Cessation Of Bleeding Research Articles

EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video)

Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.

Physico chemical characterisation of pectin incorporated gelatin sponge and its functional evaluation in modulating contact activation haemostasis.

Even though it is a common occurrence in practice, maintaining haemostasis can sometimes become a challenging issue in case of trauma, perioperative period, coagulation disorders, cancers, etc. Hemostatic materials are extensively used to assist in the cessation of bleeding. However, the definition of efficiency of haemostasis varies between intended procedures. This paper explores the feasibility of incorporating agents to increase the efficiency of local haemostasis. Pectin or β -D galacto hexopyranuronic acid/β Gal A, a structural polysaccharide widely present in terrestrial plants having an intrinsic hemostatic potential, is blended with gelatin and is explored in modulating passive haemostasis. The sponges are physico chemically characterized, and their hemostatic efficiency is evaluated in vitro using various assays. Biocompatibility evaluation is done by in vitro cytotoxicity assay. The results suggest that this biopolymer combination is a promising candidate for hemostatic control.

Outcomes of additional local antibiotic to local analgesic and vasodilator in acute anal fissure - A randomized controlled study

Acute anal fissure is a common and painful condition of ano-rectal region characterized by tear in the anoderm causing pain during defecation. Mainstay of its treatment is pharmacotherapy with lifestyle modification. Current study was undertaken to evaluate the role of add-on local antimicrobial in recovery and relief of symptoms of acute anal fissure in comparison to local anesthetic and vasodilator without any antimicrobial. It was a randomized, assessor-blinded, active-controlled clinical study in which data of 68 eligible participants were analyzed. Participants of both group received local lignocaine and nifedipine and the test group (Group B) received metronidazole ointment in addition. Healing was assessed by clinical examination and pain by Numeric Pain Rating Scale. Sample size was calculated based upon result of older pilot study and the proportion of recovery were assessed by Chi-square test. After 6 weeks of treatment, 61 out of 68 (i.e., 89.7%) patients receiving add-on antimicrobial recovered completely compared to 75% of the comparator group. Reduction of pain and cessation of bleeding were also significantly better in patients receiving additional antibacterial. Healing and symptom relief in acute anal fissure is better with addition of local antibacterial along with local vasodilator and anesthetic.

Occlusion of rectal arteries in the treatment of recurrent hemorrhoidal disease after transanal surgical interventions

The article presents data on variant X-ray anatomy of the superior rectal artery and types of arterial architectonics of the rectum. The causes of recurrent hemorrhoidal disease after traditional transanal surgical interventions are highlighted. The possibilities of endovascular occlusion of rectal arteries in the treatment of relapses of chronic hemorrhoids are shown. Its technical variants are given depending on the number of hemorrhoidal arteries and types of arterial architectonics of the rectum.Over a 2-year period, clinical results of endovascular occlusion of hemorrhoidal arteries were evaluated in 11 patients with relapse of the disease after various transanal interventions: after latex ligation of internal hemorrhoids – in 5, transanal desarterization of internal hemorrhoids with mucopexia – in 4, hemorrhoidectomy – in 2. The average age of patients was 44.2 ± 12.5 years. Men – 5, women – 6. Superselective occlusion of the target hemorrhoidal branches of the upper rectal artery was performed with EmboGold (Merit Medical) microparticles, 500–700/300–500 mkm in size. Immediate results: cessation of bleeding on the first day – in 4 patients, after 3 days – in 5, after 7 days – in 2. Terms of hospitalization – 1 day, disability – 4.3 ± 0.7 days. Long-term results (from 1 to 2 years) were observed in all 11 patients. The course is relapse-free.As an illustration, a clinical case is presented – successful treatment of a patient with recurrent hemorrhoidal disease by endovascular occlusion of hemorrhoidal arteries after five traditional transanal surgical interventions: sclerosing, ligation, dearterization of internal hemorrhoids, dearterization of internal hemorrhoids with mucopexia, removal of external hemorrhoids. Within 3 months after endovascular occlusion – complete regression of all symptoms of hemorrhoidal disease. According to the questionnaire (after 1 and 2 years) there is no relapse of the disease, the patient is subjectively satisfied with the endovascular treatment.

