Etiology Of Bleeding Research Articles

To determine the various causes of thrombocytopenia and its clinical correlation with bleeding in children and adolescents

Thrombocytopenia refers to a reduction in platelet count below 1,50,000/cumm. It is the most common cause of defective primary hemostasis that can lead to significant bleeding in children. It was a retrospective observational study conducted in a tertiary care hospital in Bhilai, chattisgarh between Augusts to December 2021. Data collection was done from Sept 2018-Sept 2019. The aim of present study was to determine the various causes of thrombocytopenia in children and adolescents and to correlate its severity with etiology and risk of bleeding. Total 112 patients were included from age group 1y-18 yrs. Out of total 112 patients 59 were males and 53 were females. 27 patients were 1-5 years of age, 30 patients were 6-12 years of age and55 were 13-18 years. The mean platelet count in my study was 68,340/cumm with a minimum of 4000/cumm. Bleeding was present in total 19 (16.9%) patients. The main bleeding manifestations were petechie or purpurae, epistaxis, ecchymosis, gastrointestinal bleed and others. Severity of thrombocytopenia correlates significantly with risk of bleeding (The p-value is 0.001**). The most common cause of thrombocytopenia in 69 patients with fever were infective and 43 patients without fever it was vitamin b12 deficiency. Severity of thrombocytopenia (p=0.0528) and bleeding (p=0.121) in patients with fever and without fever was not significant. Thrombocytopenia in pediatric and adolescent children is caused by both infective and non infective illness. It mainly presents with cutaneous bleeds and mucosal bleeds. Severity of thrombocytopenia is significantly correlated with bleeding.

Platelet Reactivity on ECMO: Role of VerifyNow

Viscoelastic assays help in identifying disorders of clotting factors, platelet function, and detection of excessive fibrinolysis. Rotational thromboelastometry (ROTEM) assesses quantitative and qualitative aspects of whole blood coagulation which allows for the determination of the mechanism of hemostatic disturbance. This helps clinicians in targeting the correct blood component therapy transfusion. Now, using verify we aim to study platelet reactivity, VA ECMO which will reflect the platelet aggregation response to an aggregating agent like Aspirin and thus know the etiology of bleeding on VA ECMO, to know the right component therapy to be transfused with a Point of Care test. For extracorporeal membrane oxygenation, although the conventional laboratory tests are used to monitor anticoagulation on whole blood, viscoelastic tests reflect coagulation status like no other standard laboratory tests. They show the status of color propagation, formation, and stabilization. It was reported that platelet function was impaired over time in all parameters with different activators.

Postmenopausal bleeding after COVID-19 vaccination

There is a growing literature base regarding menstrual changes following COVID-19 vaccination among premenopausal people. However, relatively little is known about uterine bleeding in postmenopausal people following COVID-19 vaccination. This study aimed to examine trends in incident postmenopausal bleeding diagnoses over time before and after COVID-19 vaccine introduction, and to describe cases of new-onset postmenopausal bleeding after COVID-19 vaccination. For postmenopausal bleeding incidence calculations, monthly population-level cohorts consisted of female Kaiser Permanente Northwest members aged ≥45 years. Those diagnosed with incident postmenopausal bleeding in the electronic medical record were included in monthly numerators. Members with preexisting postmenopausal bleeding or abnormal uterine bleeding, or who were at increased risk of bleeding due to other health conditions, were excluded from monthly calculations. We used segmented regression analysis to estimate changes in the incidence of postmenopausal bleeding diagnoses from 2018 through 2021 in Kaiser Permanente Northwest members meeting the inclusion criteria, stratified by COVID-19 vaccination status in 2021. In addition, we identified all members with ≥1 COVID-19 vaccination between December 14, 2020 and August 14, 2021, who had an incident postmenopausal bleeding diagnosis within 60 days of vaccination. COVID-19 vaccination, diagnostic procedures, and presumed bleeding etiology were assessed through chart review and described. A temporal scan statistic was run on all cases without clear bleeding etiology. In a population of 75,530 to 82,693 individuals per month, there was no statistically significant difference in the rate of incident postmenopausal bleeding diagnoses before and after COVID-19 vaccine introduction (P=.59). A total of 104 individuals had incident postmenopausal bleeding diagnosed within 60 days following COVID-19 vaccination; 76% of cases (79/104) were confirmed as postvaccination postmenopausal bleeding after chart review. Median time from vaccination to bleeding onset was 21 days (range: 2-54 days). Among the 56 postmenopausal bleeding cases with a provider-attributed etiology, the common causes of bleeding were uterine or cervical lesions (50% [28/56]), hormone replacement therapy (13% [7/56]), and proliferative endometrium (13% [7/56]). Among the 23 cases without a clear etiology, there was no statistically significant clustering of postmenopausal bleeding onset following vaccination. Within this integrated health system, introduction of COVID-19 vaccines was not associated with an increase in incident postmenopausal bleeding diagnoses. Diagnosis of postmenopausal bleeding in the 60 days following receipt of a COVID-19 vaccination was rare.

