Bleeding Duodenal Ulcer Research Articles

Hemostatic Spray: What’s the Most Current Evidence?

Introduction: At times, either because of location, extent or lesion features, hemostasis can be difficult to achieve. We aimed to analyze the clinical outcomes of patients who were treated with hemospray either for primary hemostasis or when bleeding was refractory or not amenable to well establish therapy. Methods: To identify pertinent case reports, case series and clinical trials, we searched the abstracts presented at Digestive Disease Week 2014 and the PubMed database using the keywords hemospray, hemostatic spray, TC-325, and spray until June 2014. The demographic information, location and type of lesion, effectiveness, rate of recurrence and complications were extracted and recorded. Results: A total of 18 studies were identified and provided data on 206 patients. The mean age of the patients was 59.39 years and 74.2% were males. Following lesions were treated: varices n=2, esophageal ulcers n=8, peptic ulcers n=114, portal hypertensive gastropathy n=4, Dieulafoy lesions n=4, tumors n=10, Iatrogenic: post polypectomy bleed n=6, post-endoscopic mucosal resection n=16, post banding ulcers n=2, post sclerotherapy ulceration n=1, post spinterotomy n=5, anastomosis n=1, others (MWT, arteriovenous malformation, GAVE, diverticular, fistula, colonic ulcers, Post halo therapy and proctitis) n= 15 and unidentified or not reported (NR) n=18. Of the lesion treated (actively bleeding 96.2%) 10.6% were in the esophagus, 28% were in the stomach, 41.3% in the small intestine and 12.1% in the colon. Hemospray was used as first-line therapy in 58.7% of the case and as salvage therapy in 39% of the patients (NR in 2.3%). The immediate hemostasis was achieved 89.4 % of the patients (93.1 % for the salvage procedures). Recurrent bleeding within 7 days was reported in 15.3% of the patients. Complication were noted in 2.1% of the patients and included possible splenic infarct, perforation and transient obstruction of biliary obstruction. Mortality in the perioperative period (mostly thought to be unrelated to the procedure itself) was reported in 2.9% patients. Conclusion: Our review of literature showed that hemospray is safe and effective. As it is easy to use, doesn’t need direct targeting and can cover a large surface area, it might have an advantage over routinely used hemostatic therapies in situations like tumor bleed, post EMR bleeding and posterior duodenal blub ulcers. However, prospective randomized trials are needed before routine use of hemospray can be recommended.

Evaluating the effectiveness of endoscopic treatment of gastroduodenal bleeding in children