Distinct platelet F-actin patterns and traction forces on von Willebrand factor versus fibrinogen

Upon vascular injury, platelets form a hemostatic plug by binding to the subendothelium and to each other. Platelet-to-matrix binding is initially mediated by von Willebrand factor (VWF) and platelet-to-platelet binding is mediated mainly by fibrinogen and VWF. After binding, the actin cytoskeleton of a platelet drives its contraction, generating traction forces that are important to the cessation of bleeding. Our understanding of the relationship between adhesive environment, F-actin morphology, and traction forces is limited. Here, we examined F-actin morphology of platelets attached to surfaces coated with fibrinogen and VWF. We identified distinct F-actin patterns induced by these protein coatings and found that these patterns were identifiable into three classifications via machine learning: solid, nodular, and hollow. We observed that traction forces for platelets were significantly higher on VWF than on fibrinogen coatings and these forces varied by F-actin pattern. In addition, we analyzed the F-actin orientation in platelets and noted that their filaments were more circumferential when on fibrinogen coatings and having a hollow F-actin pattern, while they were more radial on VWF and having a solid F-actin pattern. Finally, we noted that subcellular localization of traction forces corresponded to protein coating and F-actin pattern: VWF-bound, solid platelets had higher forces at their central region while fibrinogen-bound, hollow platelets had higher forces at their periphery. These distinct F-actin patterns on fibrinogen and VWF and their differences in F-actin orientation, force magnitude, and force localization could have implications in hemostasis, thrombus architecture, and venous versus arterial thrombosis.

Use of four-factor prothrombin complex concentrate (4F-PCC) for management of bleeding not associated with therapeutic anticoagulant use

IntroductionFour-factor prothrombin complex concentrate (4F-PCC) may be an option for patients with bleeding unrelated to therapeutic anticoagulation to help with bleeding cessation and reduce blood component requirements. Materials and methodsRetrospective, observational study of adult patients who received 4F-PCC for bleeding not associated with therapeutic anticoagulation between June 2019 and July 2021. Primary outcome was to describe off-label 4F-PCC use in patients not on therapeutic anticoagulation for bleeding management in surgical and non-surgical patients. Additional outcomes evaluated were blood product use, chest tube and drainage output, and coagulation studies before and after 4F-PCC administration as well as other hemostatic agent use and thromboembolic events. ResultsSeventy-six patients were included; median age 64 years (IQR 50–69), 66% of bleeding events were associated with surgery, and the majority of 4F-PCC doses ordered by cardiac surgery (68.4%). A total of 110 4F-PCC doses were administered; median 1 dose/patient (IQR 1–2), median total dose 1000 units (IQR 500–1484). Other hemostatic agents commonly administered were protamine (59%), desmopressin (43%), and tranexamic acid (42%). Packed red blood cells, fresh frozen plasma, platelet, and cell saver blood administration and prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (aPTT) were significantly reduced following 4F-PCC administration. Eight patients (11%) experienced thromboembolic complications. ConclusionRelatively low doses of 4F-PCC (median total dose 1000 units) were associated with decreased blood component requirements and improved PT, INR, and aPTT values in patients with bleeding unrelated to therapeutic anticoagulation. Other hemostatic agent use was common and thromboembolic complications occurred.

Effectiveness of aortic valve replacement in Heyde syndrome: a meta-analysis.

Heyde syndrome is the co-occurrence of aortic stenosis, acquired von Willebrand syndrome, and gastrointestinal bleeding. Aortic valve replacement has been demonstrated to resolve all three associated disorders. A systematic review and meta-analysis were performed to obtain best estimates of the effect of aortic valve replacement on acquired von Willebrand syndrome and gastrointestinal bleeding. A literature search was performed to identify articles on Heyde syndrome and aortic valve replacement up to 25 October 2022. Primary outcomes were the proportion of patients with recovery of acquired von Willebrand syndrome within 24 h (T1), 24-72 h (T2), 3-21 days (T3), and 4 weeks to 2 years (T4) after aortic valve replacement and the proportion of patients with cessation of gastrointestinal bleeding. Pooled proportions and risk ratios were calculated using random-effects models. Thirty-three studies (32 observational studies and one randomized controlled trial) on acquired von Willebrand syndrome (n = 1054), and 11 observational studies on gastrointestinal bleeding (n = 300) were identified. One study reported on both associated disorders (n = 6). The pooled proportion of Heyde patients with acquired von Willebrand syndrome recovery was 86% (95% CI, 79%-91%) at T1, 90% (74%-96%) at T2, 92% (84%-96%) at T3, and 87% (67%-96%) at T4. The pooled proportion of Heyde patients with gastrointestinal bleeding cessation was 73% (62%-81%). Residual aortic valve disease was associated with lower recovery rates of acquired von Willebrand syndrome (RR 0.20; 0.05-0.72; P = 0.014) and gastrointestinal bleeding (RR 0.57; 0.40-0.81; P = 0.002). Aortic valve replacement is associated with rapid recovery of the bleeding diathesis in Heyde syndrome and gastrointestinal bleeding cessation. Residual valve disease compromises clinical benefits.

