Etiology Of Lower Gastrointestinal Bleeding Research Articles

Etiological Profile of Lower Gastrointestinal Bleeding in Children and Adolescents from Kashmir; A Tale of 5 Years.

Background: Lower gut bleeding is an alarming sign among caregivers. Determining the etiology is of utmost importance for further management. This is the first study conducted in northernmost India. Methods: This cross-sectional study was conducted at the Department of Pediatrics, Government Medical College, Srinagar. This study aimed to describe the etiology of lower gastrointestinal bleeding in the age group of 1-18 years over the past 5 years from June 2017 to June 2022. Results: A total of 310 children presented with hematochezia (53.5%), blood mixed with loose stools for > 2 weeks (39.3%), melena (1.9%), and occult blood in stools (0.3%). The mean age was 5.12 years. The age group of 1-6 years was 73.5 %. The most common findings were rectosigmoid polyps n=104 (33.5%), anal fissure n=47 (15.1%), lymphoid nodular hyperplasia (LNH) n=38 (12.2%), trichuris dysentery syndrome n=30(9.7%), cow's milk protein allergy n=27(8.7%), non-specific colitis n=18(5.8%), solitary rectal ulcer syndrome n=14(4.5%), inflammatory bowel disease n=6 (1.9%),intestinal tuberculosis n=3(0.9%), duodenal dieulafoy lesion 1(0.3%), and blue bleb nevus rubber syndrome n=1(0.3%). 21 patients had a normal colonoscopy. The colonoscopy yield was 93.3 %. Among the colonoscopy-negative patients, 6(1.6%) had Meckel's diverticulum, and 1(0.3%) had a duodenal dieulafoy lesion. Conclusion: Lower GI bleeding most commonly presents as hematochezia, and the most common cause is a rectosigmoid polyp. Colonoscopy is the procedure of choice to evaluate the etiology of lower GI bleeding. Anal fissures, LNH, Trichuris trichiura, and cow's milk protein allergy are other common causes of lower gut bleeding in Kashmir, northernmost India.

ETIOLOGICAL PROFILE OF LOWER GASTROINTESTINAL BLEED IN A TERTIARY CARE HOSPITAL IN NORTHERN INDIA

NTRODUCTION - Lower Gastrointestinal(GI) bleeding refers to blood loss of recent onset originating from a site distal to the ligament of Treitz.1It usually presents as hematochezia i.e. passage of maroon or bright red blood or blood clots per rectum. Lower GI bleeding ( LGIB) accounts for almost 20% of all cases of acute GI bleeding.2 The etiology and the epidemiology of LGIB varies according to the environmental conditions depending upon the life style, dietary habits, the prevalence of smoking, history of drug intake, age and longevity of the population etc.2 Most of the studies pertaining to the etiologies of Lower GI bleeding are from the West. Data relating to the incidence and etiologies of Lower GI bleed in India is scarce hence this study was undertaken to identify the etiological profile of patients presenting with Lower GI bleeding in a tertiary care hospital in the northern part of India. MATERIALS AND METHODS - It is a Cross-sectional study done over a period of 1 year from January, 2018 to December, 2018. All the patients above 18 years of age with first presentation of Lower GI bleeding to the Department of Medicine, SRMS- IMS, Bareilly, Uttar Pradesh during the period of study are included in the study. RESULTS - A total of 232 patients meeting the inclusion criteria were included in the study. Majority of the patients were males (69.8%). Hematochezia (86%) was the most common presenting feature and was commonly associated with constipation (46%), abdominal pain (32%) and loss of weight (11%). 8% of the patients had a history of Diabetes. Alcohol consumption was seen in 17% of the patients while 26% of the patients had a history of smoking. The most common etiology of Lower GI bleed seen was Hemorrhoids (35.3%), followed by Inflammatory Bowel disease(16.3%), Malignancy(12%) and Radiation proctosigmoiditis (11.2%). CONCLUSION - LGIB is a common and alarming presenting condition in the practice of gastroenterology. It was found that Lower GI bleed is more common in males, usually in the 3rd to 4th decade of life and most commonly presents with hematochezia. Haemorrhoids, IBD and Malignancy were the major causes of Lower GI bleed.

