Diagnosis Of Lower Gastrointestinal Bleeding Research Articles

Diagnostic accuracy of RBC scintigraphy and CTA for detection of patients with suspected lower gastrointestinal bleeding: a systematic review and meta-analysis.

Detection of lower gastrointestinal bleeding (LGIB) through noninvasive modalities is very important in the successful management of LGIB. RBC scintigraphy and CT have a role in the detection of LGIB and guiding the management of patient by localization of the bleeding site. However, only a small number of studies have evaluated the role of RBC scintigraphy and CT in the diagnosis of LGIB. This systematic review was conducted to evaluate the diagnostic performance of RBC scintigraphy and CT in the detection of LGIB in patients with clinical or biochemical findings suspicious of LGIB. This systematic review followed PRISMA guidelines. Searches in PubMed, Scopus, and Embase were conducted using relevant keywords, and articles published through 30 April 2022, were included. Using endoscopy or surgical outcomes as the reference standard, the numbers of true and false positives and true and false negatives were extracted. Pooled estimates of diagnostic test accuracy - including sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and summary ROC (SROC) curve - were generated using bivariate random-effects meta-analysis. Three studies comprising 171 patients were included in the systematic review and meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using RBC scintigraphy were 0.787 (95% CI, 0.643-0.893), 0.289 (95% CI, 0.164-0.443), 1.214 (95% CI, 0.923-1.597) and 0.576 (95% CI, 0.296-1.121) respectively. The area under the SROC curve was 0.73. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using CT were 0.931 (95% CI, 0.772-0.992), 0.870 (95% CI, 0.737-0.951), 6.085 (95% CI, 0.840-44.097), 0.126 (95% CI, 0.006-2.509) respectively. The area under the SROC curve was 0.095. RBC scintigraphy has overall good sensitivity and CTA has excellent sensitivity specificity, positive and negative likelihood ratio in the detection of LGIB in patients with clinical or biochemical findings suspicious for LGIB.CTA along with RBC scintigraphy can be used algorithmically to rule out patients who do not have a localization for the site of LGIB thereby helping these patients to avoid invasive procedures like endoscopy or surgical explorations.

Woman With Hematochezia.

As a consequence of cirrhosis, portal hypertension causes resistance to blood flow and leads to the formation of varices. However, colonic variceal hemorrhages are rarely reported but could be a lethal cause of lower gastrointestinal hemorrhage. Currently, there is no consensus on the management of colonic variceal hemorrhage. Variceal ligation, injection sclerotherapy, transjugular intrahepatic portosystemic shunt placement, and balloon-occluded retrograde transvenous obliteration or a combination of the above therapies have been reported with inconsistent success rates. We advocate considering colonic variceal bleeding as a crucial differential diagnosis of lower gastrointestinal bleeding in cirrhotic patients and initiating time-sensitive, definite operative treatment or combination therapy as soon as possible in colonic variceal patients with life-threatening bleeding events, which are often refractory to conservative treatment.

Diagnosis of lower gastrointestinal bleeding by multi-slice CT angiography: A meta-analysis

PurposeTo estimate the diagnostic value of multi-slice spiral CT angiography (CTA) in lower gastrointestinal bleeding by a meta-analysis. MethodsThe relevant clinical studies on the diagnostic value of CTA were searched on PubMed, Embase and other electronic documents databases with the deadline of 2016 September. Language was limited to English. A diagnostic meta-analysis was performed by using Meta-DiSc software. The effect sizes included sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) and 95% confidence interval (CI). The Cochran-Q test and I2 statistic based on χ2 test were used for estimation of the heterogeneity. Meta-regression was performed to explore the source of heterogeneity. SROC curve was established. ResultsA total of 14 articles including 549 patients with lower gastrointestinal bleeding were enrolled in the meta-analysis. The combined PLR, NLR and DOR were respectively 8.149, 0.158 and 56.213. There were significant heterogeneities in all estimations but we could not find the sources by meta-regression based on study design, study location, CT slices and sample size. The AUC and Q index under the fixed effect model was respectively 0.9463 and 0.8856. ConclusionsThe multi-slice CTA has high diagnostic value for lower gastrointestinal bleeding.

Lower Gastrointestinal Bleeding And Risk of Gastrointestinal Cancer.

