Life-threatening Gastrointestinal Bleeding Research Articles

Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines.

Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.

Australian and New Zealand Registry of Anticoagulation in the Obese: Prescribing Patterns, Drug Levels and Patient Outcomes

Background: There is limited data to guide prescribing of all available anticoagulants in obese patients, in particular those weighing > 150kg or with a BMI > 40kg/m2. We aimed to examine anticoagulant prescribing patterns in obese patients in Australia and New Zealand including choice of agent and dosing, determine whether patients with obesity achieve appropriate direct oral anticoagulant (DOAC) levels and evaluate the efficacy and safety of anticoagulation in obese patients. Methods: Patients with a BMI > 35kg/m2 or weight > 120kg receiving anticoagulant therapy are prospectively identified at 7 sites in Australia and New Zealand. Demographic data, indication for anticoagulation and choice of anticoagulant are collected at baseline. At follow-up visits, drug specific levels, dose adjustments and clinical progress (symptoms, imaging, recurrent thrombosis and adverse events) are recorded. Results: 155 patients have been recruited across seven sites (recruitment ongoing). The median age of patients was 53 (range 22-85) and 49% of patients were male. 77 (50%) of patients were anticoagulated for pulmonary embolus (PE) while 40% were anticoagulated for deep vein thrombosis (DVT) without PE. Initial anticoagulant prescribed was apixaban in 37 patients, dabigatran in 4 patients, rivaroxaban in 57 patients, low molecular weight heparin (LMWH) in 29 patients and warfarin in 28 patients (Table 1). A subset of patients initially received LMWH for 5-14 days prior to transition to a DOAC (rivaroxaban in 7, dabigatran in 6). There was cross-over between agents during the study period. Table 2 demonstrates median peak and trough DOAC levels. All peak apixaban levels and 25 of 37 (68%) peak rivaroxaban levels were within the therapeutic ranges published by the International Council for Standardization in Haematology (Gosselin, Thromb Haemost. 2018). Assessment of appropriate trough levels was limited by the limit of detection at different laboratories. 27 patients receiving enoxaparin had at least one peak Anti-Xa level (target peak 0.5-1.2U/ml). The median enoxaparin dose to achieve therapeutic peak Anti-Xa was 0.9mg/kg (range 0.52-1.3). 15 patients weighing > 150kg had a recorded peak Anti-Xa, 10 of these patients were prescribed a capped dose of 150mg BD (weight range 155-290kg) and nine had a therapeutic Anti-Xa and one had a supratherapeutic Anti-Xa measurement. One patient had a PE on apixaban 5mg twice daily (in the setting of suspected non-compliance), one patient had a new confirmed PE after 4 days of non-compliance with rivaroxaban 20mg daily and another patient had a confirmed recurrence on therapeutic warfarin. 1 patient had a PE when warfarin was withheld for emergency surgery. An equivocal recurrence occurred on enoxaparin with a supratherapeutic Anti-Xa (1.76 U.ml) and 1 DVT occurred on dabigatran for a cardiac indication (no drug level available). One patient had recurrent superficial thrombophlebitis on rivaroxaban 20mg daily (peak 301ng/L and trough <30ng/L). There was one episode of life-threatening gastrointestinal bleeding on dabigatran. Conclusion: There is limited data to guide prescribing of all anticoagulants in obese patients, in particular in patients weighing > 150kg or BMI > 40kg/m2. There is increasing use of DOACs in Australia and New Zealand in patients with obesity given the ease of administration and lack of monitoring required. Despite the recommendation to perform DOAC levels in this group of patients, interpretation of levels is difficult due to a lack of well validated therapeutic ranges with clinical correlation. Further data regarding the clinical utility of DOAC levels, appropriate dosing strategy for enoxaparin, and clinical outcomes in this population is required. Our registry provides data regarding drug levels in this population, prescribing characteristics and clinical outcome data. Disclosures No relevant conflicts of interest to declare.