591 Trend Analysis of Lower Gastrointestinal Bleeding 2002-2017: A Population-Based Study

INTRODUCTION: Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database. METHODS: Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016. RESULTS: Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies. CONCLUSION: The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.

2030 A Unique Case of Appendiceal Orifice Bleeding

INTRODUCTION: Appendiceal orifice bleeding is an uncommon etiology of lower gastrointestinal bleeding and is often attributed to various appendix pathologies. We report a case of appendiceal orifice bleeding in a woman with fibrous obliteration of the appendix. CASE DESCRIPTION/METHODS: A 51-year-old female with fibromyalgia and chronic abdominal pain underwent outpatient colonoscopy to evaluate several months of intermittent hematochezia. Hemoglobin four months prior to procedure was 12.3 g/dL. Colonoscopy revealed fresh blood in the cecum and right colon. After irrigation, active oozing from the appendiceal orifice was seen. There was no blood in the terminal ileum. She was also found to have a non-bleeding rectal AVM, which was cauterized. Hemoglobin the day of procedure was 11.8. She had normal vitals and physical exam. A CT scan obtained three days later revealed a normal appendix and GI tract. She was referred to general surgery and underwent laparoscopic appendectomy three months later. She reported intermittent hematochezia two months after her surgery but did not pursue further work up. Her next follow up encounter was 15 months after her surgery and no further hematochezia was reported. Pathology analysis of her appendix revealed fibrous obliteration with foci of neural hyperplasia and entrapped residual neuroendocrine nests. There was no evidence of cellular atypia, mitotic activity, or neoplasm. DISCUSSION: Available literature on appendiceal orifice bleeding is sparse and mainly compromised of isolated cases. Most case reports involve acute, inpatient situations and abnormal CT findings, so it is important to underscore the decision to pursue a CT scan despite our patient’s chronic and mild presentation. The recurrent hematochezia two months after surgery is difficult to explain, but it did resolve by the time she re-established care and could be unrelated. Pathology findings did not include previously noted etiologies of appendiceal orifice bleeding (erosions, diverticula, malignancy). However, fibrous obliteration of the appendix is a rare finding and occurs when spindle cell proliferation replaces the appendiceal lumen. Fibrous obliteration of the appendix is also termed neurogenic appendicitis or appendiceal neuroma. There does not appear to be any previous associations of documented appendiceal orifice bleeding and fibrous obliteration of the appendix. Our case highlights the need for further investigation into these two rare entities.

Itʼs Not Always the Diverticula: A Rare Case of Obscure Overt Lower Gastrointestinal Bleed Resulting From a Fistulous Tract Between Rectum and Seminal Vesicle Secondary to Metastatic Prostate Adenocarcinoma

Diverticula and hemorrhoids are the most common etiology of lower gastrointestinal bleed (LGIB) with other causes including angioectasias, malignancy, colitis (ischemic, infectious, and inflammatory), post procedural, and disorders of the anorectal region. In rare instances of surgical prostatic manipulation, LGIB has occurred. We present a rare case of fistulous tract formation resulting in ongoing obscure, overt LGIB secondary to metastatic adenocarcinoma of the prostate. We present a case of a 74 year old male with a past medical history of hypertension, paroxysmal atrial fibrillation not on anticoagulation, hemorrhoids, benign prostatic hypertrophy, and diverticulosis, who presented to his urologist with complaints of urinary retention Computed tomography (CT) of the abdomen and pelvis revealed enlarged prostate and seminal vesicle mass thought likely to be a cyst which led to a transrectal biopsy. Approximately 1 month later, patient developed acute lower gastrointestinal bleeding and underwent colonoscopy that revealed pan mild diverticulosis and hemorrhoids. The patient continued to have intermittent lower gastrointestinal bleeding requiring multiple hospitalizations and blood transfusions. Multitude of testing including EGD, multiple colonoscopies, tagged red blood cell scans and computed tomography angiography failed to localize the bleeding and patient underwent sigmoidectomy. He continued to bleed flexible sigmoidoscopy noted a brief jet of bright red blood coming from the anus near the dentate line that stopped spontaneously.. Patient underwent surgical exploration with colorectal and urology and tumor, confirmed as adenocarcinoma of the prostate, was found to be replacing the space between the rectum and the seminal vesicle likely stemming from the seminal vesicles and a noted defect in the left anterior rectum which was identified as the site of the fistula approximately 2 centimeters in size. The defect was closed during surgery. Following these procedures there was resolution of the hematochezia Although rare, metastatic adenocarcinoma of the prostate can lead to the development of a rectal-seminal vesicle fistula causing LGIB. Brief review of the literature did not return any reported cases of rectal-seminal vesicle fistula caused by tumor involvement. A thorough evaluation of the entire patient including all comorbities should be completed when evaluating etiology of recurrent lower gastrointestinal bleeding.

