Cause Of Upper Gastrointestinal Bleeding Research Articles

Ruptured Gastroduodenal Artery Aneurysm Presenting As Upper Gastrointestinal Bleed

Gastroduodenal artery (GDA) aneurysm is a very rare condition out of all vascular aneurysms. It represents only 1.5% of reported splanchnic artery aneurysms.This is a case of a 37-year-old man who presented with upper gastrointestinal bleeding.oesophagogastroduodenoscopy revealed an ulcer at first part of duodenum.During intervention towards the ulcer, it was massively bleed and unable to be controlled by endoscopic mean. Emergency angiogram was done and suprisingly showed an aneurysm of the gastroduodenal artery which ran below the ulcer.It was successfully embolized and thebleeeding arrested.The discussion is directed towards detection of rare causes of upper gastrointestinal bleeding and the best modalities to treat this condition either by endoscopic mean , interventional radiology or surgery. Keyword : gastroduodenal artery aneurysm ; upper gastrointestinal bleeding I. Introduction Aneurysms of the splanchnic arteries are rare with splenic artery aneurysm being the most common location (10.4%), while gastroduodenal artery (GDA) aneurysm represents only 1.5% of of more than 3000 reported splanchnic artery aneurysms reported since 1960's. 1,2 Most of the GDA aneurysms described in the literature are pseudoaneurysms associated with pancreatitis. 3 Rupture of GDA aneurysm is usually a dramatic manifestation of hemorrhagic shock associated with high mortality. 4 We present a case of a GDA aneurysm rupture that was diagnosed incidentally during endovascular intervention for a patient with upper GI bleed.

Varices of the Descending Duodenum Explored During Emergency Gastro-Duodenal Resection for Upper Gastrointestinal Haemorrhage. Case Report

Upper gastrointestinal haemorrhage is a major medical emergency and accounts for approximately 7,000 admissions to hospitals in Scotland each year. Over the last 10 years there has been a number of improvements in diagnosis and conservative management of the condition, which significantly reduced the ratio of life-threatening cases requiring an emergency surgery. Despite these achievements surgical intervention or, if accessible, endovascular procedures must be undertaken as emergency actions, should conservative management fail. Vascular malformations of the duodenum are less frequent causes of upper GI bleeding. Duodenal varices found endoscopically occur in 0.4% of patients with portal hypertension (PHT) and are believed to be caused mainly by liver cirrhosis, idiopathic PHT, extrahepatic PHT, or previous surgical trauma. The duodenal bulb is their most common site, followed by the second portion of the duodenum. Forty per cent of patients with PHT have duodenal varices at angiography; however, their penetration unusually affects submucosa, hence no symptoms develop. Isolated bleeding duodenal varices are scarcely reported in literature, although present a significant surgical problem: massive haemorrhage combined with failure to identify them as a source has led to catastrophic outcomes with mortality rate of 40%. The case hereby presented is unique in several aspects. Duodenal varices were explored on emergency laparotomy rather than on prior endoscopies, which, performed by the same well-established endoscopists, were twice negative. This corresponds to the study by Cottam et al. stating that duodenal varices may not penetrate the submucosa, hence haemorrhages of their origin may even be more difficult to diagnose on endocsopy. Secondly, the haemorrhage here reported was undoubtedly a life-threatening condition that required a multidisciplinary team to be managed successfully. Along with Shirashi et al. we confirm that surgical ligation followed by the excision of duodenal / small intestinal varices may be an effective method of their management--both cases have been free of recurrence at 15 months postoperatively. In contrast to the study by Hashizume et al. the duodenal varices here presented were not associated with portal hypertension (PTH). Finally, duodenal varices located in the posterolateral aspect of the descending duodenum are less common as the majority of cases reported so far were of duodenal bulb location.

Hemobilia Secondary to Transjugular Intrahepatic Portosystemic Shunt Procedure: A Case Report.