S2143 Hepatic Artery Pseudoaneurysm Due to Aortic Dissection: An Unusual Cause of Portal Hypertension and Bile Duct Compression

INTRODUCTION: Hepatic artery pseudoaneurysm is rarely seen as a result of aortic dissection. Life-threatening gastrointestinal bleeding requiring urgent therapeutic intervention can occur as a complication of pseudoaneurysm formation. CASE DESCRIPTION/METHODS: A 66 year-old male with a history of a type A aortic dissection which was repaired four years prior to presentation was evaluated in the the emergency department for multiple episodes of melena. He was previously treated at another institution for a biliary stricture with a metal stent. On physical exam, he was hemodynamically stable and had scleral icterus. Initial labs revealed hemoglobin 8.7 gm/dl, platelets 240 K/CUMM, aspartate aminotransferase 192 U/L, alanine aminotransferase 161 U/L, alkaline phosphatase 380 U/L, total bilirubin 21 mg/dl, and INR 1.6. ERCP revealed a patent stent in the common bile duct and no evidence of hemobilia. Subsequent esophagogastroduodenoscopy revealed three columns of large, non-bleeding esophageal varices with stigmata of recent bleeding. Endoscopic band ligation was performed. After completion of the procedure, abdominal aortic angiography revealed interval enlargement of a fusiform aneurysm of a false lumen of the common hepatic artery as well as resultant central compression of the adjacent portal venous system and intrahepatic bile ducts. The patient then had an episode of hypotension and tachycardia and required transfusion of four units of red blood cells. Interventional radiology emergently performed catheter-directed embolization of the common and right hepatic artery pseudoaneurysms, and the patient did not experience any further episodes of gastrointestinal bleeding. DISCUSSION: Our evaluation of this clinical case revealed two interesting points. In retrospect, the biliary stricture was the result of direct compression of the bile duct by the pseudoaneurysm, which may not have been appreciated by the endoscopist performing the initial procedure. Second, the etiology of this patient's portal hypertension was also a direct result of compression of the portal vein by the aneurysm. On his initial presentation, we did not make these associations, but further cross-sectional imaging led us to the correct answer. The patient benefited from early involvement of vascular interventional radiology, who were able to provide a therapeutic intervention via catheter-directed coil embolization. In cases where interventional radiology is unable to intervene, surgical management with vascular surgery may be necessary.Figure 1.: Aneurysmal dilation of the false lumen of the common hepatic artery (1.9 cm in diameter) causing extrinsic compression of the adjacent biliary tract and portal venous system.

S3457 Unusual Gastrointestinal Manifestation of Fabry Disease

INTRODUCTION: Fabry’s disease (FD) is a rare lysosomal storage disease caused by an X-linked deficiency of α-galactosidase A, resulting in intracellular accumulation of glycolipids, globotriaosylceramide (Gb3) in various tissues. Primarily affecting the skin (angiokeratomas), kidney (proteinuria and renal failure), heart (cardiomyopathy and arrhythmias), nervous system (acroparaesthesia, and autonomic neuropathy). Gastrointestinal (GI) manifestations are common and include diarrhea, nausea, abdominal pain, early satiety, and diverticular disease typically attributed to enteric neuropathy and myopathy caused by the accumulation of (Gb3). CASE DESCRIPTION/METHODS: A 69-year-old male with a past medical history of FD on agalsidase-β bi-weekly infusion, chronic intermittent diarrhea, autonomic neuropathy, chronic kidney disease, and atrial fibrillation on Coumadin, presented with hematochezia, four hours from his presentation, associated with blood clots, lightheadedness, diaphoresis, and near syncope. At presentation, vitals were stable, the abdomen was soft and non-tender, digital rectal exam was remarkable for scant bright red blood, and guaiac positive stool. Routine laboratory testing was significant for 8.7 g/dl decreased from baseline 13 gm/dL, BUN 61 mg/dL, Creatinine 2.57 mg/dL, lactic acid 3.9 mg/dL, INR 3.8. Therapy initiated with oral vitamin K and fresh frozen plasma for reversal of Coumadin effect. With further bloody bowel movements, hemoglobin dropped to 6.8 gm/dL requiring blood transfusion. Tagged RBC scan was negative for active bleeding, esophagogastroduodenoscopy (EGD) showed mild non-bleeding erythematous antral gastropathy, colonoscopy revealed normal mucosa without a source of bleeding. In a few days hematochezia resolved, the patient tolerated oral intake, Coumadin was resumed, and the patient was discharged home with plans for virtual capsule endoscopy as an outpatient. DISCUSSION: Gastrointestinal bleeding is a rare manifestation of FD. Cutaneous angiokeratomas are vascular lesions caused by upper dermal vessels ectasia, affect 70% of FD patients. The absence of a clear source of GI bleeding in this case on EGD, increase the likelihood of mucosal angiokeratomas bleeding in the small intestine. Mucosal angiokeratomas have been reported as a cause of life-threatening GI bleeding, which can be found anywhere in the GI tract mucosa. Given the high likelihood of arrhythmias requiring anticoagulation in FD, physicians should be more vigilant of the possibility of severe GI bleeding.