Spectrum of the causes of lower gastrointestinal bleeding in geriatric patients in tertiary care hospital

Context: Lower gastrointestinal bleeding (LGIB) patients in geriatric are the common indication of hospital admissions, with marked geographic variation in the frequency of different etiologies. Colonoscopy is considered as first-line diagnostic procedure of choice in evaluation of patients with bleeding per rectum. Aims: This study aims to determine spectrum of LGIB in our region using lower gastrointestinal (GI) endoscopy. Settings and Design: A retrospective study of 2-year period from August 2010 to July 2012, 2 years study in tertiary hospital. Subjects and Methods: The clinical data of patients admitted with per rectal bleeding were collected including age, sex, site of bleeding and the underlying cause. In all cases proctoscopy was done and colonoscopy after preparation and stabilization of the patients. Statistical Analysis Used: SPSS analysis. Results: During 2-year follow-up study, 45 patients were admitted with LGIB with mean age of 67.5 years, the bleeding site was in the colorectal causes found in 33 (73.3%) cases, while perianal in 6 (13.3%) of cases. Carcinoma was the most common cause. Conclusions: Bleeding per rectum is a common cause in geriatric patients admitted to Gastroenterology Department. Carcinoma is the most common cause of bleeding per rectum. There is wide geographic variation regarding the etiologies of LGIB. Lower GI endoscopy is very useful tool in evaluating patients with bleeding per rectum.

Etiological profile, gender difference and age group patterns of 415 patients presenting with lower gastrointestinal bleeding in the western region of Nepal

Background: Lower gastrointestinal bleeding (LGIB) is a common clinical condition associated with significant morbidity and mortality. The aims of our study were to determine the etiological profile, gender difference and age group patterns of LGIB in Nepal.Methods: A total of 415 consecutive patients presenting with LGIB from April 2011 to September 2014 underwent colonoscopy and the etiology of LGIB was determined. Each diagnosis was compared with respect to the gender and age group.Results: Among 415 LGIB patients (males 62.2%, females 37.8%), the different etiologies of LGIB were as following: hemorrhoid 35.2%, non-specific colitis 24.8%, colon polyp 18.3%, inflammatory bowel disease (IBD) 10.4%, colon cancer 6.5%, diverticulosis 1.7%, unknown 1.4%, upper gastrointestinal bleeding 1.2% and radiation colitis 0.5%. The overall LGIB was more common in male; however, colon polyps were diagnosed more commonly in female (p<0.001). Among LGIB patients, the hemorrhoid was more common in the age group of 30-49 years, colon polyp in 50-69 years, colon cancer in 70-84 years, and non-specific colitis and IBD in 16-29 years (p<0.001).Conclusion: Hemorrhoid and non-specific colitis were the common causes of LGIB in Nepal; colon polyp, IBD and colon cancer were the next common causes. More males presented with LGIB than females; however, colon polyp was diagnosed more in females, which needs to be explored further. When LGIB was presented after 50 years of age, the most likely causes were colon polyp and colon cancer; hence colonoscopy is recommended in all LGIB patients after 50 years.Journal of Advances in Internal Medicine 2014;3(2):52-55

Chicken Bone Impaction Diagnosed by Computer Tomography Angiography: A Rare Cause of Lower Gastrointestinal Bleeding