1146 Laparoscopic Retrieval of a Retained Video Endoscopy Capsule: Case Report and Review of Literature

Abstract Video-Capsule-Endoscopy (VCE) is a non-invasive method and a useful tool in determining the aetiology of obscure gastrointestinal bleeding and in the diagnosis of Crohn’s disease. Despite its proven utility, VCE carries risks, primarily capsule retention (CR). This refers to the failure of the capsule passing by day 14. CR may suggest underlying pathology, but in the process can lead to several sequelae including obstruction. We report the case of a 28-year-old patient with suspected Crohn’s disease requiring laparoscopic bowel-resection and retrieval of the capsule. The patient presented in 2019 with bloating, crampy abdominal pain and altered bowel habits. Initial endoscopic and blood investigations were unremarkable, however subsequent tests revealed raised calprotectin and anaemia. OGD and colonoscopy remained negative. In April 2021, he underwent VCE, demonstrating an inflamed distal ileum with structuring. However, the capsule failed to pass. After a period of watchful waiting and multidisciplinary discussion resulting in a trial of infliximab and steroid therapy, the capsule remained in-situ as confirmed by sequential X-rays and CTs. In March 2022, he underwent uncomplicated 3-port laparoscopic small bowel resection and retrieval of the retained capsule and was discharged 2 days later. Our case demonstrates an optimal approach in the management of CR. An initial conservative trial with medical therapy was attempted. MDT discussion ensured both gastroenterologists and surgeons were involved in the decision-making. Finally, our literature review demonstrated a lack of concise guidelines. Thus, based on the latest evidence we developed an algorithmic flow chart for the management of retained VCE.

Diagnostic Yield of Endoscopy in Upper Gastrointestinal Bleeding in Pediatrics

Introduction Esophagogastroduodenoscopy is currently considered the first-line diagnostic procedure of choice for upper gastrointestinal (GI) bleeding; however, the etiology of bleeding remains unknown in a subset of patients. This study aims to evaluate the diagnostic yield of upper gastrointestinal endoscopy in upper gastrointestinal bleeding in pediatrics and determine the clinical predictors for unreached diagnosis during endoscopy. Methods Cross sectional study, conducted at pediatric endoscopy unit, Ain Shams University, Cairo, Egypt, where 100 patients were recruited, as they were referred for diagnostic upper GI endoscopy due to overt upper GI bleeding in the form of hematemesis and/or melena. Full medical history, examination, laboratory investigations, endoscopic and histopathologic findings were documented. Results :100 patients with ages ranging from 3 months to 15 years, median age 4 years, 47% males and 53% females, 65% presented by hematemesis only, 7% with melena only, and 28 % presented with both hematemesis and melena. In 38 % of cases no endoscopic diagnosis was reached. While patients with a positive diagnostic yield 62%, had variable diagnosis, the most common of which was H pylori gastritis and reflux oesophagitis in 23% and 11% of cases respectively. Followed by nonspecific gastritis (8%), oesophageal varices (4%), and others (16%).. Melena was a negative predictor to reach a diagnosis by upper GI endoscopy. Conclusion Diagnostic yield of upper GI endoscopy in pediatric patients with upper GI bleeding was only 62%. Combining upper GI endoscopy with other tools in cases presenting with melena alone is highly recommended since bleeding from a source in the small bowel or right colon may also be the cause.