Minimally invasive methods of treatment of pulmonary bleeding

&#x0D; &#x0D; &#x0D; pulmonary bleeding is a life-threatening complication of many diseases, pathological con- ditions and respiratory injuries. In connection with the urgency of the problem of the occurrence of pul- monary bleeding, in recent years, new highly effective methods of diagnosis and treatment of this com- plication have been increasingly used in clinical practice. The main principles of treatment of pulmonary bleeding are prevention of asphyxia and immediate stopping of bleeding. The range of treatment tactics is quite wide: from conservative treatment, temporary cessation of pulmonary bleeding for a period suf- ficient to remove patients from a serious condition, diagnosis of the underlying disease and preparation&#x0D; &#x0D; &#x0D; &#x0D; for radical surgery, to emergency elimination of this complication. To date, there is no consensus on a single universal method of diagnosis and treatment of pulmonary hemorrhage, therefore, in order to improve the effectiveness of diagnosis and further treatment of this complication, a systematic approach is recommended, which involves combining several methods. Endoscopic methods cannot in all cases accurately determine the source of bleeding, so they are recommended to be combined with radiological studies, CT, angiography of bronchial arteries. With massive pulmonary bleeding, more importance is attached to surgical intervention, which includes endovascular catheter embolization of bronchial ar-teries. X-ray endovascular occlusion is a minimally invasive and highly effective method of stopping all types of bleeding from the bronchial artery pool, which can be used even in extremely critical patients. Minimally invasive methods: endoscopic and endovascular are leading in the diagnosis and treatment of respiratory diseases complicated by pulmonary bleeding. They allow not only to establish the very fact of pulmonary bleeding and its likely source, but also to implement the entire set of measures aimed at stopping bleeding. Despite the reliability and demand of minimally invasive methods, the question of using one or another method to stop pulmonary bleeding remains unclear, which requires further study of their effectiveness, reliability, and economic validity.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

Профилактика интраоперационного кровотечения из новообразованной сосудистой сети диска зрительного нерва в хирургии осложненных случаев пролиферативной диабетической ретинопатии

Proliferative diabetic retinopathy (PDR) is a major cause of vision loss in diabetic patients and is characterized by neovascularization particularly in optic nerve head (NVD). NVD may bleed spontaneously or be caused by minimal trauma. During vitrectomy, it is often difficult to stop this type of bleeding, thus surgeons are faced with such a problem as poor visualization and residual hemorrhage in the early postoperative period. Aim was to evaluate the clinical efficacy of the platelet-rich plasma (PRP) use in intraoperative bleeding from the NVD during the surgical treatment of PDR. Material and Methods. The group consists of 12 patients (12 eyes). Preoperative examination of all patients revealed the vitreous hemorrhage as well as the retinal traction detachment according to B-scan. A standard three-port vitrectomy (25 g) was performed, accompanied with the removal of proliferated blood vessels, diathermic coagulation, endolaser coagulation of the retina and an intravitreal injection of PRP on the NVD (PRP obtained by one-step closed centrifugation). Vitreal cavity was tamponaded with air. Results. We achieved an almost complete cessation of bleeding into vitreal cavity from NVD in all participants by using the intravitreal injection of the PRP. Conclusion. Intravitreal injection of PRP on the optic disc during vitrectomy is effective and safe. Keywords: proliferative diabetic retinopathy, PDR , neovascularization of the disc, vitreous hemorrhage, platelet-rich plasma, PRP, vitrectomy