A 59 year-old woman with liver cirrhosis due to hepatitis C, complicated by refractory hepatic hydrothorax was treated with a TIPS (transjugular intrahepatic portosystemic shunt) procedure. The procedure was complicated by substantial gastrointestinal hemorrhage. EGD (esophagogastroduodenoscopy) was performed and revealed hemobilia. A hepatic angiogram was then performed revealing a fistulous tract between a branch of the hepatic artery and biliary tree. Bleeding was successfully stopped by embolization of the bleeding branch of the right hepatic artery. Hemobilia is a rare cause of upper gastrointestinal bleeding with an increasing incidence due to the widespread use of invasive hepatobiliary procedures. Hemobilia is an especially uncommon complication of TIPS procedures. We recommend that in cases of hemobilia after TIPS placement, a physician should immediately evaluate the bleeding to exclude an arterio-biliary fistula.

Upper Gastrointestinal Bleeding In Children

BACKGROUND:Gastrointestinal bleeding (GIB) in infants and children is one of the more alarming conditions encountered in pediatrics. It is nonetheless an anxiety-provoking complaint. Most etiologies are self-limited and benign.AIM OF STUDY:To review the causes of upper gastrointestinal bleeding and its clinical presentations in children and evaluate the role of endoscopy for diagnostic and therapeutic purposes.PATIENTS AND METHOD:Fifty eight patients from 4 days old up to the age of 18 years who referred with upper gastrointestinal bleeding to the Gastro intestinal&Hepatology unit in the Children Welfare Teaching Hospital/ Medical City/Baghdad, in the period from 1st of April 2010 to 1st of November 2010.RESULTS: there were 58 patients (34 males and 24 females) with male to female ratio (1.4:1), 58.5% presented with hematemesis, 5.2% had melena and 31.1% had both, 5.2% of patients presented with hematochezia . The most common causes of upper GI bleeding among all patients were esophageal varices (39%), gastric erosions (19.6%), duodenal ulcer (7.4%), gastric ulcer (9.7%), (4.9%) for Mallory Weiss syndrome and also (4.9%) for oesophagitis. The causes of bleeding could not be ascertained in (30%) of cases. (15.3%) of patients, there was a history of consumption of medications predisposing them to upper GI bleeding. Fifteen patients (25.8 %) had comorbid disease. There were three deaths (5.1%) in this study.CONCLUSION: oesophagealvarices were the common cause of upper GI bleeding. Most patients presented with hematemesis. In children with upper GI bleeding, upper GI endoscopy provides an accurate diagnostic tool and also provides therapeutic intervention when needed

Non-Small Cell Lung Cancer Liver Metastases Causing Upper Gastrointestinal Bleed Secondary to Gastric Invasion

Case Description: A 69-year-old male with history of metastatic non-small cell lung cancer (NSCLC) and pulmonary embolism, on enoxaparin, presented with a 2 day history of melenic stools, dizziness and dyspnea. The patient denied a prior history of gastrointestinal (GI) bleed or NSAID use. Objective findings were notable for a hematocrit of 23 and hypotension requiring multiple blood transfusions. A computed tomography scan of the abdomen revealed a large metastatic hepatic lesion filling the left lobe and invading the anterior gastric wall. The patient then underwent upper endoscopy which revealed a friable mass with oozing not amendable to intervention. The patient underwent angiography with successful embolization of the left gastric artery. Also, during the procedure an IVC filter was placed as it was felt that re-instituting enoxaparin therapy would not be safe. Serial hematocrits post procedure remained stable, and the patient was discharged two days post procedure. Discussion: This case illustrates a rare cause of upper GI bleeding and its associated management barriers. There are previously reported cases of GI bleeds secondary duodenal invasion by liver metastases of uterine leiomyosarcoma as well as duodenal invasion from hepatocellular carcinoma. To our knowledge, this is the first reported case of GI bleed secondary to gastric invasion by liver metastases of NSCLC. This case also demonstrates successful management with arterial embolization. Palliative chemotherapy has been shown to improve life expectancy for patients with NSCLC and with longer life expectancy, there is increased risk for complications from the disease such as we present here. For this reason, direct invasion of the GI tract should always be on the differential, in similar patient populations, so that appropriate management tactics are swiftly initiated.Figure: No Caption available.