Clinical Outcomes of Older Patients with Non-Variceal Upper Gastrointestinal Bleeding Taking Anti-Thrombotic or Non-Steroidal Anti-Inflammatory Agents.

Non-variceal upper gastrointestinal bleeding is a well-established complication of non-steroidal anti-inflammatory drugs and anti-thrombotics. Both medication groups are frequently used by older populations and increase the incidence of non-var- iceal upper gastrointestinal bleeding; however, their impact on etiology and outcomes of non-variceal upper gastrointestinal bleeding has not been well defined. We aimed to compare the etiology and outcomes of non-variceal upper gastrointestinal bleeding in older patients who use anti-thrombotics and non-steroidal anti-inflammatory drugs or do not use either of them. This is a single-center prospective study of patients older than 65 years with non-variceal upper gastrointesti- nal bleeding. Endoscopic findings, laboratory values, blood transfusion, endoscopic treatment, re-bleeding, and 30-day mortality rates were recorded. A total of 257 patients (median age 77.7 ± 8.2, 59% male) were included. Re-bleeding occurred in 25 (10%) and the 30-day mortality rate was 40 (16%). There was no statistically significant difference between patients using anti-thrombotics, non-steroidal anti-inflammatory drugs or non-users for blood transfusion (P = .46), endoscopic hemostasis (P = .39), re-bleeding (P = .09), and 30-day mortality (P = .45). Peptic ulcer was the most common etiology in all groups (124, 48%). Although the incidence of peptic ulcer was similar between drug users and anti-thrombotic users (P = .75), the incidence of peptic ulcer was significantly higher in patients using non-steroidal anti-inflammatory drugs than in patients who did not use drugs (P = .05). When the patients were analyzed as using anti- thrombotic drugs or non-steroidal anti-inflammatory drugs or neither, no statistically significant difference was found between ulcer location, ulcer number, and ulcer size. Non-variceal upper gastrointestinal bleeding increasingly occurs in older populations with several comorbidities; non- steroidal anti-inflammatory drugs or anti-thrombotics do not seem to change the clinical outcomes among older patients with non- variceal upper gastrointestinal bleeding.

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.

Shear-induced acquired von Willebrand syndrome: an accomplice of bleeding events in adults on extracorporeal membrane oxygenation support.

Extracorporeal membrane oxygenation (ECMO) is an increasingly acceptable life-saving mechanical assistance system that provides cardiac and/or respiratory support for several reversible or treatable diseases. Despite important advances in technology and clinical management, bleeding remains a significant and common complication associated with increased morbidity and mortality. Some studies suggest that acquired von Willebrand syndrome (AVWS) is one of the etiologies of bleeding. It is caused by shear-induced deficiency of von Willebrand factor (VWF). VWF is an important glycoprotein for hemostasis that acts as a linker at sites of vascular injury for platelet adhesion and aggregation under high shear stress. AVWS can usually be diagnosed within 24 h after initiation of ECMO and is always reversible after explantation. Nonetheless, the main mechanism for the defect in the VWF multimers under ECMO support and the association between AVWS and bleeding complications remains unknown. In this review, we specifically discuss the loss of VWF caused by shear induction in the context of ECMO support as well as the current diagnostic and management strategies for AVWS.

Multicenter propensity score-matched analysis comparing short versus long cap-assisted colonoscopy for acute hematochezia.