Pediatric immune thrombocytopenia: a focus on eltrombopag as second-line therapy

ABSTRACTBackgroundImmune thrombocytopenia (ITP) is the most common acquired bleeding disorder. In both children and adults, the primary goal of any therapeutic approach consists of cessation of bleeding and its prevention. Several options are currently available for first-line therapy in Europe, including corticosteroids and intravenous immunoglobulin (IVIg) infusion, which has a similar efficacy and safety profile in both the pediatric and adult populations. When second-line therapy is needed in the pediatric setting, current guidelines recommend eltrombopag as the drug of choice.ProcedureThe aim of this article is to summarize the available evidence and present real-life experience on eltrombopag as second-line therapy in pediatric patients with ITP, with a focus on dosing and response to therapy as well as its tapering and discontinuation.ResultsIn our setting, eltrombopag is associated with good safety profile as well as promising efficacy; dose de-escalation was feasible in 94% of cases and often reached very low pro/kg dosage, with full discontinuation in 15% of cases. In daily practice, a standardized approach for discontinuation of eltrombopag in pediatric patients with ITP is still lacking. Herein, an easy-to-use scheme for tapering and discontinuation in candidate pediatric patients is proposed that proposes 25% dose reduction every four weeks.ConclusionsIn future management of pediatric ITP patients, it will be crucial to assess if thrombopoietin receptor agonists might be more effective in earlier phases of the disease and can modify the course of the disease.

Submucosal Injection Using Epinephrine-Added Saline in Cold Snare Polypectomy for Colorectal Polyps Shortens Time Required for Resection: A Randomized Controlled Study.

Immediate bleeding after cold snare polypectomy (CSP) for colorectal polyps might interfere with confirmation of residuals and prolong the time required for resection. We investigated whether submucosal epinephrine-added saline injection reduces the time required for the CSPprocedure. We conducted a single-center, prospective, randomized controlled trial (clinical trial registration number: UMIN000046770). Patients with colorectal polyps ≤ 10 mm were randomly allocated to either CSP with epinephrine-added submucosal injection (CEMR group) or conventional CSP (CSP group). The primary outcome was the time required for resection defined as the time from the initiation of resection (the first insertion of the snare in the CSP group or the injection needle in the CEMR group) to the end of resection (confirming complete resection endoscopically after recognizing the cessation of immediate bleeding) in each lesion, and the secondary outcome was the time to spontaneous cessation of immediate bleeding after resection defined as the time from ensnaring the lesion to confirming the spontaneous cessation of immediate bleeding. A total of 126 patients were randomly assigned. Finally, 261 lesions in 118 patients (CEMR group, n = 59; CSP group, n = 59) were analyzed. The time required for resection calculated using the least-square mean was significantly shorter in the CEMR group (106.3 s, 95% CI 97.5 to 115.4 s) than in the CSP group (130.9 s, 95% CI 121.2 to 140.7 s) (P < 0.001). The time to spontaneous cessation of immediate bleeding was also significantly shorter in the CEMR group (20.4 s, 95% CI 14.3 to 26.5 s) than in the CSP group (74.2 s, 95% CI 67.6 to 80.7 s) (P < 0.001). Neither group had cases requiringhemostasis, perforation, or delayed bleeding. CEMR shortened the time for resection by shortening the time to cessation of immediate bleeding compared with conventional CSP in colorectal polyps ≤ 10 mm.

A Rare Cause of Gastrointestinal Bleeding: Heyde Syndrome

Calcific aortic stenosis can be associated with gastrointestinal bleeding mainly from angiodysplasias which refer to Heyde syndrome. This association is considered as a form of acquiredVon Willebrand syndrome.Aortic valve replacement allows cessation of gastrointestinal bleeding and the need for blood transfusions in these patients. We describe three cases with medical history of aortic stenosisand they presented gastrointestinal bleeding related to angiodysplasias of the stomach and colon. In one case, aortic valve replacement leads to a stable hemoglobin with no further episodes of gastrointestinal bleeding.

Fluorescent microspheres can affect in vitro fibrinolytic outcomes.