Typhoid ulcer related massive gastrointestinal bleeding successfully treated with endoscopic therapy

BackgroundTyphoid fever can manifest with a variety of gastrointestinal symptoms. However, in the present-day era, gastrointestinal bleeding related to bowel ulceration is becoming increasingly sporadic especially in the urban setting.Case presentationWe present a rare case of life-threatening gastrointestinal bleeding from a typhoid ileal ulcer that was successfully managed with endoscopic therapy.ConclusionThough rare, this infective cause of gastrointestinal bleeding should still be considered in differential diagnosis, especially in developing countries.

A Review on the Use of Reversal Agents of Direct Oral Anticogulant Drugs in Case of Gastrointestinal Bleeding.

Major bleeding is a life-threatening condition and a medical emergency with high mortality risk. It is often the complication of anticoagulant's intake. Anticoagulants are commonly used for the prevention and treatment of thrombotic events. The standard therapy with vitamin K antagonist (warfarin) has been frequently replaced by direct oral anticoagulants (DOACs). The latter agents (rivaroxaban, apixaban, edoxaban, dabigatran, and betrixaban) showed better efficacy and safety compared to standard warfarin treatment and they are recommended for the reduction of ischemic stroke. Literature data reported a high risk of gastrointestinal bleeding with DOACs, in particular with dabigatran and rivaroxaban. In case of life-threatening gastrointestinal bleeding, these patients could benefit from the use of reversal agents. We performed an electronic search on PUBMED of the literature concerning reversal agents for DOACs and gastrointestinal bleeding in the Emergency Department from 2004 to 2020. This review summarizes the current evidence about three reversal agents idarucizumab, andexanet alfa and ciraparantag, and the use of the first two in the emergency setting in patients with active major bleeding or who need urgent surgery which physicians indicate for a better management approach in order to increase patient's safety. Although these agents have been marketed for five years (idarucizumab) and two years (andexanet alfa) respectively, and despite guidelines considering antidotes as first-line agents in treating life-threatening hemorrhage when available, these antidotes seem to gain access very slowly in the clinical practice. Cost, logistical aspects and need for plasma level determination of DOAC for an accurate therapeutic use probably have an impact on this phenomenon.. An expert multidisciplinary bleeding team should be established so as to implement international guidelines based on local resources and organization.

Dieulafoy Lesion of Ileum: A Case Report


 
 
 
 Dieulafoy lesion is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). A 31 yearold male presented with complaints of hematochezia. Preliminary investigations failed to locate the exact source of bleed. Enteroscopy suggested distal ileal bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.5 cm was identified in distal ileum. 30 cm of ileum along with mesentery was resected. Histology revealed it to be Dieulafoy lesion. Dieulafoy lesion is uncommon but one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. This lesion is difficult to identify and high index of suspicion is required to make diagnosis. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.
 