Trichobezoar: An Uncommon Cause of Upper GI Bleeding

Purpose: Case Report: A 21-year-old female presents with abdominal pain. The pain occurred daily for approximately one year and was rated as a 6 out of 10 in the left upper quadrant. The patient then developed coffee ground emesis and melena. Relevant history includes acute pancreatitis three years prior. Physical exam demonstrated normal vital signs and epigastric tenderness. Hemoglobin dropped from 13.4 to 8.4 g/dL. The patient was referred for an upper GI endoscopy. Upper GI endoscopy showed a massive trichobezoar extending from the fundus to the antrum. At the distal aspect, the bezoar had caused ulceration. The trichobezoar had a diameter greater than the esophagus, thus surgical extraction was recommended. The surgery was performed using the single incision laparoscopic surgery (SILS) technique. The total weight of the trichobezoar was 550 grams. The patient made an uneventful recovery from the surgery and was referred to psychiatric care for treatment of trichophagia. Discussion: Bezoars are masses or accumulations of material that fail to exit the stomach. Creation of a bezoar requires continuous consumption of the composing material. Trichobezoars (tricho= hair) are found in women under 20 years of age in 80-90% of cases. Trichobezoar is normally associated with trichophagia (the compulsion to consume hair) and trichotillomania (the compulsion to systematically pluck out one's hair). Patients rarely self report hair consumption, however there are findings which may arouse suspicion. Patches of alopecia and absence of eye brows/eye lashes, can be seen, but most lack these findings. Trichobezoars accumulate bacteria and have a particularly foul smell, which may lead to halitosis. The process takes place over several years, and is theorized to begin when hair is trapped in the gastric folds and continues to accumulate the ingested hair. Most patients have a benign presentation of poorly localized abdominal pain. It is uncommon to see hair in the stool or emesis. Peptic ulcer disease due to pressure necrosis may occur with trichobezoar in up to 25% of patients and may result in gastric perforation. The definitive diagnosis of trichobezoar is made with upper GI endoscopy. On endoscopy, the color of the hair will always be black, regardless of the hair color of the patient. Rarely the hair extends past the pyloris into the duodenum, a condition known as Rapunzel Syndrome. If the trichobezoar is small, it may be removed endoscopically, however, surgery is most often indicated. While trichobezoar is an uncommon cause of upper GI bleeding, it can be a common presentation of this condition. Follow-up with psychiatric evaluation is necessary to prevent recurrence.

Hemobilia Due to Cystic Artery Stump Pseudoaneurysm Following Laparoscopic Cholecystectomy: Case Presentation and Literature Review

Hemobilia is the process of bleeding into the biliary tree and is an unusual cause of upper gastrointestinal hemorrhage. When this event results from a cystic artery pseudoaneurysm, it is a particularly rare phenomenon; fewer than 20 cases are described in the literature. Alongside the literature review, we report a case of a 34-year-old woman presenting 3 months post laparoscopic cholecystectomy with hematemesis. Computed tomography (CT) angiography revealed a cystic artery pseudoaneurysm. Following an ineffective hyperselective arterial embolization, the patient was successfully treated by surgical ligation of the right hepatic artery. Even though this complication is uncommon, all surgeons need to be aware of its presentation and of available therapeutic options.

Hemosuccus pancreaticus treated with gastroduodenopancreatectomy: a case report and review of literature

Introduction: Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding and usually occurs as a complication of chronic or acute pancreatitis. Its recognition requires a high clinical suspicious, and sometimes the complementary exams are only suggestive but not definitive for diagnosis. The treatment strategy depends on the cause of the hemosuccus pancreaticus. Case Report: We report a patient with chronic pancreatitis that presented acute abdominal pain and acute upper gastrointestinal bleeding. An upper digestive endoscopy showed an active bleeding from the major duodenal papillae, leading the diagnosing of hemosuccus pancreaticus. An abdominal Angio-CT scan identified a gastroduodenal artery aneurism, followed with embolization of this aneurism. Due to recurrence of bleeding, the patient was submitted to a gastroduodenopancreatectomy, as a rescue measure after embolization failure. Conclusion: The diagnosis for hemosuccus pancreaticus requires a high clinical suspicious, once the visualization of an active bleeding during an upper digestive endoscopy occurs in the minority of cases. Angioembolization is the initial therapy in many cases, but sometimes surgical procedures are mandatory for a definitive treatment.

