleeding are frequently associated with iron deficiency anemia in patients without gastrointestinal symptom or other potential causes of gastrointestinal bleeding.

The outcome of esophagogastroduodenoscopy (EGD) in asymptomatic outpatients with iron deficiency anemia after a negative colonoscopy

Background: Both iron deficiency and iron deficiency anemia require extensive investigation because of their possible association with gastrointestinal malignancy. If no other sources of blood loss are apparent, the gastrointestinal tract is examined to detect sources of occult blood loss. In the absence of gastrointestinal symptoms, the colon is first examined, especially in the elderly. The aim of this study was to determine the outcome of esophagogastroduodenoscopy (EGD) after a prior negative colonoscopy in outpatients without gastrointestinal complaints, referred due to iron deficiency anemia. Methods: Thirty-five patients (22 female and 13 male) with a median age of 71 years were studied over a 2-year period. Anemia was defined as a hemoglobin (Hb) level below 7.4 mmol/l in women or below 8.0 mmol/l in men and iron deficiency if one of the following was present: ferritin level equal to or below 20 μg/l for men and equal to or below 10 μg/l for women, a serum iron concentration equal to or below 45 μg/dl (8.1 μmol/l) with a transferrin saturation of 10% or less, or the absence of iron stores in bone marrow biopsy specimens. Patients with prior gastrointestinal disease or surgery, gastrointestinal symptoms, or other obvious causes of blood loss were excluded. Lesions that were considered to be potential sources of blood loss were clearly defined. Results: The mean Hb level of the 35 patients studied was 5.5 mmol/l (range 1.8–7.8 mmol/l). Abnormalities were found in 10 patients (28.6%), all of which were benign. Erosive and ulcerative lesions in the stomach, in a hiatal hernia, or in the esophagus were diagnosed in eight patients, benign villous adenoma was seen in one patient, and celiac disease in another, although duodenal biopsies were taken in only 15 patients. Erosions and/or ulcerations were found in four of 11 patients (36%) using NSAIDs and/or salicylates (ASA). Seventy percent of the lesions were found in elderly patients (>65 years), 56% of whom were using NSAIDs and/or ASA. Conclusions: EGD should always be performed in patients with iron deficiency anemia after a negative colonoscopy, although upper gastrointestinal malignancy will probably be an infrequent finding. The presence of a significant, treatable lesion is most likely in the elderly and in those with a history of NSAID or ASA use. Routine duodenal biopsies should be performed to further increase the outcome of EGD.

Iron deficiency in children: detection and prevention.

Iron deficiency in children: detection and prevention.

Cohort study of relation between donating blood and risk of myocardial infarction in 2682 men in eastern finland

Mild iron deficiency has been hypothesised to reduce risk of heart disease risk,1 while a high concentration of body iron has been suggested as a risk factor for myocardial infarction.1...

Gastric antral vascular ectasia

A case of gastric antral vascular ectasia confined to the antrum in an elderly Japanese male patient is described. The condition is a cause of blood loss and chronic iron deficiency anemia, particularly in the elderly. The clinical, endoscopic, and pathologic findings, which were contrasted with other hyperplastic or gastric vascular abnormalities, are described.

Idiopathic pulmonary hemorrhage in pregnancy. Report of a case suggesting early pulmonary hemosiderosis with clinical recovery after steroid therapy.

THE following is a report of a young, seven-month-pregnant woman who was gravely ill with cough, breathlessness, cyanosis, bilateral pulmonary infiltration on x-ray study and a hemoglobin of only 4.8 gm. per 100 ml. Because of the characteristic clinical picture and the absence of any other cause of blood loss, the diagnosis of idiopathic pulmonary hemorrhage or of so-called idiopathic pulmonary hemosiderosis was tentatively made, and appropriate treatment was instituted. Of particular interest is the fact that complete remission rapidly followed the use of steroids in this critically ill patient. A biopsy of the lung was obtained on the tenth . . .