Hemostasis is the cessation of bleeding due to the formation of a blood clot. After the completion of wound healing, the blood clot is typically dissolved through the natural process of fibrinolysis, the enzymatic digestion by plasmin of the fibrin fibers that make up its structural scaffold. In vitro studies of fibrinolysis reveal mechanisms regulating these processes and often employ fluorescent microscopy to observe protein colocalization and fibrin digestion. In this study, we investigate the effects of labeling a fibrin network with 20 nm diameter fluorescent beads (fluorospheres) for the purpose of studying fibrinolysis. We observed fibers and 2-D fibrin networks labeled with fluorospheres during fibrinolysis. We found that the labeling of fibrin with fluorospheres can alter fibrinolytic mechanisms. In previous work, we showed that, during lysis, fibrin fibers are cleaved into two segments at a single location. Herein we demonstrate that fibrinolysis can be altered by the concentration of fluorospheres used to label the fibers, with high concentrations of fluorospheres leading to very minimal cleaving. Furthermore, fibers that are left uncleaved after the addition of plasmin often elongate, losing their inherent tension throughout the imaging process. Elongation was especially prominent among fibers that had bundled together due to other cleavage events and was dependent on the concentration of fluorophores used to label fibers. Of the fibers that do cleave, the site at which they cleave also shows a predictable trend dependent on fluorosphere concentration; low concentrations heavily favor cleavage locations at either end of fibrin fiber and high concentrations show no disparity between the fiber ends and other locations along the fiber. After the initial cleavage event bead concentration also affects further digestion, as higher bead concentrations exhibited a larger population of fibers that did not digest further. The results described in this paper indicate that fluorescent labeling strategies can impact fibrinolysis results.

HARTAL (ARSENICTRISULPHIDE) A CONCEPTUAL STUDY

In Rasa Shastra Hartal has an important place. It is mentioned under group Uprasa by many Acharyas.1 Best Hartal is Gold like in appearance, reddish yellow colour and heavy weight. It is formed of many thin layers, which are one upon another2. Hartal is a poisonous substance in which Arsenic is present. Hartal is of two kind : A) that which is obtained in Mines. B) that which is prepared at laboratory by the combination of Arsenic and Sulphur. Chemically it is As2S3 and called Orpiment in Morden, which is very important indigenous source of Arsenic. Purified Hartal destroys effect of Vitiated Vata, kapha, Rakta and Visha. It is helpful in curing the skin abnormalities, infectious fever (Bhoot Jwara), Shwas, Kasa, Kushth, Vatarakta, Visarpa. Thus the Purified Hartal is considered as a Rasayana. The cessation of menstrual bleeding can be observed even by the use of Hartal as a single drug.2

A Retrospective Single-Arm Cohort Study in a Single Center of Radiofrequency Ablation in Treatment of Chronic Radiation Proctitis

Chronic radiation proctitis (CRP) may develop in patients within months to years after undergoing pelvic radiotherapy. Numerous treatment modalities are available to achieve hemostasis in CRP, but the optimal treatment remains controversial. We report our clinical experience and long-term outcomes using radiofrequency ablation (RFA) in patients with CRP. We retrospectively reviewed patients who underwent RFA for CRP at Kaohsiung Chang Gung Memorial Hospital between October 2015 and March 2021. The patient characteristics, endoscopic findings, and clinical outcomes were collected and analyzed. 35 total patients were enrolled in the study. The mean age was 70.5 ± 12.4 years. All patients sustained repeated rectal bleeding before RFA, and 15 of 35 patients needed blood transfusion. Bleeding cessation was achieved in all patients. Mean follow-up time was 18.6 months (ranging from 2 to 52 months). The hemoglobin (Hb) levels at 6 months after RFA revealed significant improvement from 11.0 ± 2.3 to 11.8 ± 1.9 g/dL (p = 0.048). The rectal telangiectasia density (RTD) scores also showed significant improvement from 2.96 ± 0.2 to 0.85 ± 0.7 (p < 0.0001). In conclusion, RFA treatment is safe and effective in controlling rectal bleeding in CRP without serious complications and can be considered as a first-line or alternative endoscopic treatment for patients with CRP.

The role of repeated imaging in detecting complications in the post-operative period following pancreaticoduodenectomy: Serial CT imaging post-pancreaticoduodenectomy.