OBJECTIVES:Lower gastrointestinal (GI) bleeding is a well-known symptom of colorectal cancer (CRC). Whether incident GI bleeding is also a marker of other GI cancers remains unclear.METHODS:This nationwide cohort study examined the risk of various GI cancer types in patients with lower GI bleeding. We used Danish medical registries to identify all patients with a first-time hospital diagnosis of lower GI bleeding during 1995–2011 and followed them for 10 years to identify subsequent GI cancer diagnoses. We computed absolute risks of cancer, treating death as a competing risk, and calculated standardized incidence ratios (SIRs) by comparing observed cancer cases with expected cancer incidence rates in the general population.RESULTS:Among 58,593 patients with lower GI bleeding, we observed 2,806 GI cancers during complete 10-year follow-up. During the first year of follow-up, the absolute GI cancer risk was 3.6%, and the SIR of any GI cancer was 16.3 (95% confidence interval (CI): 15.6–17.0). Colorectal cancers accounted for the majority of diagnoses, but risks of all GI cancers were increased. During 1–5 years of follow-up, the SIR of any GI cancer declined to 1.36 (95% CI: 1.25–1.49), but risks remained increased for several GI cancers. Beyond 5 years of follow-up, the overall GI cancer risk was close to unity, with reduced risk of rectal cancer and increased risk of liver and pancreatic cancers.CONCLUSIONS:A hospital-based diagnosis of lower GI bleeding is a strong clinical marker of prevalent GI cancer, particularly CRC. It also predicts an increased risk of any GI cancer beyond 1 year of follow-up.

Tu1580 Determinants of Folate Metabolism in Colorectal Cancer Patients and Healthy Individuals

Introduction: Patients presenting with lower gastrointestinal bleeding may undergo multiple endoscopic and angiographic procedures. Identification of the source of bleeding may be elusive, and the end result may be a total colectomy. For those patients who have many nonoperative interventional procedures, we sought to investigate any differences that might exist with regards to overall mortality, the rate of operative intervention, and the type of operative procedure. Methods: All patients were identified nationwide who were admitted to the hospital between 2006 and 2010 with lower gastrointestinal bleeding using the Nationwide Inpatient Sample (NIS) database. Patients not requiring blood transfusions were excluded. Patients were grouped according to the number of colonoscopies, flexible sigmoidoscopies, and angiographies that were performed. We then compared the rate of bowel resection, the type of procedure, and the overall mortality for patients who underwent more than 2 nonoperative interventional procedures with those patients who had 2 or fewer procedures. Results: From 2006 through 2010, 289,501 patients were admitted with a diagnosis of lower gastrointestinal bleeding requiring blood transfusion. Of these patients, 0.33% (n = 954) underwent more than 2 nonoperative interventional procedures. The rate of large bowel resection was significantly higher for this group of patients (15.0% vs. 3.5%, p<0.0005). There was no difference in mortality (1.7% vs. 1.7%, p=0.962). For those patients who underwent large bowel resection, patients who had undergoing more than 2 nonoperative interventional procedures were significantly more likely to undergo total colectomy (20.3% vs. 8.0%, p<0.0005). Conclusions: Patient who undergo more than 2 nonoperative interventional procedures are more likely to require a bowel resection and more likely to undergo a total colectomy. Overall mortality for this group, however, is not higher. These patients may have persistent bleeding that cannot be localized, yet a stable enough clinical picture to permit repeating endoscopy or angiography and delaying resection. There is no evidence from our study to suggest that such patients should undergo resection sooner, nor is there evidence that multiple endoscopies and angiographies adversely affect survival.