Introduction: One of the current problems of emergency abdominal child surgery are gastric (GU) and duodenal ulcer (DU). Thus, domestic and foreign researchers have noted that the prevalence of peptic ulcer disease in the pediatric population in recent years has nearly doubled. GU and duodenal ulcer occurs with frequency 1,6-2,7 cases per 1000 children and is 7-12 % of diseases of the gastrointestinal tract in children. Along with the growing incidence of this disease, there is a tendency of the number of complications increase.One of the major complications that pose a threat to a child's life is gastroduodenal bleeding. InUkraine, the rate for the last five years has increased by 14% and in the structure of hemorrhagic complications of diseases of the gastrointestinal tract up to 60 % .Despite the fact that endoscopic hemostasis is considered the "gold standard" treatment of gastroduodenal ulcer bleeding, their effectiveness in the primary use and application in cases of relapse in childhood actively discussed.Insufficient number of pediatric surgeons work on the effectiveness of the treatment of these complications with the use of modern minimally invasive technologies is largely determined by the relevance and purpose of the present study.Research objective. To analyze the efficacy of endoscopic treatment of bleeding and recurrence of gastric and duodenal ulcers in children.Material and research methods. Results of the treatment of 57children with acute bleeding from gastric and duodenal ulcers in age from 2 to 16 years who were treated in the surgical departments of pediatric surgery clinics Dnepropetrovsk State Medical Academy and Zaporozhye State Medical University were presented. 38 (67 %) were girls, 19 (33 %) - boys.All patients were admitted to the intensive care unit and undergone clinical, laboratory examinations, complex etiopathogenetic treatment (infusion, hemostatic, substitution, antisecretory therapy) and fibrogastroduodenoscopy (EGD) for diagnostic and therapeutic purposes. Activity of the bleeding was defined with scale by Forrest (Forrest-Rosch W., 1986) during endoscopy exam. Endoscopic electrocoagulation monoelektrod using fiberoptic gastroduodenoscopy «Olympus» UES 10 was done. Injection of 0.18% solution of adrenaline with endoscopic injection needle 5Ch in different volumes through the working channel of the endoscope and therapy in combination with electrocautery was done. Treatment effectiveness monitoring was based on clinical, laboratory data and endoscopic studies.Results of research. The study found that duodenal ulcer bleeding substantially prevailed and was found in 44 children, whereas bleeding from gastric ulcer were found in 13 patients. Thus at 52 (91 %) there was no history information of the diagnosed ulcer. Chronic abdominal pain with PUD previously was recorded only in 9% of cases.Bleeding duration up to 6 hours before admission was detected in 39% of children, between 6 and 24 hours – in 45% and more than 24 hours – in 16% of patients. During EGD macroscopic acute ulcers appearance was detected in the majority (86 %) of children, 32% of them in the last month had mentioned nonsteroidal anti-inflammatory drugs intake and 41% of patients noted aggressive and soft products intake. Ulcers size ranged approximately 5-7 mm. Contamination of Helicobacter pylori serological test according to the level of IgG antibodies was detected in 89.8% of children. Variations in the levels of pepsinogen and serum gastrin in 98 % of children do not cross the boundaries of age-reference values. The clinical picture was characterized by vomiting blood 15% of patients, vomiting "coffee grounds" was detected in 72 % of children, melena was observed in 61% of cases.Primary hemostasis using endoscopic electrocautery combinations and epinephrine injection solution was effective in 48 (84 %) children. 9 patients that undergone only electrocoagulation treatment on the 2nd day were diagnosed rebleeding, which required re-EGD using a combined endoscopic hemostasis. According to the results of clinical laboratory and endoscopic control full bleeding stop was observed during the first 2 days of children stay in hospital.Conclusions .1. Study improved predominance of duodenal ulcer bleeding in children.2. History of alcohol and/or nonsteroidal anti-inflammatory drugs intake increases the risk of acute gastric or duodenum ulcers complicated by bleeding.3. Use of surgery endoscopic hemostasis using combined coagulation- injection method on the background of the hemostatic and parenteral antisecretory therapy for primary and preventive stop ulcer bleeding ensures maximum efficiency of complex treatment in the practice.

Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding.

Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.

Ulcer and bleeding complications and their relationship with dyspeptic symptoms in NSAIDs users: a transversal multicenter study

Objectives. To evaluate the prevalence of lesions and digestive complications secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs), the clinical profile seen for digestive complaints and the relation with the endoscopic findings. Methods. Prospective, multicentric, open study, evaluating consecutively 1231 patients, divided as follows: group I – NSAID and group II – non-NSAID. All patients answered questionnaire to evaluate the onset, the type of clinical complaint, the use of medication and possible complications associated to digestive bleeding. Results. A total of 1213 patients were evaluated. Among them, 65% were female and 13.1% were smokers; 15.6% mentioned they ingested alcoholic beverages. The main signs and symptoms reported were epigastralgy and pyrosis (67% and 62%, respectively). The upper gastrointestinal (UGI) endoscopy was normal in 3.9% in group I and in 10.7% in group II (p < 0.001). Patient who do not use NSAID will be 2.5 times more likely to have normal UGI endoscopy (p = 0.001). The presence of erosive or ulcer lesions in the stomach and duodenum was more frequent in group I. The incidence of lesions in the stomach when compared to the duodenum is observed (erosions: 49.12% vs. 13.60%, p = 0.001; ulcers: 14.04% vs. 11.84%, p = 0.05). The risk of digestive bleeding is 12 times higher (6.14% vs. 0.51%) in those who used NSAIDs, and the stomach is the site in which bleeding occurs more frequently. Conclusions. The frequency of gastric ulcer, duodenal ulcer and digestive bleeding was higher in patients who used NSAIDs. There was no connection found between endoscopic findings and dyspeptic symptoms.