Post-pancreaticoduodenectomy haemorrhage is a potentially life-threatening complication. Delay in the detection and subsequent management of complications contribute significantly to post-operative mortality and morbidity associated with pancreaticoduodenectomy. All patients undergoing pancreaticoduodenectomy at an Australian-based tertiary referral center between 2017 and 2022 were reviewed retrospectively. We identified those patients who suffered a post-pancreaticoduodenectomy haemorrhage and further analysed those patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeated CT imaging performed within 24 h of their previous CT scan. A total of 232 pancreaticoduodenectomies were identified for analysis during the study period, of which 23 patients (9.9%) suffered a post-pancreaticoduodenectomy haemorrhage. We present four patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeat CT scan in the setting of a recent (within 24 h) CT scan which showed no evidence of active haemorrhage or pseudoaneurysm formation. All patients received prompt and definitive endovascular management through stent insertion or coil embolization resulting in successful cessation of bleeding. Three patients made an uncomplicated recovery thereafter. Unfortunately, one patient died as a complication of the bleed despite early and definitive endovascular intervention. Our study highlights the importance of having a low threshold for repeated CT imaging in the post-pancreaticoduodenectomy setting, particularly when there remains a high index of suspicion clinically for a post-operative complication, even in the context of previous benign imaging. Given the complexity of pancreaticoduodenectomy, we believe early detection with liberal imaging allows the best chance at successfully managing the morbidity and mortality associated in the post-pancreaticoduodenectomy setting.

Pivotal Role of Management of Postpartum Haemorrhage by Using Intrauterine Pack during Caesarean Section

Background: Postpartum Haemorrhage (PPH) is a potentially life-threatening complication after delivery by both vaginal and caesarean section (CS). Different types of management options have been available in clinical settings including the use of oxytocin, prostaglandin analogues, ergometrine, surgical exploration of genital tract, ligation or angiographic embolization of uterine or internal iliac arteries and hysterectomy. Another simple and effective measure to manage PPH is to control the bleeding with intrauterine packing by mop during CS. This intrauterine packing during CS is very easy &amp; quick method to perform and it has pivotal role to save the patient need of major surgical procedures.&#x0D; Objective: To determine effectiveness of uterine packing by mop in control of post-partum hemorrhage, its safety and complications associated with it.&#x0D; Materials and Methods: This study was carried out in Obstetrics &amp; Gynaecology department of Eastern Medical College &amp; Hospital, Cumilla, Bangladesh from January 2020 to July 2020. It was a prospective interventional study. the patients presenting with postpartum haemorhage during CS due to atonic uterus. Patients who had PPH due to genital tract trauma were excluded from this study. Frequencies and proportions of complications were calculated along with rate of successful cessation of bleeding by the use of intrauterine mop. Data was analyzed by SPSS.&#x0D; Results: 100 patients included in the study. Among them 63% were 25-34 years, 26% were 15-24 years, 11% were 35-45 years. 73% patients were p &gt;3 and 27% were p 1-3. 77% patients belong to poor class family, 18% belong to middle class and 5% belong to high class family. These patients went through LUCS and had atonic uterus. Mop was used in those patients and successes rate were 87%. In 13% cases we needed others management. These were 11% case uterotonic drugs, 1% B-Lynch suture, 1% internal iliac artery ligation but none out of 100 patients underwent hysterectomy.&#x0D; Conclusion: Uterine packing by mop effectively controls PPH with fewer complications and its role in emergency obstetric scan not be denied.&#x0D; EMCJ. July 2022; 7(2): 1-5

P115 Trehalose modulates Dextran Sulfate Sodium-induced colitis by regulating macrophage polarization