An Unusual Cause of Recurrent Massive Upper Gastrointestinal Bleeding

Question: A 50-year-old man presented with acute onset of massive hematemesis and a transient loss of consciousness. He denied acid reflux, or abdominal pain or distension. His past history revealed bleeding duodenal ulcer diagnosed by endoscopy 1 year ago. Although treated with esomeprazole continuously, he suffered from recurrent hematemesis 4 times during the last year. Physical examination showed unstable vital signs with hypotension (92/70 mmHg) and tachycardia (heart rate, 106 bpm). The patient was treated conservatively with fluid infusion and esomeprazole. After 2 episodes of melena, there were no signs of massive rebleeding. Gastroscopy was performed and blood-like fluid effusion in the duodenal bulb was detected (Figure A). After washing with normal saline, a deep ulcer-like lesion with a diameter about 0.2 cm was revealed on noninflamed duodenal mucosa (Figure B). Both cross-sectional (Figure C) and coronal (Figure D) imaging of contrast-enhanced computed tomography (CT) showed a large hematoma between the duodenal bulb and pancreas in the artery phase. What is the most likely cause of upper GI bleeding in this patient? Look on page 872 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT angiography revealed that splenic artery coursed a pseudoaneurysm (Figure E, F). The splenic artery pseudoaneurysm (SAPA) was further disclosed by volume rendering reformatted coronal (Figure G) and left oblique sagittal images (Figure H). The patient underwent splenectomy and gastrojejunal Roux-en-Y anastomosis. Surgical findings showed a SAPA–duodenal bulb fistula that was temporarily embolized by thrombus. Postoperatively, the patient recovered uneventfully and was discharged on day 18 after admission. Gastrointestinal bleeding from SAPA is unusual but potentially lethal.1Pasha S.F. Gloviczki P. Stanson A.W. et al.Splanchnic artery aneurysms.Mayo Clin Proc. 2007; 82: 472-479Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar To date, only about 160 cases of SAPA have been reported.2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar Causes of SAPA include pancreatitis (52%), trauma (29%), iatrogenic and postoperative causes (3%), and rarely peptic ulcer (gastric ulcer; 2%).2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar To the best of our knowledge, duodenal ulcer erosion of a SAPA has yet to be reported. SAPA rupture is life threatening. A common site of hemorrhage is the pancreatic duct, with some into peritoneal cavity, stomach, or even into colon.2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 3Sweetser S.R. Wong Kee Song L.M. An unusual cause of hematochezia.Gastroenterology. 2009; 137: 1895Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, SAPA fistulizing to duodenal bulb is extremely rare, which makes accurate diagnosis difficult. In the present case, the unusual patient history and endoscopic findings preclude pharmaceutical and endoscopic approach for diagnosis and hemostasis. In this situation, imaging techniques, especially CT angiography and 3-dimensional rendering, are beneficial for survey of the bleeding vessels. Surgical intervention or endovascular therapy is recommended to repair the bleeding pseudoaneurysm. Jun Wang and Bin Wang contributed equally to this work.

Effects of early oral feeding on relapse and symptoms of upper gastrointestinal bleeding in peptic ulcer disease

Peptic ulcer is the most common cause of upper gastrointestinal bleeding (GIB) and nutritional support is a helpful strategy in malnutrition prevention during treatment. As early oral feeding in patients with GIB may shorten hospital stay and decrease costs and risk of infection, the present study was carried out to investigate the effects of early oral feeding on relapse and symptoms of upper GIB. The present clinical trial was conducted with the participation of 100 patients with upper GIB due to gastric or duodenum ulcer at Emam Reza University Hospital in Tabriz. Subjects were randomly allocated to two groups (n=50). In one group, patients received oral diet from day 1 and in other group patients were nil by mouth until day 3 and then received oral diet. Endoscopic and clinical findings of patients were recorded from day 1 to 3. The mean age of subjects was 57.6±1.7 and 63% were male. Sclerotherapy was used in most cases as a hemostasis treatment. There was no significant difference in laboratory findings and rebleeding between the two groups. In the group with early oral feeding, the time of hospital stay was significantly shorter than in the control group (P<0.001). Although early oral feeding had no significant effects on electrolyte balance and treatment outcomes in patients with upper GIB who were treated with endoscopic hemostasis, it could effectively shorten the hospital stay. Consequently, early oral feeding in these patients enables early discharge and reduces the costs of treatment.

A Fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in northwestern Tanzania: A retrospective review of 240 cases

BackgroundUpper gastrointestinal (GI) bleeding is recognized as a common and potentially life-threatening abdominal emergency that needs a prompt assessment and aggressive emergency treatment. A retrospective study was undertaken at Bugando Medical Centre in northwestern Tanzania between March 2010 and September 2011 to describe our own experiences with fibreoptic upper GI endoscopy in the management of patients with upper gastrointestinal bleeding in our setting and compare our results with those from other centers in the world.FindingsA total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients. Diagnostic accuracy was greater within the first 24 h of the bleeding onset, and in the presence of haematemesis. Oesophageal varices were the most frequent cause of upper GI bleeding (51.3%) followed by peptic ulcers in 25.0% of cases. The majority of patients (60.8%) were treated conservatively. Endoscopic and surgical treatments were performed in 30.8% and 5.8% of cases respectively. 140 (58.3%) patients received blood transfusion. The median length of hospitalization was 8 days and it was significantly longer in patients who underwent surgical treatment and those with higher Rockall scores (P < 0.001). Rebleeding was reported in 3.3% of the patients. The overall mortality rate of 11.7% was significantly higher in patients with variceal bleeding, shock, hepatic decompensation, HIV infection, comorbidities, malignancy, age > 60 years and in patients with higher Rockall scores and those who underwent surgery (P < 0.001).ConclusionOesophageal varices are the commonest cause of upper gastrointestinal bleeding in our environment and it is associated with high morbidity and mortality. The diagnostic accuracy of fibreoptic endoscopy was related to the time interval between the onset of bleeding and endoscopy. Therefore, it is recommended that early endoscopy should be performed within 24 h of the onset of bleeding.

Non-variceal Gastrointestinal Bleeding in Patients with Liver Cirrhosis: A Review

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. To review NVGI bleeding in cirrhosis. MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis." Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting. The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

Dieulafoy Lesion of the Esophagus Causing Massive Upper Gastrointestinal Bleeding and Death

Dieulafoy lesion is a rare cause of upper gastrointestinal bleeding. We present a case report of sudden and unexpected death in a previously healthy male where autopsy revealed a classic Dieulafoy lesion with a submucosal artery protruding through a small mucosal defect in the esophagus, thereby exposing it to stress and consequent rupture. Advances in endoscopic techniques have drastically reduced mortality from Dieulafoy lesion. Nevertheless, it is an important diagnosis to be kept in mind when autopsy reveals an upper gastrointestinal bleeding.

Urgent endoscopy in elderly patients with non-variceal upper gastrointestinal bleeding.

