Chronic Recurrent Bleeding Research Articles

Endoscopic research methods for morphofunctional changes in the small intestine

Purpose: to analyze the results of diagnosis and treatment of tumors of the small intestine, which served as a source of small bowel bleeding. Materials and methods: 35 patients were analyzed: men - 19 (59.4%), women - 16 (41.6%) aged 19 to 85 years, with tumors and tumor-like lesions of the jejunum and ileum. The main indication for examination of the small intestine in these patients was the search for a source of bleeding that was not identified by standard diagnostic methods (esophagogastroduodenoscopy and colonoscopy). After analyzing the clinical picture in 5 examined patients with identified tumors of the small intestine, 3 (15.5%) clinical symptoms were manifested by obvious intestinal bleeding characterized by melena or hematochezia, and in 2 (10.5%) patients the course was latent. Conclusion: After analyzing the results of the diagnosis of small intestine tumors complicated by bleeding in young and middle-aged patients, the survey data demonstrate the importance of enteroscopy techniques in patients with iron deficiency anemia and chronic recurrent bleeding

Randomized, double-blind, placebo-controlled, crossover trial of oral doxycycline for epistaxis in hereditary hemorrhagic telangiectasia

BackgroundVascular malformations in hereditary hemorrhagic telangiectasia (HHT) lead to chronic recurrent bleeding, hemorrhage, stroke, heart failure, and liver disease. There is great interest in identifying novel therapies for epistaxis in HHT given its associated morbidity and impact on quality of life. We aimed to measure the effectiveness of oral doxycycline for the treatment of epistaxis and explore mechanisms of action on angiogenic, inflammatory and pathway markers in HHT using a randomized controlled trial.Methods13 HHT patients with epistaxis were recruited from the Toronto HHT Center at St. Michael’s Hospital. Recruitment was stopped early due to COVID-19-related limitations. The study duration was 24 months. Patients were randomly assigned to the treatment-first or placebo-first study arm. We compared the change in weekly epistaxis duration and frequency, biomarkers, blood measurements, and intravenous iron infusion and blood transfusion requirements between treatment and placebo.ResultsThere was no significant difference in the change in weekly epistaxis duration (p = 0.136) or frequency (p = 0.261) between treatment and placebo. There was no significant difference in the levels of MMP-9, VEGF, ANG-2, IL-6 or ENG with treatment. Hemoglobin levels were significantly higher (p = 0.0499) during treatment. Ferritin levels were not significantly different between treatment and placebo. There was no significant difference in RBC transfusions between treatment periods (p = 0.299).ConclusionOverall, our study did not demonstrate effectiveness of doxycycline as a treatment for epistaxis in patients with HHT, though the study was underpowered. Secondary analyses provided new observations which may help guide future trials in HHT.Trial Registration ClinicalTrials.gov, NCT03397004. Registered 11 January 2018 – Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03397004