Use of the Over-The-Scope Clip for treatment of refractory upper gastrointestinal bleeding: a case series

The Over-The-Scope Clip (OTSC; Ovesco, Tübingen, Germany) is a novel endoscopic clipping device designed for tissue approximation. The device has been used in the closure of fistulas and perforations. We hereby report on a series of patients in whom OTSCs were used for endoscopic control of refractory or major upper gastrointestinal bleeding from lesions in the gastroduodenal tract between 1 July and 31 December 2012. Nine patients were included (median age 72.5 years, range 39 - 91) with bleeding gastric ulcers (n = 2), bleeding duodenal ulcers (n = 5), bleeding gastrointestinal stromal tumor in the stomach (n = 1), and bleeding from ulcerative carcinoma of the pancreas (n = 1). The median size of the ulcers was 2.5 cm (range 1 - 4). Six of the nine patients had undergone previous endoscopic hemostasis. Technical success was achieved in all patients and the clinical effectiveness was 77.8 %. The OTSC is a safe and effective method of endoscopic hemostasis for major bleeding from miscellaneous upper gastrointestinal causes and should be considered in patients with refractory bleeding after failure of conventional methods of endoscopic hemostasis.

The importance of a patient’s background in formulating a management approach

Peptic ulcer disease is uncommon in childhood, with non-specific clinical features. A tendency to late diagnosis makes it more likely for a patient to present with complications. Here we discuss a child with low socio-economic status from a developing country who presented with severe anemia secondary to a bleeding duodenal ulcer. The case highlights the importance of the patient&amp;rsquo;s background in the formulation of a management approach. In some cases this may be intuitive to an experienced physician. However, we demonstrate this with a simple mathematical diagnostic model using disease prevalences which are tied to our individual patient&amp;rsquo;s circumstances. The model shows how the negative predictive value of a test can change according to the patient&amp;rsquo;s background. We also suggest that the best treatment option will be influenced by the patient&amp;rsquo;s circumstances. Our patient comes from Nepal, but the principles involved are universally applicable.

Cyanoacrylate spray for treatment of difficult-to-control GI bleeding

Although endoscopic therapy is highly effective for control of GI bleeding, a small proportion of patients experience persistent bleeding and may require radiologic or surgical intervention. Experience with cyanoacrylate spray for treatment of difficult-to-control GI bleeding is limited. To evaluate the efficacy and safety of an endoscopic cyanoacrylate spray technique for treatment of difficult-to-control GI bleeding. Case series. Two tertiary-care centers. This study involved consecutive patients with overt GI bleeding who were treated with n-butyl-2-cyanoacrylate spray during endoscopy for persistent bleeding despite conventional hemostatic therapies. Cyanoacrylate spray. Hemostasis, rebleeding, adverse events, and technical failure associated with cyanoacrylate spray. Five patients were treated with cyanoacrylate spray during endoscopy for persistent bleeding (duodenal ulcer in 3, gastric vascular ectasia in 1, rectal postpolypectomy bleeding in 1) after failed conventional therapies. Immediate hemostasis and technical success were achieved in all patients. At a median follow-up of 42 days (range 38-120 days), 2 patients developed recurrent bleeding. One patient experienced rebleeding 2 days after the procedure, subsequently requiring radiographic intervention and surgery. Another patient had recurrent bleeding from a different bleeding source 18 days after the procedure. No adverse events attributed to the cyanoacrylate spray were observed. Small number of patients. In patients with difficult-to-control GI bleeding failing conventional endoscopic therapies, cyanoacrylate spray was effective in achieving immediate hemostasis. Prospective studies with a larger number of patients to evaluate the role of the cyanoacrylate spray technique during endoscopy for GI bleeding are needed.