A 71-year-old man presented with hematochezia and paraumbilical abdominal pain. The patient had a history of left hemicolectomy for unresectable large colonic polyps, but he had no prior episodes of gastrointestinal bleeding and was not on anticoagulants, antiplatelet therapy, or non-steroidal anti-inflammatory drugs. Upon arrival, the patient was hemodynamically stable with a normal complete blood count and international normalized ratio (INR). A computerized tomography angiogram (CTA) utilizing a “bleeding scan protocol” was performed. The radiologist identified a foreign body in the proximal sigmoid colon with adjacent inflammatory changes, with structural characteristics suggesting a chicken gracile bone (Figure 1). The radiologist felt that the location of the gracile bone was the likely source of gastrointestinal hemorrhage due to visible extravasation of contrast. The patient underwent colonoscopy, which demonstrated an impacted gracile bone not adjacent to any diverticula at 25 cm from the anal verge, which was removed via snare (Figure 2). No residual bleeding was detected on careful inspection of the colon after extraction of the bone. Although gracile bone impaction has been described in the past as a cause of upper gastrointestinal bleeding, only 1 case report described lower gastrointestinal bleeding from a chicken bone.1-4 Vosskamp et al described a case in which the patient underwent a hemicolectomy for lower gastrointestinal bleeding that showed a submucosal gracile bone adjacent to a bleeding diverticulum.4 Our case report exemplifies a rare etiology of lower gastrointestinal bleeding caused by acute gracile bone impaction in the sigmoid colon.

Etiology Profile of Lower Gastrointestinal Bleeding

Background: Lower gastrointestinal bleeding (LGIB) is still a significant health problem since the unknown etiology had not existed until now. Similar condition occurs at Adam Malik Hospital. No data about the etiology of LGIB has been defined. Therefore, this study was aimed to recognize the etiology profile of LGIB at Adam Malik Hospital, Medan. Method: A retrospective descriptive study was conducted on medical records of patients who had undergone lower gastrointestinal tract endoscopy (colonoscopy) at Adam Malik Hospital, Medan between January 2009 and December 2010 based on their complaint of hematochezia. Data was analyzed using SPSS version 19. The data was categorized based on subjects’ age, sex and etiology of their hematochezia. Results: There were 116 patients consisted of 61 (52.6%) males and 55 (47.4%) females with mean age of 50.52 (17-84) years. The colonoscopy revealed 52 (44.7%) cases of hemorrhoidal varices, 17 (14.7%) cases of rectal carcinoma, 17 (14.7%) normal endoscopic results, 8 (6.9%) cases of sigmoid carcinoma, 8 (6.9%) of proctitis, 6 (5.1%) cases of colitis, 4 (3.5%) cases of colon carcinoma, and 4 (3.5%) cases of rectosigmoid carcinoma. Conclusion: This study found that hemorrhoidal varices is the most common etiology of LGIB. Keywords: LGIB, colonoscopy, hemorrhoids

Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality

Many factors can cause morbidity and mortality in patients with severe acute lower gastrointestinal bleeding (LGIB). The objectives of this study are to analyze three aspects related to severe acute LGIB: (1) indications and prognostic factors for urgent surgery, (2) risk factors for morbidity and mortality, and (3) relapse rates. A retrospective cohort was collected between 1985 and 2002 in a tertiary referral center. One hundred seventy-one patients with severe acute LGIB were reviewed (LGIB is defined as frank rectal bleeding either with a hematocrit decrease >/=10 points or when a transfusion of at least three units of concentrated red blood cells is needed). The main outcome measures are: (1) indications for urgent surgery and results, (2) morbidity and mortality, and (3) relapse. There were 158 (92%) stable patients, and in 61% of these, the bleeding was identified via colonoscopy. Bleeding was identified using urgent colonoscopy in a higher percentage of patients compared to delayed colonoscopy (68% versus 14%; p < 0.001). Urgent surgery was indicated in 24 (14%) patients, and the approach was peri-anal in 5 (21%) patients and abdominal in the rest. Local intestinal resection was performed on the 15 patients in which bleeding was identified, whereas a subtotal colectomy was performed on the remaining 4 patients. The presence of hypotension (p = 0.001; 35 versus 10%) and etiology of LGIB (p < 0.001) are prognostic factors of urgent surgery. Morbidity was 6.4%, and mortality was 4.7%. The only morbidity or mortality risk factors detected were the presence of associated comorbidities (p = 0.008) and the need for urgent surgery (p = 0.002). The most frequent etiology was diverticulosis (25%). After a mean follow-up of 132 +/- 75 months, bleeding relapsed in 30% of patients. It is difficult to predict which patients are going to need urgent surgery in severe acute LGIB; only the presence of hypotension on arrival at the emergency ward would lead us to suspect a negative outcome for the hemorrhage. In severe acute LGIB, morbidity and mortality is high, and this is mainly due to the high level of associated comorbidity and the need for urgent surgery. It is necessary for strict hemodynamic monitoring of the patients at risk if we want to improve outcomes. The bleeding relapse rate is high in LGIB, although generally, it is not severe.

