First Episode Of Bleeding Research Articles

Left Internal Capsule Cavernoma Using the Superior Frontal Sulcus as a Surgical Corridor: Why and How to Do It: 2-Dimensional Operative Video.

Cavernous angioma is a sinusoidal dilatation covered by a single layer of endothelium, separated by a collagen matrix with elastin and smooth muscle.1 The prevalence in the general population is estimated at 0.4% to 0.9%,2 representing around 5% to 10% of all vascular malformations.3 Studies indicate 9% to 35% of cavernomas are found in deep locations such as the brainstem, thalamus, and basal ganglia.4-6 Common symptoms of these deep lesions are cranial nerve deficit, hemiparesis, and paresthesia. These lesions have high rates of rebleeding after the first episode of bleeding but present excellent results of surgical resection and modified Rankin in the long term.7-13 Internal capsule cavernomas are particularly challenging due to the important projection fibers surround them. Although the gold standard of treatment is microsurgery, there needs to be a consensus on the best approach for lesions of this topography. We present a video case of a female in her 50s with right hemiparesis and dysphasia, exhibiting grade 3/5 strength on the right side. T1 MRI revealed a high intensity, heterogeneous, multinodular signal in the left basal ganglia, with tractography showing the lesion dividing the posterior limb of the internal capsule amid fibers of the right corticospinal tract. The patient consented to the procedure and to the publication of his/her image. This study was approved by the Ethics and Research Committee of our institution. We demonstrated that the superior frontal sulcus is a safe corridor to surgically cure cavernomas of the internal capsule, with the recovery of previous deficits.

Risk factors associated with unplanned caesarean section in women with placenta previa: a cohort study

Unplanned/emergency caesarean section (CS) can lead to an increased risk of increased risk of adverse maternal and perinatal outcomes. This prospective observational study was conducted in a tertiary centre in South India to determine the factors associated with increased risk of unplanned/emergency CS among women with placenta previa (PP). Primary outcome was the unplanned CS defined as emergency CS performed, prior to the scheduled date of delivery, for profuse vaginal bleeding or onset of labour pains. Obstetric morbidity and maternal–foetal outcomes were also compared between major and minor degree of PP. Major degree PP (OR 3.56; 95% CI: 1.73–7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14–18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57–0.91) were found to be associated with higher odd for undergoing unplanned CS. Identifying these women at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications along with facilities for blood transfusion and interventional radiology can help to optimise maternal and perinatal outcomes. Impact Statement What is already known on this subject? With increasing numbers of caesarean sections (CSs) and assisted reproductive techniques, the rate of PP is constantly on the rise. Unplanned CS is associated with increased risk of adverse maternal and perinatal complications. What do the results of this study add? Nearly, 40% among those who underwent CS were unplanned. Major degree placenta previa (PP) (OR 3.56; 95% CI: 1.73–7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14–18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57–0.91) were found to be associated with higher odd for undergoing unplanned CS. What are the implications of these findings for clinical practice and/or further research? Identifying women with PP at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications, facilities for blood transfusion and interventional radiology, which optimise maternal and perinatal outcomes.

Best quality indicator of vitamin K antagonist therapy to predict mortality and bleeding in haemodialysis patients with atrial fibrillation.

There is a high prevalence of atrial fibrillation (AF) in patients undergoing haemodialysis. Oral anticoagulant therapy with vitamin K antagonists (VKAs) is the only accepted treatment for the prevention of thromboembolism in haemodialysis patients with AF. However, in this population, the risk of bleeding is greatly increased. The aim of the study was to evaluate the ability of treatment quality indicators of VKA therapy to predict mortality and bleedings in a population of haemodialysis patients with AF. A total of 129 patients were included in this cohort study. Deaths and bleeding events were recorded during a follow-up of 4 years. In all patients, International Normalized Ratio (INR) values were assessed at least once a month. Time in therapeutic range (TTR) and INR variability, as measured by the standard deviation of INR, were updated at each INR measurement. A Cox model with time-dependent co-variates and sandwich variance was applied. During follow-up, 71 patients died and 55 bleeding episodes occurred in 31 patients. INR variability was the only indicator associated with both mortality (hazard ratio [HR]=1.67, 95% confidence interval [CI] 1.12; 2.49, p=0.012) and bleeding (HR=2.85, 95% CI: 1.71; 4.75, p=0.0001). HR of mortality was higher in patients with INR >3 (HR=2.06, 95% CI: 1.09; 3.88, p=0.0259) than in subjects in therapeutic range 2<INR≤3. TTR was inversely associated with the risk of recurrent haemorrhagic events (HR=0.88, 95% CI: 0.80; 0.95, p=0.0023), but not with a first episode of bleeding. Results were consistent after censoring patients at VKA withdrawal. Our study suggests that, in haemodialysis patients with AF taking VKAs, INR variability is the quality indicator that best predicts clinical outcomes. In this population, if more treatment quality indicators are considered together, it may become easier to identify patients at particularly high risk of bleeding and death.