Bedside colonoscopy in intensive care units: indications, techniques, and outcomes

Colonoscopy performed in critically ill patients is poorly documented in the literature. The clinical setting is completely different from routine outpatient colonoscopy with different aims and techniques. We proposed to examine the role of urgent colonoscopy in critically ill patients. This was a retrospective review of patients in a prospectively recorded database. All patients undergoing colonoscopy in an intensive care unit were identified from a colonoscopy database. A chart review yielded indications, diagnoses, co-morbidities, depth of intubation, and outcome. Main outcome measures were indications for colonoscopy, type and dose of sedation, bowel preparation, completion rate, findings, treatment, and complications. Forty one patients underwent 49 bedside colonoscopies (31 men (79 percent), 10 women, mean age of 68.1years). The most common indications were to exclude ischemic colitis in 25 (confirmed in 19, operated in 14), decompression of colonic distension in 7 (all decompressed, 0 operated), and diagnosis of lower gastrointestinal hemorrhage in 7 (cause found in 7, 0 operated). All patients had major co-morbidities and 28 were being ventilated at the time of the colonoscopy. A minority of patients received sedation. 14 (36%) of the patients died. Colonoscopy reached the cecum in 16 patients (41%), the hepatic flexure in 25 (64%), and the splenic flexure in 36 (92%). Prep was poor in 15 patients and stool prevented completion in 13. In 30% of patients, colonoscopy was not pursued to the cecum. Bedside colonoscopy is helpful in the diagnosis and management of acute lower gastrointestinal disease in intensive care patients.

Use of CT enterography for the diagnosis of lower gastrointestinal bleeding in pediatric patients

Diagnosis of lower gastrointestinal bleeding (LGIB) represents a significant diagnostic and therapeutic challenge for any physician. While CT enterography (CTE) has been applied in adults with occult LGIB, its use in children has been limited to evaluation of Crohn's disease. We reviewed 6 patients ages 4–15 who underwent CTE for LGIB at a tertiary pediatric institution. In sum, CTE appears to be a valuable tool for localizing the source of LGIB prior to surgical or endoscopic intervention. However, rapid lesion identification must be weighed against the increased radiation exposure and patient discomfort due to bowel distention associated with this diagnostic technique.

The critical role of CT angiography in the detection and management of lower gastro-intestinal bleeding

Lower gastro-intestinal bleeding (LGIB) is defined as a bleeding site localised in the colon or anorectum. (1) In the past, the diagnosis of LGIB has been a serious challenge for the radiology department because of its possible intermittent character, making it difficult to pinpoint the bleeding site. Patients with a LGIB will typically have undergone a long diagnostic work-up before they end up on the interventional radiology department. The development of multi-detector computed tomography (CT) has made radiological diagnosis of LGIB easier. CT is not only able to localize the active bleeding site but may also demonstrate the vascular anatomy and the underlying cause, hereby directing further management and guiding therapeutic interventions, as will be illustrated in both of our cases.

Acute Lower Gastrointestinal Bleeding from a Dieulafoy lesion: Three Case Reports and a Literature Review

Purpose: Dieulafoy lesion is a rare cause of gastrointestinal (GI) bleeding, accounting for 1-2% of cases. It can be seen anywhere in the GI tract but is usually found in the stomach. Here we present three cases of lower GI bleed secondary to Dieulafoy lesions. Case #1: 84-year-old man with history of prostate cancer treated with radiation therapy, and recurrent hematochezia for several years, was admitted with lower GI bleeding with hemodynamic compromise, and a hemoglobin of 5.2 g/dL. Prior upper endoscopy, colonoscopy and small bowel capsule endoscopy, were significant only for radiation proctitis. Colonoscopy, on this admission, revealed pools of bright red blood in the right colon, with a vessel protruding from a small mucosal defect in the ascending colon, spurting fresh blood. Hemostasis was achieved with four hemoclips. No further bleeding was reported. Case #2: 86-year old man presented with rectal bleeding. Colonoscopy revealed an actively bleeding exposed vessel in the rectum, without surrounding ulceration. Hemostasis was achieved with application of a hemoclip to the base of the vessel. No further bleeding was reported. Case #3: 64-year old woman presented with intermittent rectal bleeding. Colonoscopy revealed copious amounts of fresh blood in the rectum, and after careful irrigation and inspection, a pulsatile active bleeding site was identified with surrounding normal mucosa. Hemostasis was achieved by application of two hemoclips. No further bleeding was reported. Dieulafoy lesions are a rare cause of lower GI bleeding. While 75% of Dieulafoy lesions are found in the stomach; only 2% are in the colon, and 2% in the rectum. A Dieulafoy lesion, is a tortuous submucosal artery, which retains its large caliber as it approaches the mucosa, and protrudes through a small mucosal defect. The lesion ruptures spontaneously and bleeds massively for reasons that are unclear. In the colon, solid bowel contents may lead to stercoral ulceration with resultant exposure of the vessel and hemorrhage. Given the intermittent nature of the bleeding and normal appearance of the mucosa, repeated endoscopies are often necessary to make the diagnosis. A complete bowel prep to clear the colon of retained blood and colonic contents enables the endoscopist to see the characteristic appearance of a protruding vessel or blood spurting from a pinpoint mucosal defect, or otherwise normal appearing mucosa. Endoscopic therapeutic intervention is the treatment of choice. Hemostasis has been reported with thermal coagulation, mechanical (banding or hemoclip) therapy, or regional injection (epinephrine). Dieulafoy lesions should be included in the differential diagnosis of lower GI bleeding.