Colonoscopic Findings in African Americans Referred for Lower Gastrointestinal Bleeding

Purpose: The etiology of lower gastrointestinal bleeding (LGIB) varies widely among different populations of the world with a paucity of data on the African American population. We conducted a study to assess the etiology of lower gastrointestinal bleeding (LGIB) exclusively in African Americans, to compare with available data from North America, and the rest of the world. Lower gastrointestinal bleeding in this study was defined as the presence of occult blood in stool or hematochezia of any amount. Methods: The consecutive medical records of African American patients who were evaluated with colonoscopy for lower gastrointestinal bleeding between January 1, 1999 and May 31, 2000 were reviewed in an inner city teaching hospital. We excluded patients with history of colectomy as well as screening, surveillance, and incomplete colonoscopies. Results: A total of 318 patients' colonoscopic reports and associated biopsy reports were analyzed. 49 (15.4%) were in-patients, and the remaining 269 (84.6%) were out patients with 170 (53.5%) being female. Colonoscopy identified the cause of bleeding in 238 patients (74.8%). The commonest lesions found were adenomatous polyps (25.5%), followed by colitis (acute and chronic) which constituted 16%, diverticulosis 12.3%, carcinoma 7.5%, benign anorectal diseases 5.7% with vascular ectasia being relatively uncommon (0.9%). Our findings are somewhat similar to comparable studies in the US, that show polyps, carcinoma, diverticulosis, inflammatory bowel disease including infectious and ischemic colitis, and vascular ectasia as the descending frequency of occurrence for L.G.I.B. of all types, but at significant variance from comparable study from Africa which has benign anorectal diseases, acute amebic colitis, cancer, and polyps as the descending order of findings. Conclusions: Environmental factors including dietary practices probably play the major role in determining the etiology of lower gastrointestinal bleeding. Further studies are necessary to better define ethnic variations in lower gastrointestinal bleeding.

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Lower GI Bleeding and Acute Colorectal Obstruction