While short and long attachment caps are available for colonoscopy, it is unclear which type is more appropriate for stigmata of recent hemorrhage (SRH) identification in acute hematochezia. This study aimed to compare the performance of short versus long caps in acute hematochezia diagnoses and outcomes. We selected 6460 patients who underwent colonoscopy with attachment caps from 10 342 acute hematochezia cases in the CODE BLUE-J study. We performed propensity score matching (PSM) to balance baseline characteristics between short and long cap users. Then, the proportion of definitive or presumptive bleeding etiologies found on the initial colonoscopy and SRH identification rates were compared. We also evaluated rates of blood transfusions, interventional radiology, or surgery, as well as the rate of rebleeding and mortality within 30 days after the initial colonoscopy. A total of 3098 patients with acute hematochezia (1549 short cap and 1549 long cap users) were selected for PSM. The rate of colonic diverticular bleeding (CDB) diagnosis was significantly higher in long cap users (P = 0.006). While the two groups had similar rates of the other bleeding etiologies, the frequency of unknown etiologies was significantly lower in long cap users (P < 0.001). The rate of SRH with active bleeding was significantly higher in long cap users (P < 0.001). Other clinical outcomes did not differ significantly. Compared to that with short caps, long cap-assisted colonoscopy is superior for the diagnosis of acute hematochezia, especially CDB, and the identification of active bleeding.

Hospital Length of Stay Independently Predicts Mortality in Patients Emergently Admitted for Esophageal Hemorrhage: Sex, Frailty, and Age as Additional Mortality Factors.

Upper gastrointestinal bleeding results in greater than $7.6 billion of in-hospital economic burden in the United States yearly. With a worldwide incidence between 40-100/100,000 individuals and a mortality rate of approximately 2-10%, upper gastrointestinal bleeding represents a major source of mortality and morbidity. The goal of this study was to describe mortality risk factors in patients emergently admitted with esophageal hemorrhage, the second most common etiology of upper gastrointestinal bleeding. Patients emergently admitted with esophageal hemorrhage between 2005-2014 were evaluated using the National Inpatient Sample database. Patient characteristics, clinical outcomes, and therapeutic trends were obtained. Relationships between morality and all other variables were determined via univariable and multivariable logistic regression analyses. In total, 4,607 patients were included, of which 2,045 (44.4%) were adults, 2,562 (55.6%) were elderly, 2,761 (59.9%) were males, and 1,846 (40.1%) were females. The average age of adult and elderly patients were 50.1 and 78.7 years, respectively. The multivariable logistic regression analysis revealed, for every additional day of hospitalization, the odds of mortality for nonoperatively treated adult and elderly patients increased by 7.5% (p=<0.001) and 6.6% (p=<0.001), respectively. Every additional year of age was associated with a 5.4% (p=0.012) increase in mortality odds for nonoperatively managed adult patients. Frailty increased the odds of mortality by 31.1% (p=0.009) in nonoperatively treated elderly patients. Undergoing invasive diagnostic procedures in conservatively treated adults reduced mortality significantly (odds ratio=0.400, p=0.021). Frailty, age, and hospital length of stay demonstrated no significant association with mortality in surgically managed adult and elderly patients. Nonoperatively managed patients emergently admitted for esophageal hemorrhage with longer hospital length of stay and higher modified frailty index exhibited higher odds of mortality. Invasive diagnostic procedures were negatively correlated with mortality in nonoperatively treated adult patients. Age is only associated with higher mortality rates in adults, while elderly patients revealed no association between age and mortality.