S3612 A Clotting and Bleeding Interplay in Ulcerative Colitis

Introduction: Inflammatory bowel disease (IBD) patients are at increased risk of venous thromboembolic (VTE) events. Here we present a case of a patient with ulcerative colitis (UC) with incidental findings of pulmonary embolism (PE) and, further complications on anticoagulation. Case Description/Methods: A 50-year-old female with a past medical history of anxiety and recently diagnosed UC on steroid taper presented to the hospital with complaints of intractable diarrhea, diffuse abdominal discomfort, and worsening fatigue. Lab findings were consistent with previously diagnosed iron deficiency anemia, downtrending C-reactive protein, ESR, negative C.diff, and gastric pathogen panel. A repeat CT abdomen pelvis with contrast showed improving inflammation of the colon, mesalamine was added to steroid regimen . There was an incidental finding of PE in the bilateral segmental arteries without right heart strain, treated with heparin infusion and transitioned to rivaroxaban.Later, patient had two episodes of hospital admission for rectal bleeding complicating the treatment course. Rivaroxaban was resumed after first episode of bleeding, but since the further episode of rectal bleeding required cardiopulmonary resuscitation, anticoagulation was discontinued. During this time for UC, mesalamine was discontinued and infliximab was initiated. She developed another episode of bilateral deep vein thrombosis off anticoagulation, hence IVC filter was placed to avoid new PE and plan to restart anticoagulation after resolution of bleeding was made. Discussion: Patients with IBD are at higher risk ( 2 to 3 fold) of developing the extraintestinal complication of VTE compared to general population with incidence varying from 1.3% to 6.2% and mortality from 8% to 25%. The exact pathophysiology of thrombosis in IBD is not fully understood and is considered to be a complex interplay of inflammation and coagulation, affecting the procoagulant, anticoagulant and fibrinolytic factors of the coagulation cascade. Patients in an acute flare of IBD are associated with highest risk of VTE compared to patients in remission. Patients admitted for IBD flare should be on pharmacological prophylaxis for VTE and can be safely administered for patients with minor hematochezia. Treatment of VTE in IBD patients is the same as patients without IBD, but duration of therapy is not well established. Risk is lower in patients in remission, another important reason for providers to have IBD patients in endoscopic and clinical remission.

Massive Gastric Variceal Hemorrhage Due to Splenic Vein Thrombosis: A Rare Initial Presentation of Asymptomatic Metastatic Pancreatic Adenocarcinoma

Isolated sinistral portal hypertension (SPH) is extremely rare, representing less than 5% of all portal hypertension cases [1]. Rare cases of gastric varices can cases occur due to non-cirrhotic splenic venous thrombosis causing SPH. Here, we present massive gastric variceal bleeding from splenic vein thrombosis as the initial presentation of pancreatic adenocarcinoma. A 71-year old man presented to the emergency department with acute onset massive hematemesis and epigastric pain. He had tenderness in the epigastric and left upper quadrant without peritoneal signs. Hemoglobin was decreased at 8.3 g/d from baseline 12. Total bilirubin and liver function tests were within normal limits. Contrast enhanced CT showed splenic vein thrombosis (Figure 1A), gastric varices (Figure 1B) with active hemorrhage noted, and a 5 cm mass in the pancreatic tail (Figure 1C). No changes of cirrhosis were noted in the liver. The patient underwent successful splenic artery embolization (Figure 2). Diagnosis of metastatic pancreatic adenocarcinoma was confirmed with peritoneal biopsy. Gastric variceal bleeding as the initial presentation of pancreatic adenocarcinoma is incredibly unusual. Splenic vein thrombosis causes SPH and formation of collateral pathways to shunt blood around the occluded splenic vein, increasing pressure within the submucosal veins of the gastric fundus forming varices. Splenic vein thrombosis arising from pancreatic cancer carcinoma represents a rare occurrence. One study showed only 49% of 209 patients were correctly diagnosed with SPH after the first episode of bleeding with a median delay of 11 months[2]. Splenectomy is the standard treatment for splenic vein thrombosis, with splenic artery embolization reserved for patients who are poor surgical candidates with metastatic disease. Massive gastricvariceal hemorrhage due to non-cirrhotic portal hypertension from splenic vein thrombosis as the initial presentation of pancreatic adenocarcinoma is a rare occurrence. Recognizing rare causes of gastric varices such as SPH due to splenic vein thrombosis is important for early diagnosis of possible pancreatic adenocarcinoma.1357.tif Figure 1: Figures for Case Report