Background and Aim: Although urgent colonoscopy is often used to diagnose and treat severe lower gastrointestinal (GI) bleeding, its role in the management of acute colorectal obstruction is uncertain. Regardless of the site of colorectal obstruction, the development of a new device and techniques for its use have made it possible to endoscopically decompress acute colorectal obstruction (GI Endoscopy 2001;54:229-32). The aim of this study was to clarify the role of urgent colonoscopy in the diagnosis and treatment of acute colorectal obstruction in addition to severe lower GI bleeding. Method: From January 2001 to November 2004, 106 patients (64 males and 42 females, age 46 to 94, mean = 68.7) were identified in a colorectal database, and their cases were reviewed. All patients were hospitalized because of severe hematochezia or acute colorectal obstruction based upon abdominal CT findings. Urgent colonoscopy was performed within 24 hours for the purpose of the definite diagnosis of active lower GI bleeding or acute colorectal obstruction. After the diagnosis was confirmed, endoscopic hemoclip placement or endoscopic decompression using a transanal drainage tube was attempted. Results: In 49 (92.5%) of 53 patients who had severe lower GI bleeding, endoscopic hemoclip placement was successful. The etiology of lower GI bleeding was post-polypectomy bleeding (17), diverticulosis (14), postoperative bleeding (8), anorectal bleeding (5) or other (5). In 4 patients, bleeding sources were not identified. Endoscopic decompression by means of a transanal drainage tube was technically successful in 50 of 53 patients (94.3%). Two patients had colonic perforation. The site of obstruction was cecum in 3, ascending colon in 4, transverse colon in 5, descending colon in 11, sigmoid colon in 18, and rectum in 12. Following adequate cleansing of the colon, 42 patients underwent surgery after 7 days ± 3.2 (SD; range, 4-10 days). Stent placement was used as final palliative treatment in 4 patients. Conclusions: Urgent colonoscopy is very useful for the treatment and management of acute colorectal obstruction as well as severe lower GI bleeding. Since endoscopic decompression using a transanal drainage tube seems to be effective, acute colorectal obstruction should be considered as another indication for urgent colonoscopy to prevent emergency surgery in addition to severe lower GI bleeding. Background and Aim: Although urgent colonoscopy is often used to diagnose and treat severe lower gastrointestinal (GI) bleeding, its role in the management of acute colorectal obstruction is uncertain. Regardless of the site of colorectal obstruction, the development of a new device and techniques for its use have made it possible to endoscopically decompress acute colorectal obstruction (GI Endoscopy 2001;54:229-32). The aim of this study was to clarify the role of urgent colonoscopy in the diagnosis and treatment of acute colorectal obstruction in addition to severe lower GI bleeding. Method: From January 2001 to November 2004, 106 patients (64 males and 42 females, age 46 to 94, mean = 68.7) were identified in a colorectal database, and their cases were reviewed. All patients were hospitalized because of severe hematochezia or acute colorectal obstruction based upon abdominal CT findings. Urgent colonoscopy was performed within 24 hours for the purpose of the definite diagnosis of active lower GI bleeding or acute colorectal obstruction. After the diagnosis was confirmed, endoscopic hemoclip placement or endoscopic decompression using a transanal drainage tube was attempted. Results: In 49 (92.5%) of 53 patients who had severe lower GI bleeding, endoscopic hemoclip placement was successful. The etiology of lower GI bleeding was post-polypectomy bleeding (17), diverticulosis (14), postoperative bleeding (8), anorectal bleeding (5) or other (5). In 4 patients, bleeding sources were not identified. Endoscopic decompression by means of a transanal drainage tube was technically successful in 50 of 53 patients (94.3%). Two patients had colonic perforation. The site of obstruction was cecum in 3, ascending colon in 4, transverse colon in 5, descending colon in 11, sigmoid colon in 18, and rectum in 12. Following adequate cleansing of the colon, 42 patients underwent surgery after 7 days ± 3.2 (SD; range, 4-10 days). Stent placement was used as final palliative treatment in 4 patients. Conclusions: Urgent colonoscopy is very useful for the treatment and management of acute colorectal obstruction as well as severe lower GI bleeding. Since endoscopic decompression using a transanal drainage tube seems to be effective, acute colorectal obstruction should be considered as another indication for urgent colonoscopy to prevent emergency surgery in addition to severe lower GI bleeding.

Embolization as First-Line Therapy for Diverticulosis-Related Massive Lower Gastrointestinal Bleeding: Evidence From a Meta-analysis

The study goal was to determine which etiologies of lower gastrointestinal bleeding (LGIB) may best be treated with superselective embolization. A meta-analysis was undertaken of 25 identified publications reporting the use of embolization and an unpublished series of 12 consecutive patients with LGIB from the authors' institution. Six published series and the authors' series met selection criteria for further analysis. Multiple regression analysis demonstrated no significant difference in pooled outcomes when varying the included study, age, or embolization method on the outcome of rebleeding. The pooled odds ratio for arteriovenous dysplastic lesions and other diseases was 3.53 compared with rebleeding after localization and embolization for diverticular disease (95% confidence interval odds ratio, 1.33, 9.41; P < 0.01). Embolization for diverticular bleeding was successful in 85% of patients. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in greater than 40% of patients and over a more protracted period. Embolization for LGIB is most effective for the treatment of diverticular bleeding. Caution should be used when applying embolization therapy for nondiverticular causes due to the considerably higher associated failure rate. An inpatient observation period of 2 days is suggested following embolization for diverticular bleeding.

Embolization as first-line therapy for diverticular massive lower gastrointestinal bleeding: Evidence from a meta-analysis