P-584 Treatment of benign uterine bleeding in morbidly obese postmenopausal women with an aromatase inhibitor

Abstract Study question Can morbidly obese women with postmenopausal bleeding, a benign endometrial biopsy, and no response to an oral progestin be successfully treated using an aromatase inhibitor? Summary answer Postmenopausal uterine bleeding in morbidly obese women with benign endometrial histology and an elevated serum estrone level do respond to treated with an aromatase inhibitor. What is known already Morbidly obese postmenopausal women who have uterine bleeding and a benign endometrial biopsy are commonly not good surgical candidates, and need good medical treatment options especially when treatment with an oral progestin has failed. The etiology for uterine bleeding in these individuals can stem from elevated estrogen production from peripheral sources. Study design, size, duration This was a prospective, proof of concept study with no placebo control group. Ten morbidly obese postmenopausal women with elevated serum estrone levels and uterine bleeding for &amp;gt; eight weeks who had failed oral progestin therapy were treated with letrozole 2.5 mg/d and evaluated monthly for 3 months duration. At the first monthly follow-up visit, serum estrone levels were re-assessed. Vaginal bleeding was re-assessed at each monthly follow-up visit. Participants/materials, setting, methods This study was performed in an outpatient setting at a private health system. Inclusion criteria included postmenopausal uterine bleeding (not spotting), age &amp;gt; 50, postmenopausal status (based on an FSH level of &amp;gt; 40 mIU/mL and an estradiol &amp;lt; 25 pg/mL), an estrone level &amp;gt; 30 pg/mL, a BMI &amp;gt; 40 kg/m2, a benign endometrial biopsy, a normal pelvic ultrasound, and failure of progestin therapy. All women received letrozole 2.5 mg/d and were evaluated monthly. Main results and the role of chance Ten women were enrolled in the study. Their ages ranged from 51 to 68. Their mean BMI was 50.75 kg/m2. All of the women in the study had daily vaginal bleeding for &amp;gt; 8 weeks that was greater than spotting, and had additional co-morbidities that made them poor surgical candidates. Serum estrone levels pre-treatment ranged from 63 pg/mL to 550 pg/mL with a mean of 216 pg/mL. After 4 weeks of treatment with letrozole, 8 women had complete cessation of their vaginal bleeding which was sustained for the complete 3 months of follow-up. The two other women in the study had significantly reduced vaginal bleeding from treatment month one to 3 based on self-reporting. Serum estrone levels after 4 weeks of treatment with letrozole dropped by an average of 71% with a range of 50% to 93%. There were no serious adverse events, and no treatment tolerability complaints. Since there was no control group for comparison, the reductions in both vaginal bleeding and serum estrone levels could be from chance alone, including regression to the mean, and not treatment related. Limitations, reasons for caution This was a small, proof of concept study that was performed in a select population of patients. Although a very favorable outcome was obtained in our study population, a much larger study might show both a reduced success rate in regards to vaginal bleeding and some significant adverse events. Wider implications of the findings The data from this study suggests that morbidly obese postmenopausal women with uterine bleeding and benign endometrial histology who have failed oral progestin therapy, are poor surgical candidates, and in whom IUD placement may be very difficult, may have another good treatment option. Trial registration number N/A

Vaginal Bleeding In Prepubertal Girls-A Case Series in Malaysia

The etiology of prepubertal vaginal bleeding varies from isolated pubertal causes to malignant tumors and generates significant anxiety among girls and their caretakers. Hence, these cases require careful assessment and management. This is a report of five cases of prepubertal vaginal bleeding with various causes and were managed in a tertiary referral center in Malaysia. The first case was a 6-year-old girl who had no pubertal changes with 3 weeks’ history of bleeding. She underwent examination under anesthesia and found to have multiple vaginal polyps. Another 6-year-old girl noted to have a doughnut-shaped mass protruding from her urethral meatus. She was treated with estrogen cream and sitz baths. Another child had early breast development while pelvic ultrasound revealed a multiseptated ovarian cyst requiring a cystectomy. A 19-month-old toddler had a large intravaginal mass. She required further investigation, referral to the pediatric surgeon and oncologist for treatment of a malignant yolk sac tumor. Lastly, an 8-year-old girl was noted to have monthly vaginal spotting without any secondary sexual characteristics development. Prepubertal vaginal bleeding is abnormal thus requires prompt assessment to ascertain the cause and administer appropriate management. It is important to rule out sexual abuse and malignancy. Examination under anaesthesia and vaginoscopy is recommended when imaging modality is inconclusive. Referral to tertiary centres experienced in managing such cases ensures good outcomes. Thorough targeted history-taking and pediatric-specific gynecological examination skills are crucial to formulate accurate diagnosis and appropriate management.