Efficacy of a new hemostatic forceps during gastric endoscopic submucosal dissection: A prospective randomized controlled trial.

Currently, endoscopic submucosal dissection (ESD) is a widely accepted standard treatment for early gastric cancer, but one challenging aspect of ESD is hemostasis. We developed a new hemostatic forceps (FD-Y0007) with the aim of achieving more effective hemostasis and investigated the hemostatic ability of the FD-Y0007 during gastric ESD in humans. This study was a prospective randomized controlled trial, which was conducted at a cancer referral center. Sixty-six patients who were scheduled to undergo ESD were enrolled and randomly assigned to either the Coagrasper or the FD-Y0007, which was used for hemostasis throughout the case. The primary end point was the time required to obtain hemostasis, which was measured for the first episode of bleeding during each case. Hemostasis time for the first bleeding episode during ESD was 73.0 s for the Coagrasper and 21.5 s for the FD-Y0007 (P < 0.001). When all episodes of bleeding were included, hemostasis time was 56.8 s in the Coagrasper group and 25.5 s in FD-Y0007group (P < 0.0001). The frequency of adverse events (perforation: 3.4% vs 7.1%; delayed bleeding: 0% vs 0%) was not significantly different between the two groups. Compared with the Coagrasper, the FD-Y0007 efficiently reduces the hemostatic time during gastric ESD with no increase in adverse events.

Gastric Varices in Cirrhosis vs. Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-butyl-2-cyanoacrylate Injection

Gastric varices (GV) are found in patients with portal hypertension. Incidence of bleeding from GV is relatively low, but is severe, and associated with higher mortality. To compare the types of GV in cirrhosis vs. extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection. Four hundred and fifty-four patients undergone glue injection of GV for primary prophylaxis or control of bleeding for first episode of bleeding from GV between August 2010 and August 2015 were analyzed. Of 454 patients, 64% (n=292) were cirrhotics and 36% (n=162) had EHPVO. Types of GV were GOV1 in 16.4% (n=48) of cirrhotics vs. 7.4% (n=12) of EHPVO, GOV2 in 76.7% (n=224) of cirrhotics vs. 53.1% (n=86) of EHPVO, Isolated gastric Varices (IGV1) in 39.5% (n=64) of patients with EHPVO vs. 6.8% (n=20) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 2.89±1.59ml over a median of 1 session (range: 1-7). The total volume of glue required was lower in cirrhotics (2.44±1.17ml vs. 3.69±1.91ml, P<0.05) than in EHPVO patients. One hundred and seventeen (40.1%) of cirrhotics required >1 sessions of glue injection as compared to 102 (63%) of EHPVO patients. Over mean follow up of 14.7±6.46 months, rebleeding (10% vs. 13%) was similar in patients with cirrhosis and EHPVO and mortality (15.4% vs. 2.5%) was higher in cirrhotics than EHPVO. In patients with bleeding from GV, GOV2 are more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for GV obturation.