Platelet aggregation measurement for assessment of hemostasis failure mechanisms in patients with gastroduodenal ulcer bleeding

BackgroundThe purpose of this study was to identify factors associated with the risk of unsustainable hemostasis in patients with gastric and duodenal ulcer bleeding by in vitro assessment of platelet reactivity using artificial neural networks.MethodsPatients with gastroduodenal ulcers complicated by bleeding were studied. Platelet aggregation was measured using aggregometry with adenosine diphosphate 5 μM, epinephrine 2.5 μM, 5-hydroxytryptophan 10 μM, collagen 1 μM, and thrombin 0.06 NIH Unit/mL as agonists. Multiple logistic regression was used to evaluate the independent relationship between demographic, clinical, endoscopic, and laboratory data and in vitro assessment of platelet reactivity and local parameters of hemostasis in patients with ulcer bleeding.ResultsAnalysis of platelet aggregation in patients with gastroduodenal ulcer bleeding allowed the variability of platelet response to different agonists used in effective concentration which induces 50% platelet aggregation (EC50) to be established. The relationship between platelet aggregation and the spatial-temporal characteristics of ulcers complicated by bleeding was demonstrated. Adrenoreactivity of platelets was associated with time elapsed since the start of ulcer bleeding and degree of hemorrhage. The lowest platelet response to collagen and thrombin was detected in patients with active bleeding (P < 0.001) and unsustainable recent bleeding (P < 0.01). Decreased adenosine diphosphate-induced platelet aggregation in patients with ulcer bleeding was correlated with the platelet response to thrombin (r = 0.714, P < 0.001) and collagen (r = 0.584, P < 0.01).ConclusionEstimation of platelet reactivity in vitro indicates the key mechanisms of failure of hemostasis in patients with ulcer bleeding. In addition to gender, an important determinant of unsustainable hemostasis was a decreased platelet response to thrombin and adenosine diphosphate.

Rezidivierte duodenale Ulkusblutung als Erstmanifestation einer hepatisch metastasierten solid-pseudopapillären Neoplasie des Pankreas

In a 17-year-old girl recurrent duodenal ulcer bleeding had led to severe anemia. Sonography and computed tomography revealed a partially cystic tumour of the pancreatic head and suspicious hepatic lesions. TREATMENT AND PATHOLOGICAL DIAGNOSIS: A partial duodenopancreatectomy was performed and two liver metastases were resected. Histological examination of the resected pancreatic specimen revealed a solid pseudopapillary neoplasm of the pancreas (SPN) with hepatic metastases. CLINICAL COURSE AND PROGNOSIS: The seven remaining liver metastases were removed in a second procedure (right hepatectomy). One year later two new liver metastases were treated by radiofrequency ablation. Two years after the initial operation, the patient is well and tumor-free. SPN is a rare cystic tumor that is mainly found in young women. Direct tumor infiltration of stomach or duodenum can cause gastrointestinal bleedings in rare cases. Resection of the primary tumor and surgical or interventional removal of metastases are the treatment of choice.