Topical hemostatic agents in the management of upper gastrointestinal bleeding: a meta-analysis.

Background and study aims Novel topical hemostatic agents have shown promising results in treating patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, data are limited even in published meta-analyses as to their role, especially compared to conventional endoscopic approaches. The aim of this study was to perform a highly comprehensive systematic review assessing the effectiveness of topical hemostatic agents in UGIB in different clinical settings. Methods We performed a literature search of OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases through September 2021. Studies assessing the efficacy of topical hemostatic agents in UGIB were included. Main outcomes were immediate hemostasis and overall rebleeding. Results A total of 980 citations were identified and 59 studies with a total of 3,417 patients were included in the analysis. Immediate hemostasis was achieved in 93 % (91 %; 94 %), with similar results according to etiology (NVUGIB vs. variceal), topical agent used, or treatment strategy (primary vs. rescue). The overall rebleeding rate was 18 % (15%; 21 %) with the majority of rebleeds occurring in the first 7 days. Among comparative studies, topical agents achieved immediate hemostasis more often than standard endoscopic modalities (OR 3.94 [1.73; 8.96), with non-different overall rebleeding odds (OR 1.06 [0.65; 1.74]). Adverse events occurred in 2 % (1 %; 3 %). Study quality was overall low to very low. Conclusions Topical hemostatic agents are effective and safe in the management of UGIB with favorable outcomes when compared to conventional endoscopic modalities across a variety of bleeding etiologies. This is especially true in novel subgroup analyses that assessed immediate hemostasis and rebleeding among RCTs and in malignant bleeding. Due to methodological limitations of available data, additional studies are needed to ascertain their effectiveness more confidently in the management of patients with UGIB.

Primary and secondary non-traumatic intra-cerebral haemorrhage: MRI findings

Intracranial haemorrhage (ICH) accounts for 10–30% of strokes, being the form with the worst prognosis. The causes of cerebral haemorrhage can be both primary, mainly hypertensive and amyloid angiopathy, and secondary, such as tumours or vascular lesions.Identifying the aetiology of bleeding is essential since it determines the treatment to be performed and the patient's prognosis. The main objective of this review is to review the main magnetic resonance imaging (MRI) findings of the primary and secondary causes of ICH, focusing on those radiological signs that help guide bleeding due to primary angiopathy or secondary to an underlying lesion. The indications for MRI in the event of non-traumatic intracranial haemorrhage will also be reviewed.

Adherence to guidelines in patients with non-variceal upper gastrointestinal bleeding (UGIB) – results from a retrospective single tertiary center registry

Background Guidelines for the management of upper gastrointestinal bleeding (UGIB) are regularly published, yet little is known concerning adherence to recommendations in practice. Objectives We aimed to assess adherence to European Society of Gastrointestinal Endoscopy (ESGE) recommendations in patients with non-variceal UGIB. Materials and methods All hospitalized patients with an esophagogastroduodenoscopy (EGD) performed due to suspected non-variceal UGIB at our department were included in a prospective registry. Data between 2018–2020 from this registry were retrospectively analyzed. Adherence to the 2015 ESGE bleeding and propofol sedation guidelines was assessed. Adherence to recommendations concerning preendoscopic (risk) evaluation, preendoscopic PPI, transfusion management, and endoscopic management of peptic ulcers was analyzed. Results Among 1005 patients (mean age 70.4 years, 42.1% women) the most common bleeding etiologies were gastric or duodenal ulcers (16.8%), esophagitis/GERD (11.1%), and angiodysplasia (9.9%); mortality was 7.6%. Adherence to preendosopic risk evaluation was low, in 0% a Mallampati classification and in 37.5% an ASA scoring was documented. Preendoscopic PPI was started at 58.6%, and adherence to recommended transfusion management was >98%. Peptic ulcers were Forrest-graded in 72.8%. High-risk ulcers were treated appropriately in 77.9% and low-risk ulcers were not treated in 73.6%. Especially Forrest Ib ulcers were undertreated, with an adherence of 59.6%. Only 22/179 (12.3%) patients with peptic ulcers and early endoscopy were consistently managed according to ESGE recommendations. Conclusions Adherence to ESGE guidelines in patients with non-variceal UGIB is moderate to low, even at a tertiary university hospital. Strategies must be devised for guidelines to reach patients in everyday practice.