Small and medium size intracranial aneurysms - a 5 years retrospective analysis trial and multimodal treatment

Abstract Clinical context. Subarachnoid hemorrhage (SAH) due to rupture of an aneurysm is one of the most common neurosurgical emergencies who account for onethird of stroke .In the SAH cases , aneurysms accounted for 70%. Aneurysms had a bleeding rate of 12 per 100,000 population per year, and in particular between 50 to 60 years of age with a high morbidity and mortality, especially in the first episode of bleeding at about 43% of cases (1, 4, 14). Surgery is indicated to prevent rebleeding. 2.5% of patients in the general population may have unbroken aneurysms with a prevalence of 0.65%, with a preponderance of aneurysms in a 2: 1 in women. ACI aneurysms are more common in women and Acom aneurysms are more common in men and in 15-30% of patients with presence of multiple aneurysms. Surgical timing, the assessment in each individual case for rebleeding usage of endovascular techniques (3, 12), neurological status, the presence or absence of intraparenchymal hematoma or intraventricular hemorrhage with or without vasospasm, have an influence on the result. Over a period of 5 years from January 2010 to November 2014, 317 cases of patients with intracranial aneurysms in four clinics of neurosurgery in Bagdasar -Arseni hospital have been studied. The follow up period range between 6 month and 4 years and 3 month.

Risk of falls and bleeding in elderly patients with acute venous thromboembolism

Whether or not a high risk of falls increases the risk of bleeding in patients receiving anticoagulants remains a matter of debate. We conducted a prospective cohort study involving 991 patients ≥ 65 years of age who received anticoagulants for acute venous thromboembolism (VTE) at nine Swiss hospitals between September 2009 and September 2012. The study outcomes were as follows: the time to a first major episode of bleeding; and clinically relevant nonmajor bleeding. We determined the associations between the risk of falls and the time to a first episode of bleeding using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate. Four hundred fifty-eight of 991 patients (46%) were at high risk of falls. The mean duration of follow-up was 16.7 months. Patients at high risk of falls had a higher incidence of major bleeding (9.6 vs. 6.6 events/100 patient-years; P = 0.05) and a significantly higher incidence of clinically relevant nonmajor bleeding (16.7 vs. 8.3 events/100 patient-years; P < 0.001) than patients at low risk of falls. After adjustment, a high risk of falls was associated with clinically relevant nonmajor bleeding [subhazard ratio (SHR) = 1.74, 95% confidence interval (CI) = 1.23-2.46], but not with major bleeding (SHR = 1.24, 95% CI = 0.83-1.86). In elderly patients who receive anticoagulants because of VTE, a high risk of falls is significantly associated with clinically relevant nonmajor bleeding, but not with major bleeding. Whether or not a high risk of falls is a reason against providing anticoagulation beyond 3 months should be based on patient preferences and the risk of VTE recurrence.

Exam 2: Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-term Risks of Rebleeding and Death

Exam 2: Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-term Risks of Rebleeding and Death

Tu1523 Multicenter Comparative Study of Detection and Evaluation of the Size of Oesophageal Varices With the Use of 12 and 20mhz Frequency Radial Endosonography vs Oesophagogastroduodenoscopy

Gastrointestinal bleeding from oesophageal and gastric varices may be fatal in as many as one third of patients with liver cirrhosis. Early diagnosis of varices is necessary for prophylaxis and prevention of the first episode of bleeding.

Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-term Risks of Rebleeding and Death

Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes. We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years. After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival. Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.

A successful rescue with extra-anatomical bypass for massive bleeding of the brachiocephalic artery following salvage pharyngo-esophagectomy

Massive bleeding from large vessels is a serious and life-threatening complication after radical esophagectomy. Here, we present the rare case of patient survival following two episodes of massive bleeding from a tracheo-brachiocephalic artery fistula after salvage surgery for cervical esophageal cancer following definitive chemoradiation. During the first episode of bleeding, the damaged part of the brachiocephalic artery was transected with an extra-anatomical arterial bypass (right femoro-axillo artery bypass graft) to maintain the arterial blood flow to the brain and the free jejunal graft. During the second bleeding, the distal stump of the brachiocephalic artery was reclosed. During both episodes of bleeding, the musculocutaneous flap was effectively employed to seal the stumps of the brachiocephalic artery and fill the dead space. Finally, the patient was discharged 351 days after the first surgery. (132/150).

Esophageal Varices: Pathophysiology, Approach, and Clinical Dilemmas

Esophageal Varices: Pathophysiology, Approach, and Clinical Dilemmas

Prevention and management of gastroesophageal varices in cirrhosis.

Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.