Gastrointestinal Bleeding due to Arteriovenous Malformation of the Intestine

A 75-year-old woman presented with a 6-month history of bloody stool. She had no documented medical history and showed no signs of gastrointestinal disease. Laboratory tests and abdominal computed tomography were unremarkable. Double-balloon enteroscopy was performed after an initial negative esophagogastroduodenoscopy and colonoscopy. A double-balloon enteroscopy view showed oozing of blood from a miniscule point source on the jejunum mucosa (Figure A). Endoscopic treatment was ineffective because bleeding remained unchanged. Therefore, an exploratory laparotomy was performed which detected the localization of bleeding point from the mucosa marked by double-balloon enteroscopy (Figure B). The patient then underwent jejunal local excision and the bleeding point was completely removed (Figure C). Histologic examination of the bleeding jejunum mucosa confirmed irregularly expanded arteries and veins which were aggregated in the submucosal layer with a missing intervening capillary network (Figure D). There was no evidence of abnormal proliferation of the vascular endothelial cells. And based on these findings, the patient received a diagnosis of arteriovenous malformation. Finally, the patient recovered postoperatively. Arteriovenous malformation arises during embryogenesis which is relevant to hormones and hereditary susceptibility.1 Arteriovenous malformation rarely affects the gastrointestinal tract, but the small intestine and right hemicolon are the most common sites for gastrointestinal arteriovenous malformation.2,3 Most patients with suspected arteriovenous malformation present with sudden onset of middle intestinal or chronic recurrent bleeding. Infrequent symptoms of arteriovenous malformation include both anemia and tenesmus. It may be challenging to differentiate arteriovenous malformation from hemangioma with a high rate of misdiagnosis.4,5 Vascular anomalies are divided into hemangioma and vascular malformation according to histopathology and hydrodynamics. The presence of abnormal proliferation of vascular endothelial cells is the specific characteristic of arteriovenous malformation. Surgical resection remains the mainstay of arteriovenous malformation treatment because of ineffective pharmacologic options for treating arteriovenous malformation and a high recurrence rate of arterial embolization. Here we present a rare case of a terminal jejunal arteriovenous malformation in an aged woman whose first manifestation was active bleeding. Our report also highlights that this etiology should be considered when oozing of blood from a miniscule point source on the jejunum mucosa is visualized without mucosal lesions although arteriovenous malformation may be difficult to confirm without histopathology.

Technique and emerging role of cryotherapy

Cryotherapy is a novel endoscopic method of ablating abnormal gastrointestinal (GI) mucosa with cryogens originating from either liquid nitrogen or carbon dioxide gas. The ablation is performed by passing a catheter through the accessory channel of an endoscope and the cryogen is sprayed onto the target tissue in a noncontact manner. Cell death is induced by producing extracellular ice. Recently, several reports have been published on the efficacy of cryotherapy for clinical use in the GI tract. In Barrett's esophagus, reports describe that cryotherapy was effective to eradicate or downgrade Barrett's associated dysplasia. Cryotherapy has also been reported to be useful for palliation of squamous cell carcinoma. Chronic recurrent bleeding from watermelon stomach (gastric antral vascular ectasia [GAVE]) and radiation-induced proctitis have also been found responsive to cryotherapy. Although based on results with relatively small numbers of patients and short follow-up periods, cryotherapy has been demonstrated to be safe and effective. This is a promising technology that will require multicenter controlled trials to better define its role as an effective and alternative form of tissue ablation.

Major haemoptysis in children with cystic fibrosis: a 20-year retrospective study

Background: Major haemoptysis occurs in approximately 1% of children with cystic fibrosis (CF). This report describes management and follow-up of these children at a tertiary centre in Australia. Methods: Retrospective review of medical records from 1980–1999. Results: Fifty-one children (45% female) had major haemoptysis (102 episodes). Mean age at first episode was 15 years (range 7–19) and mean FEV 1 was 56% predicted (range 14–98). Massive life-threatening haemoptysis was not confined to those with severe lung disease (FEV 1<50% predicted). Bronchial artery embolisation (BAE) was more likely to be the initial treatment for those with massive haemoptysis and chronic recurrent bleeding tended to be treated conservatively ( P=0.01). Overall, 52 BAE were performed in 28 children with an immediate success rate of 98%; 13 children (46%) had repeated BAE. Four patients died as a direct result of severe haemoptysis. Mean follow-up was 54 months (range 0.5–183). Median survival time (Kaplan–Meier estimate) after first haemoptysis was 70 months, with a significantly longer survival for male patients independent of age (RR 3.8; 95% CI 1.7–8.8; P=0.001). Median survival time following initial treatment with BAE was longer (103 months) compared to conservative treatment (52 months, P=0.09). Conclusions: Massive haemoptysis was unrelated to the severity of lung disease and was more likely to be treated with embolisation. BAE was highly effective, however, 46% of the children required re-embolisation at some time, which is similar to the recurrence risk for major hemoptysis treated conservatively on longer term follow-up.