Diagnostic yield of esophagogastroduodenoscopy in upper gastrointestinal bleeding in pediatrics: a cross-sectional study at a tertiary center

BackgroundEsophagogastroduodenoscopy (EGD) is currently considered the first-line diagnostic procedure of choice for upper gastrointestinal bleeding (UGIB); however, the etiology of bleeding remains unknown in a subset of patients. This study aimed to evaluate the diagnostic yield of EGD in UGIB in pediatrics and determine the clinical predictors for positive endoscopic diagnosis.MethodsA cross-sectional study was conducted at the pediatrics endoscopy unit, Ain Shams University, Cairo, Egypt, where 100 children were included. They were referred for EGD due to overt UGIB in the form of hematemesis and/or melena. Full medical history, thorough physical examination, laboratory investigations, and endoscopic and histopathologic findings were documented.ResultsForty-seven males and 54 females were included. Their ages ranged from 3 months to 15 years, with a median age of 4 years. Sixty-five percent presented with hematemesis only, 7% presented with melena only, and 28% presented with hematemesis and melena. An endoscopic diagnosis could be reached in 62% of cases, with Helicobacter pylori (H. pylori) gastritis (23%) and reflux esophagitis (11%) as the most common endoscopic diagnoses, with the former being the most common in children above 4 years and the latter for younger ones. Other diagnoses included non-specific gastritis (8%) and esophageal varices (4%). Presentation with melena only was a negative predictor to reach a diagnosis by EGD, while splenomegaly and thrombocytopenia were independent predictors of variceal bleeding.ConclusionEGD is the investigation of choice in children suffering from hematemesis especially in older age groups. Clinical and laboratory parameters might help in the prediction of the underlying etiology.

Outcomes of Transarterial Embolization for Acute Nonvariceal Upper Gastrointestinal Bleeding: Correlation with Periprocedural Endoscopy

PurposeTo evaluate gastric and intestinal mucosal changes on postembolic endoscopy and mortality after transarterial embolization (TAE) for upper gastrointestinal bleeding (UGIB). Materials and MethodsAn institutional review board–approved retrospective review of patients who underwent arteriography for refractory UGIB at a multicenter health system from December 2003 to August 2019 was performed. Two hundred sixty-nine patients underwent TAE for UGIB. Data on etiology of bleeding, embolization technique, pre-embolic and postembolic endoscopic results, blood product requirements, and mortality were collected from the medical record. Endoscopy results were compared at the site of the target lesion before and after TAE. Multivariable logistic regressions were performed to assess predictors of new adverse mucosal responses and mortality. ResultsThe most common etiology of UGIB was peptic ulcer. Twenty-five percent (n = 68) of the patients had clinical evidence of rebleeding after TAE, and the 30-day mortality rate was 26% (n = 73). Eighty-eight (32%) patients underwent post-TAE endoscopy, with only 15% showing new adverse mucosal changes after embolization. Procedural characteristics, including vascular territory and embolic choice, were not significantly predictive of increased risk of development of adverse mucosal response after TAE or increased mortality risk. No patients in the study were found to have bowel lumen stenosis at the time of post-TAE endoscopy or at 6 year follow-up. ConclusionsTAE is a safe and effective intervention for patients with UGIB. Post-TAE endoscopy demonstrated that most patients had either stability or improvement in the target lesion after TAE, and only a minority of patients demonstrated adverse mucosal changes.

