Episodes Of Lower Gastrointestinal Bleeding Research Articles

Gastrointestinal Bleeding in COVID-19 Infected Patients, and Management Outcomes.

Gastrointestinal bleeding in COVID-19-infection poses unique challenges to patients owing to the high risk of concomitant respiratory failure. However, endoscopic care providers are prone to transmission. This study aimed to understand the risk and management outcomes of gastrointestinal bleeding in COVID-19-infected patients. Data were abstracted from electronic patient medical records, using ICD 10 codes, and demographic and clinical data were collected, for COVID-19-infected patients who developed gastrointestinal (GI) bleeding. Complications related to COVID-19 infection and management outcomes of GI bleeding were studied. Statistically, descriptive analysis was used because of the small sample size. Eighteen COVID-19-infected patients developed episodes of GI bleeding, yielding a prevalence of 0.45%. Their mean age was 74.8 years, 55.5% were female, and 66.6% of patients (n=12) had upper GI bleeding symptoms, predominantly melena (55.5%), followed by coffee ground nasogastric aspirates (n=2). Only two patients (11.11%) had episodes of lower GI bleeding, and the remaining four patients (22.2%) had recurrent acute anemia requiring blood transfusion. The Glasgow-Blatchford score (GBS) at presentation ranged between 6 to 16 (mean 8.8) and seven patients (38.8%) underwent endoscopic evaluation for GI bleeding. The predominant comorbid conditions included hypertension (22.2%), diabetes mellitus (27.7%), chronic kidney disease (50%), ischemic heart disease (33%), atrial fibrillation (11.1%), and peripheral vascular disease (11.1%). The median hospitalization was 24.6 days (range: 3-54 days). The 30-day mortality rate in our cohort was 22.2%, (4/18) mainly noted in older patients aged> 60 years with comorbid conditions and severe COVID-19 infection. The prevalence of GI bleeding observed in our cohort was approximately 0.45%, significantly lower than the global prevalence observed, majority (66%) had upper GI bleeding. The exact reasons for the observed low prevalence of GI bleeding cannot be explained and will be the subject of future research.

AN UNCOMMON PRESENTATION OF THROMBUS-IN-TRANSIT AND MASSIVE ACUTE PULMONARY EMBOLISM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Thrombus-in-transit is a rare presentation of venous thromboembolism, characterized by the presence of a floating clot traveling from the right heart into the pulmonary arterial vasculature. We present a case associated with massive pulmonary embolism (PE) in a patient with a contraindication to thrombolysis successfully treated with surgical thrombectomy. CASE PRESENTATION: A 50-year-old female with the diagnosis of Crohn’s disease presented with a one-week history of shortness of breath. On admission the patient was tachycardic, hypotensive and hypoxemic. The patient received intravenous fluids (IVF) and supplemental oxygen resulting in a transient stabilization of vital signs. Electrocardiogram showed ST depressions and T wave inversions in anteroseptal leads, Troponin- I was negative and D-dimer was elevated at 0.275 ug/mL. A chest computed tomography angiography revealed bilateral main pulmonary artery large filling defects, extending into segmental and sub-segmental arteries. Anticoagulation was started and the patient was admitted to the Medical Intensive Care Unit for close hemodynamic monitoring. A later transthoracic echocardiography showed a large hyperechoic, highly mobile mass in the right atrium, consistent with a thrombus-in-transit. The patient remained symptomatic and persistently hypotensive despite IVF. Thrombolysis was considered, but patient developed episodes of lower gastrointestinal bleeding due to Crohn’s disease flare. Cardiothoracic Surgery Service was consulted and patient underwent surgical bilateral pulmonary artery thrombectomy and removal of the right atrial thrombus. The patient was subsequently restarted on anticoagulation and discharged on day 19th post-surgery with excellent recovery. DISCUSSION: PE with thrombus-in-transit is a medical emergency that entails a high morbidity and mortality. Mortality rates can be as high as 50% in contrast to less than 10% in PE without a clot in transit. Early detection and intervention may decrease the risk of a catastrophic pulmonary embolism that can result in a poor outcome. Current therapeutic options include anticoagulation alone, medical thrombolysis and surgical thrombectomy. Although no randomized controlled trials have directly compared these treatment options, a systematic review article published in 2010 described a trend toward improved survival in surgical thrombectomy compared to thrombolysis and anticoagulation alone. On the other hand, a large study published in 2015, showed lower mortality rates with medical thrombolysis compared to surgical thrombectomy or anticoagulation alone (13.7%, 18.3% vs. 37.1%). CONCLUSIONS: PE with thrombus-in-transit is a life-threating condition that requires urgent intervention. Although no guideline recommendations have been established, surgical thrombectomy has shown high success rates and should be consider especially if contraindications to thrombolysis are present. Reference #1: Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of heart thrombi in transit: a pooled analysis. Vasc Med. 2015;20(2):131-8. Reference #2: Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systemic review of prognostic factors and treatment. Chest.2010;137(1):164-70. Reference #3: Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll.2003; 18:41(12):2245-51. DISCLOSURES: No relevant relationships by Renaud Gueret, source=Web Response No relevant relationships by VICTOR PRADO, source=Web Response No relevant relationships by MARTIN WATANABE, source=Web Response No relevant relationships by Luis Watanabe-Tejada, source=Web Response