122 Cholecystokinin-8 Regulates Pacemaker Activities in Cultured Interstitial Cells of Cajal From Murine Small Intestine

Background: Acute lower gastrointestinal bleeding (LGIB) accounts for about 30 percent of episodes of gastrointestinal bleeding. It encompasses a wide spectrum of symptoms ranging from trivial hematochezia to massive hemorrhage with shock. Identifying those who will later develop severe bleeding is a challenge. Strate and colleagues have identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to provide external validation for the Strate clinical prediction rule for severe acute LGIB. Methods: We retrospectively selected patients with a principal diagnosis of LGIB between January 2007 and August 2011 at a busy urban hospital. Predictor variables were those from Strate's original study: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 hours of evaluation, aspirin use, and >2 comorbid conditions. Severe LGIB was defined as the presence of any of the following: transfusion of ≥2 units of red blood cells in the first 24 hours, recurrent rectal bleeding after 24 hours of stability (requiring additional blood transfusions), need for ICU placement or readmission for acute LGIB within one week of discharge. An overall risk score was created by adding the number of predictive factors present. Patients were stratified into 3 risk groups: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). Results: Analysis was performed on 378 patients. The risk of severe bleeding in each category was: low risk 31%, moderate risk 55%, and high risk 84%. The area under the receiver operating characteristic curve (AUROC) was 0.70 with good calibration (H-L chi sq.= 0.98). The magnitude of the risk score was significantly correlated with need for blood transfusions, ICU placement and length of stay but not with need for surgery or death. Inclusion of additional variables including age, gender, actual heart rate and systolic blood pressure did not improve the AUROC for the prediction of severe bleeding. Conclusions: Strate and colleagues developed a promising clinical prediction rule for acute severe LGIB. The risk factors are simple and available within 4 hours of presentation. However, we find the predictive ability of the rule to be lower than in the original study as evidenced by the lower AUROC (0.70 versus 0.75). The Strate LGIB score does not have sufficient discriminatory power to improve the triage of patients to appropriate levels of care, nor promote a more standardized approach to acute LGIB. Further research is needed to improve our ability to identify patients presenting with LGIB who are at high risk for severe bleeding.

119 Validation of a Predictive Rule for Severe Acute Lower Intestinal Bleeding

Background: Acute lower gastrointestinal bleeding (LGIB) accounts for about 30 percent of episodes of gastrointestinal bleeding. It encompasses a wide spectrum of symptoms ranging from trivial hematochezia to massive hemorrhage with shock. Identifying those who will later develop severe bleeding is a challenge. Strate and colleagues have identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to provide external validation for the Strate clinical prediction rule for severe acute LGIB. Methods: We retrospectively selected patients with a principal diagnosis of LGIB between January 2007 and August 2011 at a busy urban hospital. Predictor variables were those from Strate's original study: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 hours of evaluation, aspirin use, and >2 comorbid conditions. Severe LGIB was defined as the presence of any of the following: transfusion of ≥2 units of red blood cells in the first 24 hours, recurrent rectal bleeding after 24 hours of stability (requiring additional blood transfusions), need for ICU placement or readmission for acute LGIB within one week of discharge. An overall risk score was created by adding the number of predictive factors present. Patients were stratified into 3 risk groups: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). Results: Analysis was performed on 378 patients. The risk of severe bleeding in each category was: low risk 31%, moderate risk 55%, and high risk 84%. The area under the receiver operating characteristic curve (AUROC) was 0.70 with good calibration (H-L chi sq.= 0.98). The magnitude of the risk score was significantly correlated with need for blood transfusions, ICU placement and length of stay but not with need for surgery or death. Inclusion of additional variables including age, gender, actual heart rate and systolic blood pressure did not improve the AUROC for the prediction of severe bleeding. Conclusions: Strate and colleagues developed a promising clinical prediction rule for acute severe LGIB. The risk factors are simple and available within 4 hours of presentation. However, we find the predictive ability of the rule to be lower than in the original study as evidenced by the lower AUROC (0.70 versus 0.75). The Strate LGIB score does not have sufficient discriminatory power to improve the triage of patients to appropriate levels of care, nor promote a more standardized approach to acute LGIB. Further research is needed to improve our ability to identify patients presenting with LGIB who are at high risk for severe bleeding.