Current Medical and Surgical Management of Nonvariceal Upper Gastrointestinal Bleeding

Various pharmaceutical agents have been assessed for their ability to impact on the course of acute nonvariceal upper gastrointestinal hemorrhage. The results of the randomized trials to date have not revealed consistent benefit for any of these medications to halt ongoing bleeding or prevent recurrent bleeding within the same hospitalization. Conversely, encouraging data suggesting a benefit to estrogens in chronic recurrent bleeding from gastrointestinal angiodysplasias are accumulating. Additionally, stress ulcer syndrome with a significant gastrointestinal bleeding appears to be seen less frequently, and this probably relates to the availability of effective prophylactic agents. Surgical intervention for ongoing gastrointestinal bleeding remains necessary in a significant number of patients. The timing of such intervention and the type of procedure performed depends on the source and severity of bleeding and the clinical characteristics of the patient.

Reversal of microcephaly and developmental delay after cure of hyperinsulinemic hypoglycemia

ing has also been reported with normal cerebrospinal fluid opening pressure) Cranial nerve VI palsy may result from generalized increased intracranial pressure or localized pontine ischemia. In severe iron deficiency anemia, the neurologic abnormalities are probably also related to deficient iron in cytochrome enzymes and other metalloenzymes involved in oxygen metabolism, DNA synthesis, and catecholamine and steroid metabolism. 1,4'7 Our patient had papilledema as a result of increased intracranial pressure. Bilateral cranial nerve VI palsies were also most likely a result of increased intracranial pressure; this interpretation is supported by the bilaterality of these deficits, the associated headache, the elevated lumbar puncture opening pressure 5 days after admission, and the rapid reversal of neurologic abnormalities with treatment. The patient's syncopal episodes most likely resulted from postural hypotension in combination with inadequate blood oxygen content. Normal to elevated platelet counts often accompany iron deficiency anemia, although thrombocytopenia has also been reported. 8 Our patient's thrombocytopenia persisted until her fifth day of hospitalization, and then rapidly resolved. The role of iron in the regulation of thrombopoiesis is not well elucidated. On the basis of clinical observations and animal studies, Karpatkin et al. 9 postulated that a minimal amount of iron is necessary for platelet production, and that iron may also have a role in inhibiting excessive platelet production. The blood in our patient's stools during hospitalization likely resulted from nasal and gingival bleeding, and was possibly augmented by intestinal polyp bleeding. During hospitalization, her father's medical records were obtained and revealed that he had multiple intestinal polyps with malignant change. Hereditary hemorrhagic telangiectasia was also diagnosed. In this autosomal dominant multisystemic disease, chronic recurrent bleeding occurs despite normal platelet and Coagulation studies. Epistaxis is the most common initial symptom, followed by intestinal bleeding. 1~ The intestinal lesions are characteristically small nodular angiomas surrounded by a pale halo and located primarily in the stomach and duodenum, 1~ unlike the lesions seen in our patient. She therefore appears to have had both generalized polyposis and hereditary hemorrhagic telangiectasia.

Endoscopic Laser Therapy for Gastrointestinal Bleeding from Congenital Vascular Lesions

SummaryEndoscopic laser therapy may be useful in controlling upper gastrointestinal bleeding due to vascular abnormalities. This report presents the case of an 11‐year‐old boy with an unusual vasculocutaneous disorder complicated by chronic recurrent bleeding that necessitated frequent blood transfusions. Of a number of investigative tests, only endoscopy was diagnostic in determining that the bleeding was secondary to multiple gastric vascular lesions. Moreover, laser photocoagulation of the identified lesions resulted in a dramatic decrease in both transfusion requirements and hospitalization.

Angiography in the diagnosis of chronic gastrointestinal bleeding.

Abstract Correlation was positive between angiographic and subsequent pathologic findings in 40 of 53 patients with chronic unexplained gastrointestinal bleeding. It is believed that, in a patient with a history of chronic recurrent bleeding, an anatomic lesion is generally present and can be demonstrated by arteriography even if active bleeding is not in progress at the time of examination. Only 2 of the 53 patients in this study were actively bleeding at the time of examination. The arteriographie details of an intussusception and an ulcerated Meckel's diverticulum are also described.