Objective. To determine which etiologies of lower gastrointestinal bleeding (LGIB) may best be treated with super-selective embolization. Methods. A meta-analysis was undertaken of all 25 identified publications reporting the use of embolization and 12 consecutive cases of LGIB from the authors’ institution. Seven series met selection criteria for further analysis. Results. Multiple regression analysis demonstrated no significant difference in pooled outcomes when varying the included study, age, or embolization method on the outcome of rebleeding. The pooled odds ratio for rebleeding up to 30 days postlocalization and embolization for arteriovenous malformations (AVM) and other diseases was 3.53 compared to re-bleeding after localization and embolization for diverticular disease [95% Confidence Interval OR (1.33, 9.41), P < 0.01]. Embolization for diverticular bleeding demonstrated was successful in 85% of cases. Moreover, the vast majority of cases that rebled did so within 48 h. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in greater than 40% of cases and over a more protracted period. Conclusion. Embolization for LGIB is most effective for the treatment of diverticular bleeding. Given the low observed complication rate, minimal post-procedure recovery time, and low failure rate, super-selective embolization may be considered first-line therapy for severe diverticular LGIB regardless of age. Caution should be used when applying embolization therapy for non-diverticular causes due to the considerably higher associated failure rate.

The Therapeutic Barium Enema Revisited

The diagnosis and etiology of lower gastrointestinal bleeding from diverticulosis has been well-documented [1,2]. However, the clinical management of lower gastrointestinal bleeding remains a therapeutic dilemma for the physician. Although most bleeding episodes are mild and abate spontaneously with conservative therapy, there remains a subset of patients who present with persistent, massive lower gastrointestinal bleeding. It is the therapy of this subset that remains unde®ned. Although the mainstays in the treatment algorithm for lower gastrointestinal bleeding include the isotope bleeding test, angiography, colonoscopy, and eventual surgical resection for persistent bleeding, these procedures have associated morbidity and mortality [3]. Additionally, those patients whose bleeding persists despite conservative therapy are typically elderly, have associated atherosclerosis, and as a group are not optimal surgical candidates. For example, in a series of 49 patients who underwent total abdominal colectomy for persistent bleeding from diverticulosis, an operative mortality of 27% was reported [4]. In view of the signi®cant risk associated with these invasive procedures, there have been anecdotal reports of the use of the barium enema as a treatment for diverticular bleeding. We present a case where barium enema successfully stopped an episode of bleeding from diverticulosis, and review the literature.

VASCULAR ECTASIA OF THE COLON TREATED BY ARGON PLASMA COAGULATION: REPORT OF A CASE

A 72‐year‐old woman presented with hematochezia. Colonoscopy revealed branch‐like vasodilation in the ascending colon and chronic hemorrhage from vascular ectasia of the colon was suspected. Argon plasma coagulation was performed. After treatment, epithelialization of the lesion site was noted and her anemia improved. Vascular ectasia of the colon is recognized as the etiology of lower gastrointestinal bleeding with increasing frequency. Infrared ray electronic endoscopy is useful for determining the extent of disease and argon plasma coagulation, a new hemostatic technique, is suitable for treatment of this condition.

Importância da hemorragia digestiva nos doentes com insuficiência renal crónica em hemodiálise.

Gastrointestinal Bleeding (GIB) is a complication in patients with Chronic Renal Failure (CRF) on regular hemodialysis (HD). To analyse the importance of GIB we studied, retrospectively, the causes of hospitalization in 301 patients, all on HD in the same Unit in January 1990. The average age was 57.4 +/- 14.2 years (17 to 87), time on HD 58.3 +/- 44.9 months, male = 166, female = 135. Of a total of 169 hospitalizations, the infectious disease were the most frequent cause with 37 admissions (21.9%), followed by gastrointestinal diseases with 34 admissions (21.1%). Of these, 23 (13.6%) were due to GIB (Upper GIB = 19, Lower GIB = 4). The etiologies of Upper GIB were: Peptic Ulcer = 9, erosive Gastritis/Duodenitis = 7. Angiodysplasia = 1, Mallory Weiss = 1 and unknown = 1. The etiologies of Lower GIB were: Angiodysplasia of the colon = 3, Cancer of the colon = 1. Non-steroid anti-inflammatory drugs (NSAID) had a positive correlation (p less than 0.01) with Upper GIB due to erosive Gastritis/Duodenitis. Surgery was necessary in a 8 cases of GIB, 7 of them due to Peptic Ulcer. GIB is an important cause of morbidity in patients with CRF on HD. Peptic Ulcer and erosive Gastritis/Duodenitis were the most frequent causes of GIB in the population studied. Angiodysplasia of the colon was the most important cause of Lower GIB. NSAID appear to be a risk factor for GIB from erosive Gastritis and or Duodenitis.