Bleeding Risk Secondary to Deep Vein Thrombosis Prophylaxis in Patients With Lower Gastrointestinal Bleeding

Deep vein thrombosis (DVT) and pulmonary embolism (PE) continue to pose a major burden on the health care system in the United States. The precise timing of anticoagulation initiation in critically ill patients with recent or active lower gastrointestinal bleeding (LGIB) is not well defined. We set out to study the safety and efficacy of early heparin administration for DVT prophylaxis in these patients. A review of all patients admitted to the ICU with a diagnosis of LGIB over a 13-year period was performed. A total of 60 patients received subcutaneous heparin along with mechanical prophylaxis, whereas 59 patients had intermittent pneumatic compression devices alone. There was no difference in morbidity or mortality between the groups who received heparin and the nonheparin cohort. Neither of the groups developed a DVT or PE during the study period. Patients who received heparin had a median ICU LOS of 3 days, when compared with 2 days for patients who did not receive heparin (P < .0118). There was a significant association between units of blood received during the first 24 hours in the ICU and heparin usage (P < .0229). Those administered heparin received more units (median 3) than those who did not receive heparin (median 2). Administration of subcutaneous heparin increases the transfusion requirements and LOS in ICU patients with LGIB. After 24 hours, however, the blood transfusion requirements are equivalent. DVT prophylaxis in patients with a diagnosis of LGIB should be initiated after 24 hours of ICU admission.

Massive Lower Gastrointestinal Hemorrhage Caused by a Large Extraluminal Leiomyoma of the Colon: Report of a Case

The occurrence of leiomyoma of the colon is uncommon. Most of these lesions are clinically silent and are found incidentally during laparotomy or endoscopic procedures for unrelated conditions. Symptomatic leiomyomas of the colon are encountered less frequently, with only sporadic reports in the literatures. We describe a heretofore unreported case of a large extraluminal leiomyoma of the sigmoid colon presenting as massive lower gastrointestinal hemorrhage. Because it was extraluminal in position, it was difficult to make an accurate diagnosis endoscopically and the condition was easily misdiagnosed as angiodysplasia of the colon until CT scan results were seen. Although rare and benign in nature, leiomyoma of the colon may cause life-threatening complications that require emergency surgery and should be included in the differential diagnosis of lower gastrointestinal hemorrhage.

The usefulness of transabdominal ultrasound for the diagnosis of lower gastrointestinal bleeding

Lower gastrointestinal bleeding is a frequent cause of hospitalization, but diagnostic methods for this condition are not fully established. Transabdominal ultrasound is a widely accepted diagnostic tool in bowel diseases. To evaluate the usefulness of transabdominal ultrasound for lower gastrointestinal bleeding. We reviewed the medical records of consecutive patients who underwent transabdominal ultrasound as the first diagnostic procedure for acute haematochezia during the period June 1999 to June 2004. The study group comprised 111 patients and all underwent colonoscopy thereafter. Detection and diagnosis of lower gastrointestinal bleeding by ultrasonographic examination were evaluated by comparing the ultrasound diagnosis with the colonoscopic findings and final diagnosis. The bleeding site was localized by colonoscopy in 90 of the 111 patients (81%). The bleeding site was localized by ultrasound in 59 of the 90 patients (66%). When the bleeding site was in the rectum, ultrasonographic detectability was 30% (10/33); ultrasonographic detectability was 82-100% when the bleeding site was elsewhere. Rectal bleeding and diverticular bleeding were difficult to diagnose by ultrasound, but for the other diseases, diagnosis by ultrasonographic examination was possible in 91-100% of cases. Ultrasonographic examination may be an effective screening method for lower gastrointestinal bleeding.