The “Prometeo” Study

To implement an online, prospective collection of clinical data and outcome of patients with acute nonvariceal upper gastrointestinal bleeding (UGIB) in Italy ("Prometeo" study). Epidemiology, clinical features, and outcomes of nonvariceal UGIB are mainly known by retrospective studies and are probably changing. Data were collected by 13 Gastrointestinal Units in Italy from June 2006 to June 2007 (phase 1) and from December 2008 to December 2009 (phase 2): an interim analysis of data was performed between the 2 phases to optimize the online database. All the patients consecutively admitted for acute nonvariceal UGIB were enrolled. Demographic and clinical data were collected, a diagnostic endoscopy performed, with endoscopic hemostasis if indicated. One thousand four hundred thirteen patients (M=932, mean age±SD=66.5±15.8; F=481, mean age±SD=74.2±14.6) were enrolled. Comorbidities were present in 83%. 52.4% were treated with acetyl salicylic acid or other nonsteroidal anti-inflammatory drugs (NSAIDs): only 13.9% had an effective gastroprotection. Previous episodes of UGIB were present in 13.3%. Transfusion were needed in 43.9%. Shock was present in 9.3%. Endoscopic diagnosis was made in 93.2%: peptic lesions were the main cause of bleeding (duodenal ulcer 36.2%, gastric ulcer 29.6%, gastric/duodenal erosions 10.9%). At endoscopy, Helicobacter pylori was searched in 37.2%, and found positive in 51.3% of tested cases. Early rebleeding was observed in 5.4%: surgery was required in 14.3% of them. Bleeding-related death occurred in 4.0%: at multivariate analysis, the risk of death was correlated with female sex [odds ratio (OR=2.19, P=0.0089)], presence of neoplasia (OR=2.70, P=0.0057) or multiple comorbidities (OR=5.04, P=0.0280), shock at admission (OR=4.55, P=0.0001), and early rebleeding (OR=1.47, P=0.004). Prometeo database has provided an up-to-date picture of acute nonvariceal UGIB in Italy: patients are elderly, predominantly males, and with important comorbidities. Gastroprotection is underutilized during NSAIDs treatment. With respect to previous studies, Prometeo shows a higher incidence of low-dose acetyl salicylic acid use and comorbidities, whereas no significant difference were found in other items (etiology of bleeding, NSAIDs use, need for endoscopic hemostasis, incidence of rebleeding, and overall mortality).

Incremental change in acute esophageal necrosis: report of two cases

Acute esophageal necrosis, also called "black esophagus" because of its characteristic appearance on endoscopy, is a life-threatening disease; however, its temporal evolution on endoscopy is not well understood. We describe the serial changes in acute esophageal necrosis in two patients, who underwent four upper endoscopic examinations each. Serial endoscopy demonstrated progressive necrosis extending from the lower esophagus proximally to involve the middle or upper thoracic esophagus in both patients. The first patient was treated with transhiatal esophagectomy, followed by esophageal reconstruction, and medical control of repeated duodenal ulcer bleeding. The second patient died of esophageal perforation, as a complication of Sengstaken-Blakemore tube stent placement to control esophageal bleeding. We report these cases to demonstrate the importance of early detection and prompt surgical treatment of acute esophageal necrosis.

In-Hospital Mortality Risk Estimation in Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding Undergoing Hemodialysis: A Retrospective Cohort Study

Background: Upper gastrointestinal bleeding (UGIB) is a major cause of clinical bleeding among patients with end-stage renal disease (ESRD). This study aimed to investigate the association between mortality and UGIB in patients with uremia. Methods: From 2004 to 2010, a tertiary hospital-based retrospective cohort comprising 322 patients undergoing hemodialysis was investigated. All the patients were diagnosed with UGIB according to the International Classification of Diseases, 9th Revision (ICD-9) that included peptic ulcer bleeding, duodenal ulcer bleeding, and other symptoms. UGIB was required to be one of the first three discharge diagnoses. Rehospitalization within 3 days after discharge was regarded as the same course. Exclusion criteria were age <20 years, previous gastric resection or vagotomy, esophageal and gastric variceal bleeding, or gastric cancer within the first 2 years of the index hospitalization. Results: The all-cause in-hospital mortality rate of patients with UGIB undergoing hemodialysis was high, with the first-month mortality rate of 13.7%, sixth-month mortality rate of 26.7%, and first-year mortality rate of 27.0%. Using Cox regression models, we found that the high mortality rate of the UGIB group was significantly correlated with older age [adjusted hazard ratio (HR) = 1.02, 95% confidence interval (CI) = 1.01–1.04], female sex (adjusted HR = 1.62, 95% CI = 1.05–2.51), infection during hospitalization (adjusted HR = 1.85, 95% CI = 1.13–3.03), single episodic UGIB (adjusted HR = 2.00, 95% CI = 1.08–3.70), abnormal white blood cell (WBC) count (adjusted HR = 1.59, 95% CI = 1.03–2.45), and albumin level ≤3 g/dL (adjusted HR = 2.67, 95% CI = 1.51–4.72). Conclusion: In conclusion, patients with ESRD who are admitted with primary UGIB have a profoundly increased risk of all-cause in-hospital mortality during the follow-up period.