IntroductionAge of the patient is an important prognostic factor in patients with non-variceal upper gastrointestinal bleeding (UGIB). Despite that fact, current treatment algorithms do not differentiate UGIB management according to the patient's age.AimTo compare treatment outcomes in patients below and above 75 years of age, treated for UGIB with urgent endoscopy.Material and methodsProspective analysis of treatment outcomes in 295 patients with non-variceal UGIB divided into two age groups (group A < 75 years of age, group B > 75 years of age). Urgent endoscopy (up to 3 h since admission) was performed in 292 patients. The groups were compared in regards to the duration of symptoms, previous UGIB, presence of factors predisposing to UGIB (NSAIDs, peptic ulcer disease, liver cirrhosis, and previous gastrointestinal surgery), haemodynamic state and haemoglobin (Hb) levels on admission. We analysed the causes of UGIB, severity of UGIB on the Forrest scale, type of endoscopic bleeding control method, and co-morbidities with use of the Charlson Co-morbidity Index (CCI). Treatment outcomes were assessed in regard of mortality rate, UGIB-recurrence rate, duration of hospital stay, amount of transfused blood products and the requirement of intensive therapy unit (ITU) or other departments’ admissions. Patients were followed until their discharge home.ResultsMortality rate was 6.8% (group A vs. B: 3.5% vs. 18.7%; p = 0.001). Upper gastrointestinal bleeding recurrence was noted in 12.2% of patients (group A vs. B: 12.5% vs. 10.9%; p = 0.73). 2.4% of patients required surgery for UGIB (group A vs. B: 1.7% vs. 4.7%; p = 0.16). Patients in group B required ITU admission more frequently (group A vs. B: 1% vs. 4.7%; p < 0.01). The mean hospital stay (4.3 days) and the mean number of transfused packed red blood cells (PRBCs) (2.35 Units) did not differ between the groups. Patients in group B used NSAIDS much more frequently, more often had hypovolaemic shock and had a higher CCI score.ConclusionsUrgent endoscopy is an important and broadly accepted method of treatment of UGIB. Despite strict adherence to the modern UGIB-treatment algorithms, mortality remains high in the elderly. Thus, these patients need particular attention. The presented study indicates that the standard management might not be sufficient in elderly patients.

Managing antiretrovirals in co-infected patients in 2012

In patients with HIV and hepatitis B or C co-infection initiation of early HAART therapy is clearly recommended by the international guidelines reflecting the overall survival benefit with regard not only to HIV but also clinical endpoints of liver disease in the co-infected patient population. In patients with hepatitis C co-infection administration of successful HAART is associated with less inflammation in liver biopsies and hence, over time less fibrosis generation. Obviously, drugs which are dually active against HIV and HBV do not only prevent HIV disease progression, but also decrease the progression of chronic hepatitis B related liver disease. Nevertheless, recent reports on the emergence of non cirrhotic portal hypertension as a rare cause of upper gastrointestinal bleeding in HIV patients most likely following prolonged didanosin exposure have raised questions with regard to potential drug toxicity as sequelae of HAART causing possible damage to the liver and the portal vascular system. Under consideration of metabolic changes including dislipidemia and insulin resistance caused by various components of different drug classes the question also remains in how far risk for fatty liver disease may rise after decades of HAART administration. Therefore, close surveillance programs and monitoring are required to answer the long term safety questions around HAART administration and liver safety. Nevertheless, the clear demonstration of overall increased survival under HAART in patients with concomitant hepatitis and HIV clearly underlines that the benefits of HAART outweighs potential toxicity risks. Also with the knowledge obtained around mitochondrial toxicity observed under D-nucleoside therapy treatment algorithms for co-infected patients now specifically refrain from using these drugs in particular. With the advent of new drug classes with low hepatotoxicity profiles new combinations arise which potentially improved liver safety profile over time. But again, long term data will be needed to eventually decide what are the best HIV treatment options in patients with concomitant liver disease.

CHRONIC LIVER DISEASE (CLD);

Objective: To determine the frequency of chronic liver disease in patients presenting with upper gastrointestinal bleeding(UGIB) at Nishtar Hospital, Multan. Study Design: Descriptive case series. Duration of study: Six months from August 2009 to January 2010.Setting: Department of Internal Medicine, Nishtar Hospital Multan. Methodology: A total of 88 patients with upper GI bleed were registered.Prior permission was taken from Institutional Ethical Committee to conduct this study. Informed consent was taken from each patient. Upper GIEndoscopy was done to find out the source of bleeding. For identification of each patient, personal data was collected. All the data collectedwere entered and analyzed using SPSS-10. Results: Mean age was 41.64±13.56 years with 49 (55.70%) male patients and 39 (44.30%)female patients. Majority of the patients 38(43.18%) were between 36-50 years of age. In our series frequency of chronic liver disease was56.82%. Conclusions: Chronic liver disease is the most common cause of upper GI bleeding in our setting.