Nonsteroidal anti-inflammatory drug associated lesions and mortality among African American and Hispanic patients with lower gastrointestinal bleeding

Nonsteroidal anti-inflammatory drugs (NSAIDs) are toxic to the entire gastrointestinal (GI) tract. Although there is a plethora of data about upper GI toxicity of NSAIDs, the data are scant about lower GI toxicity, particularly in African Americans and Hispanics, our main patient population. We studied the association between NSAIDs use and lower GI lesions in patients with lower GI bleeding (LGIB). Records of 988 patients, 19 to 103 years old, admitted with a diagnosis of LGIB over 12 years (from 1991 to 2002), were reviewed retrospectively. We excluded 230 patients (44 white, 45 Asian, 98 with upper GI source of LGIB, and 43 with incomplete data). The information abstracted included admission diagnoses, NSAIDs and/or aspirin (NSAIDs/AS) use, colonoscopic findings, and outcome measures (duration of hospitalization; surgery; mortality). Among the 758 patients (411 African American and 347 Hispanics), 47% were taking NSAIDs/AS regularly and 53% were not taking NSAIDs/AS. Colonoscopic findings revealed that the common lesions were colonic diverticulosis (36%), angiodysplasia (29%), colonic polyps (25%), and hemorrhoids (24%). Colonic diverticulosis, colonic ulcers, and inflammatory bowel diseases were significantly higher among NSAIDs/AS users than among nonusers ( P < 0.05). On average, NSAIDs/AS users had longer hospital stays (5 days) than nonusers (3 days). Of the 758 patients, 13% had surgery because of severe bleeding. Surgical intervention was more likely among NSAIDs/AS users (16%) than among nonusers (11%) (odds ratio OR = 1.6, 95% confidence interval CI = 1.0–2.4, P = 0.04). Overall, 160 deaths occurred (21%). Mortality was significantly higher among NSAIDs/AS users (29%) than among nonusers (14%) (OR = 2.6, 95% CI = 1.8–3.7, P = 0.0001). Morbidity, mortality, and need for surgery were higher among NSAIDs/AS users than nonusers. Future prospective studies in this population may help in better management and possible risk reduction.

Selective arterial embolization for control of lower gastrointestinal bleeding: recommendations for a clinical management pathway

Purpose Angiography remains as the modality of choice in the diagnosis of lower gastrointestinal bleeding. Traditionally, angiography is used for localization of a bleeding source for surgical resection. Advances in transcatheter techniques have allowed for hemorrhage control through embolization of bleeding points, without the need for emergent laparotomy. Methods A series of 10 consecutive patients who underwent angiographic embolization for lower gastrointestinal hemorrhage was retrospectively reviewed. Success and complication rates, as well as post-embolization follow-up methods, were recorded. Results Over a 3-year period, 10 angiographic embolizations were performed for lower gastrointestinal hemorrhage. Average age of the patients was 75 years. Source of hemorrhage included diverticular disease in 4 patients, cancer in 2, polyps in 2, angiodysplasia in 1, and anastomotic bleeding in 1. Six patients required no further therapy. Four patients went on to have surgery: Three secondary to recurrent hemorrhage, 1 due to sepsis from ischemic bowel necrosis. There were no deaths. Four patients had an abdominal and pelvic computed tomography (CT) scan within 48 hours of embolization. Four patients had a colonoscopy within 48 hours of the procedure. Conclusions Angiography remains an important diagnostic tool in the management of lower gastrointestinal bleeding. In addition, it is a safe and effective treatment option, especially in patients with high surgical risk. Hemorrhage control obtained in the angiography suite may allow for patient stabilization and resuscitation with staging and bowel preparation for surgery. Patients need to be carefully monitored for evidence of bowel ischemia through the use of colonoscopy or computed tomography.

Nonsteroidal antiinflammatory drugs and lower gastrointestinal bleeding.