Effects of proton pump inhibitors and H2-antagonists on neutrophil oxidative metabolism in patients with gastric and duodenal ulcer bleeding

Event Abstract Back to Event Effects of proton pump inhibitors and H2-antagonists on neutrophil oxidative metabolism in patients with gastric and duodenal ulcer bleeding Natalia Obraztsova1*, Oksana Sulaieva1, Stanislav Zharikov1 and Victoria Delii1 1 Donetsk national medical university of M. Gorky, Ukraine Background. Despite the progress in pharmacotherapy and endoscopic management of bleeding 20-30% of patients demonstrate the recurrent bleeding. One of the reasons of it may be inflammation propagation related with dysfunction of neutrophils (Nph). The goal of this research was to estimate the effects of the most common antisecretory drugs as proton pumps inhibitors (PPI) and H2 antagonists (H2A) on Nph oxidative metabolism. Material and methods: Characteristics of bleeding were defined in 124 patients by clinical, laboratory and endoscopic criteria according to Forrest class. In total, 63 patients were treated with PPI, and 61 with H2A. To assess Nph oxidative metabolism, superoxide production was measured using the nitroblue tetrazolium reduction test (NBT) in isolated neutrophils at 1st, 3d and 7th day of therapy. Results. NBT reduction rate was significantly higher in patients with active bleeding (F1a) than that in patients with sustained haemostasis (p<0.05). It has been shown that intensity of superoxide radicals’ production by Nph was higher in patients who were admitted at 12-24 hours than at 3-6 hours after first clinical manifestation of hemorrhage (p<0.05). Administration of PPI was associated with decrease the NBT reduction rate (p<0.01), whereas H2A administration was associated with stimulation of NADPH-oxidase activity (p<0.05) in neutrophils. Conclusion. Administration of PPI and H2A not only affect gastric acid production but also change innate immunity mechanisms since NADPH-oxidase activity of Nph is related with pagocytosis and lifespan. So antisecretory drugs can modulate the acute inflammatory reaction by cells kinetics in ulcer region. Keywords: Neutrophils, bleeding, superoxide, H2-antagonists, PPI Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Innate immunity Citation: Obraztsova N, Sulaieva O, Zharikov S and Delii V (2013). Effects of proton pump inhibitors and H2-antagonists on neutrophil oxidative metabolism in patients with gastric and duodenal ulcer bleeding. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.00545 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 05 Jun 2013; Published Online: 22 Aug 2013. * Correspondence: Miss. Natalia Obraztsova, Donetsk national medical university of M. Gorky, Donetsk, Ukraine, natalionus@gmail.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Natalia Obraztsova Oksana Sulaieva Stanislav Zharikov Victoria Delii Google Natalia Obraztsova Oksana Sulaieva Stanislav Zharikov Victoria Delii Google Scholar Natalia Obraztsova Oksana Sulaieva Stanislav Zharikov Victoria Delii PubMed Natalia Obraztsova Oksana Sulaieva Stanislav Zharikov Victoria Delii Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Focal neurological deficit in acute anemia: Case reports and review of the literature

Introduction: Although anemia is not regarded as an usual vascular risk factor for stroke, it is one of the potential mechanism by which the brain does not receive adequate oxygenation. Moreover, the relationship between drop of hemoglobin and acute focal neurological deficits is not clear. We report two patients with cerebral infarction due to acute anemia. Case Reports: Case 1 was a 73-year-old man who complained an episode of loss of consciousness followed by right hemiparesis and dysarthria after few hours. The day after admission he presented melena caused by a duodenal ulcer bleeding. The hemoglobin dropped from 11.3 g/dl to5.6 g/dl in 24 hours. Areas of acute infarctions were evident at diffusion-weighted imaging (DWI) of the brain. Case 2 was a 77-year-old man with a transient episode of aphasia, right lower limb paresis and mental confusion twelve hours after an intervention of PTA and stenting of the left internal carotid artery. Hemoglobin was11.8 g/dl before intervention and9 g/dl 48 hours later. DWI showed bilateral and widespread acute infarcts. Conclusion: Anemia has to be considered as a potential factor in determining or worsening cerebral infarction, especially in patients with carotid or intracranial stenosis, high cerebrovascular lesions load or insufficient collateral supply. Acute or severe anemia may negatively impact the cerebral blood flow and decrease oxygen-carrying capacity, promote rapid deterioration of ischemic penumbra. Brain DWI and treatment of the underlying etiology of acute anemia are crucial in early identification and recovery of cerebral infarctions.