Upper gastrointestinal bleeding in children: an 11-year retrospective endoscopic investigation

Upper gastrointestinal bleeding (UGIB) may present as hematemesis, coffee-ground emesis, or melena requiring esophagogastroduodenoscopy (EGD) for diagnosis and/or therapy. Worldwide, differences exist for the etiology of UGIB reflecting geographical differences in common disease states. In the past 25 years, there have been improvements in endoscopic optics. This study was undertaken to determine: 1) if identifying a bleeding source in UGIB have improved with better endoscopic optics, 2) geographic differences in causes of UGIB, 3) differences in severity of UGIB based on clinical factors, and 4) the likelihood of finding a bleeding source based on symptom duration and time to endoscopy. A retrospective chart review was made on children having EGD for evaluation of UGIB. Data collected included type, etiology, and degree of bleeding. Of 2569 diagnostic procedures, 167 (6.5%) were performed for UGIB. The most common presentation was hematemesis (73.4%). Melena was associated with lower hemoglobin levels and higher transfusion rates. A source of UGIB was found in 57.0%, no cause in 11.4% and a questionable cause in 29.7%. A source was found less commonly in children with a history of UGIB less than one month and in those undergoing endoscopy over 48 hours after a bleeding episode. Improved endoscopic optics has not changed diagnostic ability for UGIB. Etiologic differences for UGIB in children from varying geographic areas are related to indication for endoscopy, patient selection, and co-morbid conditions. Duration of bleeding and time to endoscopy after a bleeding episode may help predict when endoscopy should be performed to determine a bleeding source.

Mo1245 Clinical Outcomes and Complications of Histoacryl Injection for Gastric Variceal Hemorrhage; What are the Determining Factors?

Gastric variceal hemorrhage is an uncommon cause of upper gastrointestinal bleeding, mostly related to portal hypertension, however it associates with very high mortality and morbidity. Histoacryl injection had been reported to be effective haemostatic method, but it has several drawbacks due to complications. Up to the present, there was limited data regarding of the factors determining the clinical outcomes and complications.

Adherent Clot at the Esophagogastric Junction

Mallory-Weiss syndrome is one of the causes of upper gastrointestinal bleeding and in most of the cases bleeding stops spontaneously and requires no intervention. However, in some patients bleeding does not stop and may require therapeutic intervention in order to control active bleeding. Herein, we report a case of Mallory-Weiss syndrome with adherent clot whose bleeding was controlled with injection sclerotherapy. doi:10.4021/jmc506e

Portal vein thrombosis in children and adolescents: 20 years experience of a pediatric hepatology reference center

Portal vein thrombosis refers to a total or partial obstruction of the blood flow in this vein due to a thrombus formation. It is an important cause of portal hypertension in the pediatric age group with high morbidity rates due to its main complication - the upper gastrointestinal bleeding. To describe a group of patients with portal vein thrombosis without associated hepatic disease of the Pediatric Hepatology Clinic of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil with emphasis on diagnosis, presentation form and clinical complications, and the treatment of portal hypertension. This is a descriptive study of a series of children and adolescents cases assisted from January 1990 to December 2010. The portal vein thrombosis diagnosis was established by ultrasound. Of the 55 studied patients, 30 (54.5%) were male. In 29 patients (52.7%), none of the risk factors for portal vein thrombosis was observed. The predominant form of presentation was the upper gastrointestinal bleeding (52.7%). In 20 patients (36.4%), the initial manifestation was splenomegaly. During the whole following period of the study, 39 patients (70.9%) showed at least one episode of upper gastrointestinal bleeding. The mean age of patients in the first episode was 4.6 ± 3.4 years old. The endoscopic procedure carried out in the urgency or electively for search of esophageal varices showed its presence in 84.9% of the evaluated patients. The prophylactic endoscopic treatment was performed with endoscopic band ligation of varices in 31.3% of patients. Only one died due to refractory bleeding. The portal vein thrombosis is one of the most important causes of upper gastrointestinal bleeding in children. In all non febrile children with splenomegaly and/or hematemesis and without hepatomegaly and with normal hepatic function tests, it should be suspect of portal vein thrombosis. Thus, an appropriate diagnostic and treatment approach is desirable in an attempt to reduce morbidity and mortality.