Hemorragia cerebral primaria y secundaria no traumática: Hallazgos en RM

Intracranial hemorrhage (ICH) accounts for 10-30% of strokes, being the form with the worst prognosis. The causes of cerebral hemorrhage can be both primary, mainly hypertensive and amyloid angiopathy, and secondary, such as tumors or vascular lesions.Identifying the etiology of bleeding is essential since it determines the treatment to be performed and the patient's prognosis. The main objective of this review is to review the main magnetic resonance imaging (MRI) findings of the primary and secondary causes of ICH, focusing on those radiological signs that help guide bleeding due to primary angiopathy or secondary to an underlying lesion. The indications for MRI in the event of non-traumatic intracranial hemorrhage will also be reviewed.

Timing of Colonoscopy for Hemodynamically Stable Patients With Acute Lower Gastrointestinal Bleeding.

The detection rate of the etiology of the lower gastrointestinal system (GIS) hemorrhage has been low, although urgent colonoscopy has been performed. Even if the etiology has been specified, the possibility of rebleeding is uncertain. Furthermore, adequate bowel cleansing required for colonoscopy cannot be achieved in emergency situations, so the procedure may fail. The aim of this study is to compare the etiological diagnoses of patients with lower GIS bleeding after bowel preparation at their first hospitalization and after discharge. Patients who were hemodynamically stable after upper GIS bleeding were identified and divided into 2 groups. Colonoscopy was performed in the first group of patients at their first hospitalization. The second group of patients was called again for colonoscopy within 2 weeks after discharge. Patients were classified according to their age, gender, bleeding etiology, whether complete colonoscopy procedure was possible (The cecum was intubated, and the bowel cleansing was sufficient to evaluate the intestinal mucosa), and whether the colonoscopic intervention was performed. The rate of patients who are hemodynamically stable and require emergency intervention at their first hospitalization is 5%. The colonoscopy repeat rate is 70% for the first hospitalization group, and the patients with no findings despite the second colonoscopy at a rate of 50% are re-evaluated electively. Our study suggests that colonoscopy should be performed in elective conditions after a complete bowel cleansing in hemodynamically stable patients.

Congenital glioblastoma – prenatal diagnosis becoming a diagnostic challenge after birth: a case report

Abstract Objectives The incidence of congenital brain tumors is estimated at 1.1–3.6 per 100.000 live births, accounting for 0.5–2 % of all cancers in the pediatric population. Congenital gliomas account for 3.1–8.9 % of all congenital brain tumors and are cancers with a poor prognosis. The rate of stillbirth and death on the first day of life reaches 29 %; 38 % die within the first week, and 56 % die within the first two months. The average length of survival is two years. Case presentation In the 29th week of pregnancy, a female fetus was diagnosed with intracranial hemorrhage complicated by hydrocephalus. Postnatal brain MRI imaging showed a solid proliferative lesion of the left hemisphere with dilatation of the ventricular system. Brown cerebrospinal fluid was collected during the puncture of the left lateral ventricle to reduce hydrocephalus. No tumor cells were detected by cytology. Due to increasing hydrocephalus, the patient was qualified for Rickham reservoir implantation. On day 27th, a craniotomy was performed to determine the etiology of recurrent prenatal intraventricular bleeding. During surgery, the bleeding mass raised the suspicion of neoplasm—histopathological examination of the retrieved tissue diagnosed WHO stage IV malignant glioma. The patient died at 8 months of age. Conclusions Prenatal diagnosis of an abnormal structure in the fetal brain remains a diagnostic challenge in neonates. Glioblastoma is a rare neoplasm with a poor prognosis.