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Covering the Cover

Radioguided surgery in Meckel's diverticulum

We analyze the case of a patient with intermittent episodes of lower gastrointestinal bleeding and suspected Meckel's diverticulum, whose presence was confirmed by (99m)Tc-pertechnetate scintigraphy. A previous exploratory laparotomy had been performed without finding the diverticulum. In spite of years of medical treatment, the patient presented a new episode of lower gastrointestinal bleeding with normal colonoscopy. A new (99m)Tc-pertechnetate scintigraphy (including SPECT/CT) was performed and allowed the anatomical location of a Meckel's diverticulum and enabled its removal by laparoscopic radioguided surgery. The introduction of SPECT/CT in the scintigraphic diagnostic protocol in Meckel's diverticulum increases diagnostic safety and improves lesion location. Furthermore, it favors the performance of radioguided surgery and facilitates the lesion resection, particularly when the patient has suffered previous abdominal surgery, with a more conservative procedure, reducing the morbidity associated with the surgical procedure.

Blue Rubber Bleb Nevus Syndrome as a Cause of Lower Digestive Bleeding

Introduction. Blue rubber bleb nevus syndrome is a rare disorder that is characterized by multiple recurrent vascular malformations that involve the skin and the gastrointestinal tract. The disease can present chronic anemia and severe episodes of gastrointestinal bleeding. Case Report. A 41-year-old man was admitted with recurrent episodes of lower gastrointestinal bleeding and anemia that had worsened over the last 3 months. The physical examination showed soft, diffuse, compressible, bluish nodules on all of the skin surfaces of the body. A biopsy from one of these skin lesions allowed a histological diagnosis of cavernous hemangioma. He submitted to a colonoscopy, which showed hemorrhoids and a plane vascular lesion mainly located on the right colon with recent signs of bleeding; this lesion was treated by local excision and sclerosis. The pathological study of the colon specimens also reflected the presence of cavernous hemangioma. The cutaneous hemangiomas and the presence of colonic venous malformations were compatible with blue rubber bleb nevus syndrome. The patient presented a favorable follow-up with clinical control of the anemia and without relapse of the gastrointestinal bleeding two years after the procedure. Conclusion. Although rarely diagnosed, blue rubber bleb nevus syndrome may be responsible for lower digestive bleeding.

Hemangioblastoma of the Gastrointestinal Tract

We present the first documented case of hemangioblastoma located in the left colon. A 75-year-old woman undergoing adjuvant chemotherapy for breast cancer experienced rectal bleeding. Colonoscopy revealed a roundish mass covered with normal mucosa in the sigmoid colon. Endoscopic ultrasound showed an isoechoic lesion originating from the third layer of the intestinal wall; underlying layers were normal. Endoscopic ultrasound features were not suggestive of either cancer or malignant stromal tumor. Left hemicolectomy was subsequently performed due to repeated episodes of lower gastrointestinal bleeding. Grossly, a circumscribed submucosal yellowish nodule (13 mm) was observed, which was not attached to any peripheral nerve. Histologically, the lesion was composed of large, atypical cells traversed by a network of blood vessels. Immunohistochemically, the cells showed positivity for inhibin and NSE and weak positivity for S-100. A diagnosis of hemangioblastoma was made. This case highlights that hemangioblastoma of the gastrointestinal tract can also occur.