Abstract Background Inflammatory bowel disease (IBD) is a collective term for chronic inflammatory diseases resulting from complex genetic susceptibility, microbial flora, and immune abnormality. Due to the complicated pathogenesis, therapies for IBD are largely limited to the treatment of symptoms. However, these existing drugs sometimes fail or lead to adverse effects in long-term therapies. The development of new drugs and new therapies for IBD are still the top priorities. Trehalose (TRE) is an autophagy inducer through an mTOR-independent pathway. Given its safe and protective nature, TRE has gained significant attention for the potential application in disease treatment. It is a natural product that may be used as a harmless autophagy regulator. In our research, we use the Dextran Sulfate Sodium (DSS)-induced IBD model to explore the therapeutic effects of trehalose on autophagy and inflammation in mice. Methods 6-8 weeks old C57BL/6J male mice were used for experiments. Mice were given 2% DSS (MP Biomedicals) in autoclaved drinking water for 4 days to induce colitis, Then TRE (2 g/kg body weight, Sigma-Aldrich), rapamycin (1.25mg/kg body weight, MedChemExpress) or normal saline were intraperitoneally injected for 5 days. Mice were weighed daily, and stool consistency, diarrhea, or blood in the stools were monitored to calculate the disease activity index (DAI). At the end of the experiment, the colons were measured, opened longitudinally, and handled according to standard procedures. The tissue samples were collected for RNA, protein extraction, histology, and macrophage isolation respectively. Western Blot was used for autophagy analysis and flow cytometry was used for macrophage subtype and apoptosis analysis. Besides, Real-time quantitative PCR assay was used for examining the cytokine expression. Results In TRE-treated mice, the cessation of diarrhea and anal bleeding occurred earlier and hence the DAI scores decreased more rapidly when compared to the other groups. Correspondingly, the colons in TRE-treated mice shortened less than the saline treated control suggesting recovery from DSS-induced colitis. Even though no significant difference was observed in H&amp;E staining and tissue scores for mice in different groups, significant difference in macrophage polarization and cytokine production was observed. DSS-induced intestinal CD86+ macrophages, whereas TRE treatment increased CD206+ macrophages and decreased the expression of pro-inflammatory cytokines, such as IL-6 and TNF-alpha. Conclusion Our results demonstrate that TRE decreases the symptoms of experimental colitis by regulating macrophage polarization, probably mediated by macrophage autophagy. These findings indicate the potential of TRE to be an adjuvant therapy for IBD.

Success Rate and Long-Term Effects of Embolization of Pelvic Arteries for the Treatment of Postpartum Hemorrhage

Introduction: Postpartum hemorrhage (PPH) is the leading cause of peripartal maternal mortality and accounts for 25% of all maternal deaths worldwide. The most common reasons of PPH are uterine atony, retained placenta, or placenta accreta spectrum. Treatment of PPH depends on the etiology and corresponds to a stepwise approach, which follows the German, Austrian and Swiss guideline for the diagnosis and therapy of PPH in Switzerland. In severe ongoing PPH, hysterectomy has been the ultima ratio for many decades. Nowadays, interventional embolization of the pelvic arteries (PAE) has become a popular alternative. Besides being a highly effective minimally invasive method, PAE avoids hysterectomy with consecutively reduced morbidity and mortality. However, data on the long-term effects of PAE on fertility and menstrual cycle are scarce. Methods: We performed a monocentric study consisting of a retro- and a prospective part including all women who had undergone a PAE between 2012 and 2016 at University Hospital Zurich. Descriptive characteristics of patients and efficacy of PAE defined as cessation of bleeding were analyzed retrospectively. In the prospective part, all patients were contacted for a follow-up questionnaire regarding menstruation and fertility after embolization. Results: Twenty patients with PAE were evaluated. Our data showed a success rate of PAE in 95% of patients with PPH; only 1 patient needed a second, then successful, PAE. No patient needed a hysterectomy or any other surgical intervention. In our study, an association between mode of delivery and identified etiology of PPH is observed. After spontaneous delivery (n = 6), the main reason of severe PPH was retained placenta (n = 4), while after cesarean section (n = 14), uterine atony was identified in most cases (n = 8). Regarding menstruation after embolization, all women reported regular menstruation after the breastfeeding period (100%). The majority reported a regular pattern with a shorter or similar duration (73%) and lower or similar intensity (64%). Dysmenorrhea decreased in 67% of patients. Four patients planned another pregnancy, of whom only one had become pregnant with assisted reproductive technology and ended up in a miscarriage. Discussion: Our study confirms the efficacy of PAE in PPH, thus obviating complex surgical interventions and associated morbidity. The success of PAE does not depend on the primary cause of PPH. Our results may encourage the prompt decision to perform PAE in the management of severe PPH in case of failure of conservative management and help physicians in the post-interventional counseling regarding menstruation patterns and fertility.