CLINICAL PROFILE OF PATIENTS WITH RARE INHERITED COAGULATION DISORDERS: A RETROSPECTIVE ANALYSIS OF 67 PATIENTS FROM NORTHERN INDIA

IntroductionInherited bleeding disorders are characterized by the absence or reduced level of clotting factors, and the clinical manifestations vary according to the type and magnitude of the deficient factor.AimTo study the clinical presentation of the rare inherited coagulation factor disorders in a tertiary care hospital and to compare the data from those reported in other populations.MethodsSixty-seven patients, who presented to the Department of Hematology, All India Institute of Medical Sciences, New Delhi, were evaluated retrospectively from 2005 to 2011. The tests performed included platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), factors assay and clot solubility test in 5 M urea. Factor XI assays were aPTT based while factors V, VII and X assays were PT based.ResultsMale to female ratio was 2:1. The median age of onset of the first episode of bleeding was at 6 months (range, from birth to 20 years) whereas the median age of presentation to our hospital was 9 years (range, 2 months to 54 years). The most common deficient factor was factor X (43%), followed by factor XIII (27%) and factor VII (10%).ConclusionThere is a wide gap between the initial manifestation of the bleeding disorders and first presentation to the tertiary care hospital for assessment and treatment. Factor X deficiency is the most common among these rare coagulation disorders in our population, whereas factor VII deficiency is more common in Iranian and North American population.

Radial endosonography versus oesophagogastroduodenoscopy for detecting oesophageal and gastric varices

Gastrointestinal bleeding from oesophageal and gastric varices may be fatal in as many as one third of patients with liver cirrhosis. Early diagnosis is necessary for prophylaxis and prevention of the first episode of bleeding.

Preventing a first episode of esophageal variceal hemorrhage

In patients with esophageal varices, hemorrhage is common and often lethal, so we need to take a proactive approach to preventing a first episode of bleeding. All patients with cirrhosis should undergo endoscopy to look for varices. Depending on the size and appearance of the varices and the patient's Child-Pugh grade, prophylactic treatment may be indicated.

Prevalence and Predictors of Esophageal Varices in Patients With Primary Biliary Cirrhosis

Esophageal varices and bleeding are among the most feared complications of primary biliary cirrhosis (PBC). We aimed to determine the prevalence of esophageal varices in patients with PBC, to evaluate noninvasive markers of esophageal varices in this population, and to validate the results in an independent set of patients. Data were collected on all patients with PBC seen for the first time at the University of Florida (study group) and at Case Western Reserve University hospitals (cross-validation group) during 7 consecutive years. Logistic regression analysis was used to identify independent predictors of esophageal varices. The best cut-off values were calculated based on receiver operating characteristic curves. The diagnostic accuracy of the independent predictors of esophageal varices identified in the study group were retested in the cross-validation group. Of 210 patients with PBC seen at the University of Florida, 113 had an endoscopy and 49.6% (56 of 113) were found to have esophageal varices. After excluding 22 patients with a history of variceal bleeding, data on 91 patients were analyzed. Thirty-four patients had esophageal varices (37%). Multivariate analysis revealed that a platelet count of less than 140,000 (odds ratio, 7.6; 95% confidence interval, 1.6-37) and a Mayo risk score of 4.5 or greater (odds ratio, 10.6; 95% confidence interval, 1.8-62) were independent predictors of esophageal varices. The diagnostic accuracy of these predictors was confirmed in an independent set of patients. Among patients with PBC, a platelet count of less than 140,000 and/or a Mayo risk score of 4.5 or greater appears to identify those patients more likely to benefit from a screening endoscopy.

MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

The role of model for end stage liver disease (MELD) and the presence of hepatocellular carcinoma (HCC) as risk factors of short-term mortality in patients bleeding from oesophageal varices were evaluated. From February 2002 to August 2003, 172 cirrhotic patients admitted for the first episode of bleeding from oesophageal varices received vasoactive and endoscopic therapy. Patients' survival was evaluated at 6 weeks and 3 months. The role of MELD and HCC as independent risk factors of mortality was evaluated. In the 172 patients, the overall mortality was 21.5% at 6 weeks and 30.2% at 3 months. MELD score resulted a good predictor of mortality either at 6 weeks or 3 months. Fifty-four patients (31.3%) had HCC. The presence of advanced HCC was an independent risk factor of mortality at 3 months. Patients with MELD score>15 and advanced HCC had a significantly worse survival than patients with MELD<or=15 and without HCC or with early HCC either at 6 weeks or 3 months MELD score and the presence of HCC allow to identify patients at different risk of short-term mortality among cirrhotic patients at first episode of bleeding from oesophageal varices.