Long-term Outcomes of Endoscopic Variceal Ligation to Prevent Rebleeding in Children with Esophageal Varices

After an episode of acute bleeding from esophageal varices, patients are at a high risk for recurrent bleeding and death. However, there are few reports regarding the long-term results of secondary prophylaxis using endoscopic variceal ligation (EVL) against variceal rebleeding in pediatrics. Thirty-seven, who were followed for over 3 yr post-eradication, were included in the study. The mean duration of follow up after esophageal variceal eradication was 6.4±1.9 yr. The mean time required to achieve the eradication of varices was 3.25 months. The mean number of sessions and O-bands needed to eradicate varices was 1.9±1.2 and 3.8±1.5, respectively. During the period before the first EVL treatment, 145 episodes of bleedings developed in 37 children. Over the 3 yr of follow-up after variceal eradication, only 4 episodes of rebleeding developed in 4 of 37 patients. The four rebleeding episodes consisted of an esophageal variceal bleed, a gastric variceal bleed, a duodenal ulcer bleed, and a bleed caused by hemorrhagic gastritis. There was no mortality during long-term follow up after variceal eradication. During long-term follow up after esophageal variceal eradication using solely EVL in children with esophageal variceal bleeds, rebleeding episodes and recurrence of esophageal varices were rare. EVL is a safe and highly effective method for the long-term prophylaxis of variceal rebleeding in children with portal hypertension.

Could application of epinephrine improve hemostatic efficacy of hemoclips for bleeding peptic ulcers? A prospective randomized study

Bleeding from peptic ulcers can be effectively and safely treated with endoscopic hemoclips therapy. However, due to certain limiting factors of hemoclips, application of combination with another endoscopic method may give better results. The aim of this study was to examine the efficacy and safety of endoscopic hemoclips therapy and to evaluate potential benefits of this therapy combined with epinephrine in the treatment of bleeding peptic ulcers. This prospective randomized study included 70 patients with bleeding gastric or duodenal ulcer. In 34 of the patients endoscopic hemoclips therapy was applied (group I), and in 36 of them a combined therapy of hemoclips and epinephrine (group II). Initial hemostasis was achieved in most patients treated with endoscopic hemoclips therapy (94.1%) as well as in the patients treated with combination therapy (97.2%). After initial hemostasis achieved rebleeding occurred in 3 (9.3%) patients treated with hemoclips and in 2 (5.7%) patients treated with combination therapy, but this difference was not statistically significant (p > 0.05). The difference in the achieved final hemostasis between the group I (91.1%) and the group II (94.4%) was not statistically significant. Also, the differences between the two groups of patients in the need for blood transfusions, length of hospital stay, need for surgery and mortality were not statistically significant (p > 0.05). Endoscopic hemoclips therapy is effective and safe in treatment of bleeding peptic ulcers. Combination therapy of hemoclips and epinephrine has no advantage over hemoclips monotherapy.