Haemoperitoneum with hereditary haemorrhagic telangiectasia

In August, 2011, an 83-year-old woman presented to our emergency department with several days of diff use persistent abdominal pain. She also reported an episode of lower gastrointestinal bleeding with symptoms of orthostasis. She had a history of cardiac failure, pulmonary hypertension, and epistaxis of un known cause. On initial physical examination she was haemodynamically stable without signs of acute ab dom inal disease. She had oral mucocutaneous telangiectases. Gastric lavage was done, and no evidence of upper gastrointestinal bleeding was seen. Blood tests showed a haematocrit concentration reduction from 25% to 20%, and a haemoglobin of 69 g/L. She was admitted for blood transfusion and assessment. After 5 days, she developed acute abdominal pain, tachycardia (135 beats per min), and hypotension (80/40 mm Hg). Sonography of the abdomen showed a large amount of free abdominal fl uid. Multi-detector computed tomography (MDCT) of the abdomen and pelvis confi rmed intra-abdominal fl uid and also showed liver arteriovenous malformations. CT-guided paracentesis confi rmed a diagnosis of haemo peritoneum. An emergency surgical exploration of the abdominal cavity was done because of her poor clinical condition. Explor ation showed haemo peritoneum and a portal vein branch with active bleeding due to the vascular malformations (fi gure). Haemostatic suturing was done to stop bleeding, and the abdominal cavity was drained. She had an uneventful postoperative course and was discharged at postoperative day 10. At last follow-up in Lancet 2013; 381: 962

Mesenteric Embolization for Lower Gastrointestinal Bleeding

Mesenteric embolization is an established treatment for lower gastrointestinal bleeding. The aim of this study was to determine the outcome of angiography and embolization and its influencing factors. A prospective database of all mesenteric angiograms performed for lower gastrointestinal bleeding at a tertiary center between 1998 and 2008 was analyzed in combination with chart review. There were 107 angiograms performed during 83 episodes of lower gastrointestinal bleeding in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. Twelve (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. Nine patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient. Mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolization in 45%. Embolization achieves clinical success in 76% of patients but repeat embolization is associated with a high rate of complications.

Recurrent lower gastrointestinal bleeding from idiopathic ileocolonic varices: a case report

IntroductionVarices of the colon are a rare cause of lower gastrointestinal bleeding, usually associated with portal hypertension due to liver cirrhosis or other causes of portal venous obstruction. Idiopathic colonic varices are extremely rare. Recognition of this condition is important as idiopathic colonic varices may be a cause of recurrent lower gastrointestinal bleeding.Case presentationWe report the case of a 21-year-old Asian man from north India who presented with recurrent episodes of lower gastrointestinal bleeding. Colonoscopy revealed varices involving the terminal ileum and colon to the sigmoid. Thorough evaluation was undertaken to rule out any underlying portal hypertension. Our patient underwent subtotal colectomy including resection of involved terminal ileum and an ileorectal anastomosis.ConclusionColonic varices are an uncommon cause of lower gastrointestinal bleeding. Idiopathic colonic varices are diagnosed after excluding underlying liver disease and portal hypertension. Recognition of this condition is important as prognosis is good in the absence of liver disease and is curable by resection of the involved bowel.

Graft-Versus-Host Disease or Infection: Rapid Detection of HLA Mismatch-Reactive T Cells Ex Vivo Can Facilitate Diagnosis and Guide Therapy after Allogeneic Transplantation.

Diagnosis of graft-versus-host disease (GVHD) is mainly based on clinical features and on tissue biopsies. However, clinicians and pathologists are well aware of cases, in which GVHD cannot be distinguished from infections arising from severe immunodeficiency after allogeneic stem-cell transplantation (SCT). This may pose a deep therapeutic dilemma of whether to modify immunosuppressive treatment or to use donor lymphocyte infusion (DLI) for promoting anti-microbial immunity. We observed a 68-year-old patient with myelodysplastic syndrome who developed acute GVHD grade II of skin and gut at d+16 after T-cell depleted reduced-intensity SCT (Fig. 1). GVHD was confirmed by histology and responded to prednisolone therapy. From d+90 to d+240, the patient suffered from massive diarrhea (>2L per day) and recurrent episodes of lower gastrointestinal bleeding. Histopathology analysis on gut biopsies showed a heterogeneous picture with signs of GVHD and ulcerative inflammation. In stool screening, we isolated norovirus type 2 (ELISA, PCR) between d+111 and d+229, thereby confirming the longest infection with this virus ever reported. Tapering immunosuppression did not improve diarrhea, and the patient required intensive care due to serious fluid imbalance. Because of severe lymphopenia (<100 per μL CD3 T cells), we considered DLI therapy to promote T cell reconstitution and norovirus clearance. To balance the risk for DLI-induced exacerbation of GVHD, we first analyzed peripheral blood CD8 T cells for anti-recipient reactivity ex vivo by IFN-γ ELISPOT assay. Due to the limited availability of recipient cells and a single HLA disparity between donor (B*3508) and patient (B*3503), we used HLA-deficient K562 cells transfected with mismatched (B*3503) or matched (A*0201) HLA alleles as antigen-presenting cells. Post-transplant CD8 T cells specifically recognized disparate HLA-B*3503 (Fig. 1), but not shared HLA-A*0201. Mismatch-reactive CD8 T cells were detectable at significant numbers (71/105) during the first episode of GVHD and correlated closely with the intensity of diarrhea beyond d+110. Maximum anti-HLA-B*3503 reactivity (439/105) on d+205 was in the range of IFN-γ spot production obtained in mitogen-stimulated controls. Considering this vigorous alloreactivity, we were concerned that scheduled DLI would boost GVHD rather than facilitating norovirus clearance. Therefore, we decided to omit DLI. Patient's clinical condition improved spontaneously around d+240, and diarrhea did not recur thereafter. In conclusion, we have established a new T cell assay for the rapid detection of anti-HLA mismatch reactivity using K562-HLA transfectants as substitutes for patient cells. In the meantime, we have validated this assay in two further HLA-incompatible donor-patient pairs and generated off-the-shelf K562 transfectants for more than 15 HLA alleles. Ex vivo alloreactivity toward mismatch HLA might be a surrogate marker to facilitate GVHD diagnosis and guide therapy in ambiguous clinical situations, such as the coincident viral infection described herein. [Display omitted]