To define the association of the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin (ASA), and lower gastrointestinal bleeding (GIB) a retrospective, case-controlled study was undertaken of 188 patients admitted to three community hospitals in three cities with a diagnosis of lower GIB. Information was obtained about NSAID usage among these patients, and the data were compared with an age- and sex-matched control group of 185 patients admitted with a nongastrointestinal diagnosis, derived from a daily admission list. At the time of admission, in the New Jersey group, NSAID consumption was present in 26 of 90 (29%) patients with lower GIB compared with 16 of 90 (18%) of controls (P < 0.05, odds ratio 1.88, 95% CI 1.2-3.1) whereas, in the South Carolina group 34 of 98 (35%) were taking NSAID compared with 18 of 95 (19%) of controls (P < 0.01, odds ratio 2.27, 95% CI 1.2-4.4). These data indicate that there is a significantly increased rate of NSAID ingestion in patients admitted with lower GIB, implying that NSAID may unmask bleeding from a variety of lower gastrointestinal lesions.

Lower Gastrointestinal Bleeding

The differential diagnosis of lower gastrointestinal bleeding in children can be reduced markedly simply by taking into account the age of the child. The clinical condition of the patient can further help narrow the diagnostic possibilities. Newborns and infants who are clinically unstable are more likely to have diseases such as necrotizing enterocolitis, volvulus, Hirschprung disease, intussusception, or Meckel diverticulum. A baby who appears healthy should be examined for swallowed blood, allergic colitis, anal fissures, or lymphonodular hyperplasia. An older child of healthy appearance with bleeding is likely to have a juvenile polyp or infectious colitis, but a child who appears sick may have hemolytic uremic syndrome, Henoch-Schoenlein purpura, or inflammatory bowel disease. This information, along with that gleaned from the physical examination, can lead the pediatrician to determine the need for specific tests, such as abdominal radiographs, stool cultures, and an endoscopic evaluation. We have come a long way in our ability to diagnose the causes of lower gastrointestinal bleeding. With the availability of newer radiographic and nuclear medicine modalities and the ability to visualize the colon endoscopically, the need for exploratory laparotomy for diagnosis is rarer. While surgery may still be the therapy of choice, new diagnostic modalities give the surgeon much more preoperative information.

Lower Gastrointestinal Bleeding

The differential diagnosis of lower gastrointestinal bleeding in children can be reduced markedly simply by taking into account the age of the child. The clinical condition of the patient can further help narrow the diagnostic possibilities. Newborns and infants who are clinically unstable are more likely to have diseases such as necrotizing enterocolitis, volvulus, Hirschprung disease, intussusception, or Meckel diverticulum. A baby who appears healthy should be examined for swallowed blood, allergic colitis, anal fissures, or lymphonodular hyperplasia. An older child of healthy appearance with bleeding is likely to have a juvenile polyp or infectious colitis, but a child who appears sick may have hemolytic uremic syndrome, Henoch-Schoenlein purpura, or inflammatory bowel disease. This information, along with that gleaned from the physical examination, can lead the pediatrician to determine the need for specific tests, such as abdominal radiographs, stool cultures, and an endoscopic evaluation. We have come a long way in our ability to diagnose the causes of lower gastrointestinal bleeding. With the availability of newer radiographic and nuclear medicine modalities and the ability to visualize the colon endoscopically, the need for exploratory laparotomy for diagnosis is rarer. While surgery may still be the therapy of choice, new diagnostic modalities give the surgeon much more preoperative information.

Evaluation of a complementdependent anti-Jka by various sensitization and detection methodologies: a case report

Abstract A 79-year-old woman with a diagnosis of lower gastrointestinal bleeding was found to have a complement dependent anti-Jka in her serum. The anti-Jk1 was evaluated by the antiglobulin technique with polyspecific, anti-C3, and anti-lgG antihuman globulin (AHG). A variety of sensitization and detection methods were used, including the prewarmed saline technique, enzyme treatment of test cells, a low-ionic additive solution (LISS), 22 percent albumin, Polybrene, and an increased serum/cell ratio. The anti-Jk1 was detected only when polyspecific AHG and anti-C3 were used compared to anti-lgG, regardless of the selected enhancement technique. Anti-C3 gave weaker reactions than polyspecific AHG. IgG subclassing was inconclusive. The anti-Jka was not detected when plasma was substituted for serum. The use of polyspecific versus IgG AHG in pretransfusion testing is discussed.