Analysis of Disease Classification of Upper Gastrointestinal Bleeding

Objective. To analyze and explore the disease diagnostic code for different parts of upper gastrointestinal bleeding. Methods. Utilizing ‘international statistical classification ICD-10 of diseases and related health problems’ to analyze 101 medical records of the cases diagnosed of upper gastrointestinal bleeding from July 1 2011 to June 31 2012 in a third-grade hospital from the choice of the leading words to disease diagnosis coding. Results. Of the 101 copies of medical records coded of K92.2, 92 copies of gastroscopy accounted for 91.09% of all cases diagnosed with upper gastrointestinal bleeding by doctors. By rereading the 92 copies of medical records of the cases who underwent gastroscopy, 23 cases of gastric ulcer bleeding and gastric mucosal lesions bleeding accounting for 25%, 2 cases of duodenal ulcer bleeding accounting for 2.17%, and 67 cases of esophageal variceal bleeding and esophageal mucosal laceration accounting for 72.83% were found. Conclusion. Coders should not only master the coding knowledge, but also read the medical records carefully, learn the related medical knowledge and code accurately in their daily work to serve medical treatment, teaching and research better.

Management of duodenal ulcer bleeding resistant to endoscopy: Surgery is dead!

Acute massive duodenal bleeding is one of the most frequent complications of peptic ulcer disease. Endoscopy is the first-line method for diagnosing and treating actively bleeding peptic ulcers because its success rate is high. Of the small group of patients whose bleeding fails to respond to endoscopic therapy, increasingly the majority is referred for embolotherapy. Indeed, advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage from peptic ulcers over the past decade. Embolization may be effective for even the most gravely ill patients for whom surgery is not a viable option, even when extravasation is not visualized by angiography. However, it seems that careful selection of the embolic agents according to the bleeding vessel may play a role in a successful outcome. The role of the surgeon in this clinical sphere is dramatically diminishing and will certainly continue to diminish in ensuing years, surgery being typically reserved for patients whose bleeding failed to respond all previous treatments. Such a setting has become extremely rare.

Endoscopic band ligation for peptic ulcer bleed

Introduction: Endoscopic band ligation is commonly used to treat variceal bleeding; the use of band ligation has only been described in selected cases of nonvariceal bleeding. We describe the successful use of endoscopic band ligation to arrest bleeding in two cases of duodenal ulcer hemorrhage. This to our knowledge is only the fourth such report of endoscopic band ligation in English medical literature. Case Presentation: We report the cases of a 47-year-old male and a 32-year-old female presenting with upper GI bleed who were successfully managed by endoscopic band ligation. Conclusion: EBL is an effective, safe and economical endoscopic treatment for acute peptic ulcer bleeding. Larger studies in patients with acute peptic ulcer bleeding are needed to confirm these promising results.

Fatal acute pancreatitis following sclerosis of a bleeding duodenal ulcer complicated by an intramural duodenal hematoma

An 80-year-old male was admitted with generalized weakness, pale skin and tarry stools. He had a past medical history of atrial fibrillation on anticoagulant therapy (warfarin) and osteoarthritis requiring more than occasional non-steroidal anti-inflammatory drugs. His blood pressure was 154/65 mmHg and he had no abdominal tenderness. Significant laboratory results showed: hemoglobin 9.4 g/dl, international normalized ratio (INR) 3.84, blood urea 141 mg/dl and creatinine 1.2 mg/dl. Upper endoscopy revealed an oozing ulcer at the bulbar apex (Forrest classification IB) that was treated with epinephrine (10 ml at 1:10,000) and polidocanol (5 ml at 1%) injection (Fig. 1). Warfarin was stopped and intravenous proton pump inhibitors initiated. After 24 h, he started to complain of progressively increasing epigastric pain. A drop in hemoglobin concentration to 6 mg/dl, a prolongation of the INR to 4.05, an elevated amylase (2,491 U/L) and lipase (16,100 U/L) were noted. He was transfused with two units of packed RBC. On abdominal ultrasound (US) no particular finding as to the cause of the pancreatitis was found. However, the abdominal complaints worsened and on day 3 an abdominal CT revealed pancreatic head edema, inflammatory changes in the peripancreatic fat and a huge intramural duodenal hematoma (14 x 6 cm) that involved the second portion of the duodenum and was associated with free peritoneal fluid and air (Fig. 2). Returning from the CT scan, the patient suffered cardiac arrest and died in spite of our best efforts to resuscitate him.