Laparoscopy-Assisted Surgical Management of Obscure Gastrointestinal Bleeding Secondary to Meckel's Diverticulum in a Pediatric Patient

Despite advances in endoscopy and imaging, acute gastrointestinal (GI) bleeding of obscure origin in children presents a challenge to pediatric gastroenterologist. Bleeding Meckel's diverticulum (MD) commonly presents with acute episode of lower GI bleeding. A conventional diagnostic algorithm includes endoscopy, technetium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy. The advent of minimal access surgery prompts the use of laparoscopy for children with obscure GI bleeding. Laparoscopy assists in the diagnosis and can offer definitive treatment of patients with MD. Herein, we report a case of pediatric GI bleeding of obscure origin associated with MD that was successfully diagnosed and managed via laparoscopy. This article updates the current management for pediatric patients with obscure GI bleeding and the role of laparoscopy in the management of MD.

Catheter-induced Vasospasm in the Treatment of Acute Lower Gastrointestinal Bleeding

To demonstrate results in managing lower gastrointestinal (GI) bleeding with the use of superselective catheterization and intentional induction of vasospasm of the bleeding vessel without the use of embolic agents or vasospasm-inducing medications. A retrospective review of 15 episodes of lower GI bleeding treated in the past 6 years by intentional catheter-induced vasospasm (CIV) to achieve thrombosis of a bleeding source was conducted. Nine patients had angiographically proven inferior mesenteric artery bleeding and six had angiographically proven superior mesenteric artery bleeding. Bleeding was stopped initially in all patients after effective treatment of the feeding artery. Only one patient experienced a repeat episode of bleeding 2 days later, which required hemicolectomy. Two other patients who underwent adequate embolization underwent surgery at the discretion of the surgeon involved. The remainder were clinically observed and discharged after return of stable vital signs and hematocrit levels. None of the patients treated had clinically evident intestinal ischemia or infarction. There was one significant repeat incidence of bleeding 2 months after CIV that may have represented recurrent bleeding from the original site. CIV may be a safe and effective first-line method of embolizing known lower GI bleeding. Whether CIV is used as primary therapy or as the result of spasm incurred during superselective catheterization, the patient may be regarded as successfully treated and followed accordingly, thereby possibly avoiding acute surgical therapy.

65 COLONIC ANGIODYSPLASIA PRESENTING IN PEDIATRIC PATIENTS.

Although angiodysplasia of the colon is diagnosed frequently in the elderly, it is a very rare cause of massive lower gastrointestinal bleeding in children. We report two pediatric patients ages 13 and 15, in whom life threatening gastrointestinal hemorrhage was due to colonic angiodysplasia. Both patients were in good health until they presented with painless rectal bleeding. Physical exam was unremarkable except for orthostasis. Both patients had severe anemia at presentation with hemoglobin levels ranging from 4.4 to 8.9 g/dl. Colonoscopy and angiography established the diagnosis. Both patients had ileocecal involvement; one patient also had rectal and perianal lesions. Both underwent ileocecal resection with significant improvement postoperatively. One patient has required endoscopic sclerotherapy for lesions in the rectum. Although vascular malformations account for a minority of episodes of lower gastrointestinal bleeding in pediatric patients, the occurrence of these lesions should be considered in the differential diagnosis of severe gastrointestinal hemorrhage in children.