 
 

Analysis of an improved workflow of endoscope reprocessing for bedside endoscopic diagnosis and treatment on COVID-19 patients.

Severe cases infected with the coronavirus disease 2019 (COVID-19), named by the World Health Organization (WHO) on Feb. 11, 2020, tend to present a hypercatabolic state because of severe systemic consumption, and are susceptible to stress ulcers and even life-threatening gastrointestinal bleeding. Endoscopic diagnosis and treatment constitute an irreplaceable part in the handling of severe COVID-19 cases. Endoscopes, as reusable precision instruments with complicated structures, require more techniques than other medical devices in cleaning, disinfection, sterilization, and other reprocessing procedures. From 2016 to 2019, health care-acquired infection caused by improper endoscope reprocessing has always been among the top 5 on the list of top 10 health technology hazards issued by the Emergency Care Research Institute. Considering the highly infective nature of COVID-19 and the potential aerosol contamination therefrom, it is of pivotal significance to ensure that endoscopes are strictly reprocessed between uses. In accordance with the national standard “Regulation for Cleaning and Disinfection Technique of Flexible Endoscope (WS507-2016),” we improved the workflow of endoscope reprocessing including the selection of chemicals in an effort to ensure quality control throughout the clinical management towards COVID-19 patients. Based on the experience we attained from the 12 severe COVID-19 cases in our hospital who underwent endoscopy 23 times in total, the article provides an improved version of endoscopic reprocessing guidelines for bedside endoscopic diagnosis and treatment on COVID-19 patients for reference.

Colonic Involvement of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Rare Cause of Gastrointestinal Bleeding

ABSTRACTStevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) represents a spectrum of rare but severe mucocutaneous drug reactions. Gastrointestinal involvement of SJS/TEN is associated with high morbidity and mortality and often presents 2–3 weeks after the initial appearance of skin lesions. There are no evidence-based treatment algorithms for the management of SJS/TEN. We report a case of life-threatening gastrointestinal bleeding from colonic involvement of SJS/TEN and discuss potential therapeutic options.

Endovascular and Percutaneous Treatment of Pediatric Portosystemic Varices: A Case Review

AbstractPortal hypertension is a significant cause of morbidity and mortality in pediatric patients. Complications of portal hypertension include development of portosystemic varices. The most common type of portosystemic varices are gastroesophageal varices; however, other ectopic varices can also be a cause of recurrent, life-threatening gastrointestinal bleeding. Problematic ectopic varices include isolated gastric, anorectal, small bowel, roux-limb, and stomal varices. There are no standardized treatment guidelines on how to manage ectopic varices in children; however, new innovations in endovascular treatment options provide potential therapeutic alternatives when varices are refractory to conventional therapy. This review provides a case-based literature review for endovascular treatment of isolated gastric, anorectal, small bowel, roux-limb, and stomal ectopic varices in children (age 0-9 years) and adolescents (age 10-19 years).

Bevacizumab as a treatment option in gastrointestinal bleeding associated to hereditary hemorrhagic telangiectasia. Case Report

Introduction: Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disease characterized by the presence of arteriovenous malformations in the nasal mucosa, the tips of fingers, and sometimes in the lungs, the gastrointestinal tract, the liver, the pancreas, the marrow and the brain. Its treatment is based on symptomatic control measures, but recently, the administration of anti-vascular endothelial growth factor (VEGF) molecules has been proposed as a treatment alternative, especially in patients with recurrent bleeding.Case presentation: The case of a 67-year-old man diagnosed with HHT and suffering from potentially life-threatening gastrointestinal GI bleeding is presented. The patient underwent several esophagogastric cauterization procedures but not positive outcomes were obtained, so he had to go to the Emergency Service of the hospital multiple times due to having low levels of hemoglobin (as low as 3.5g/dl). A bevacizumab based treatment was started by using a novel dosage regimen consisting of the administration of 6 5mg/kg bevacizumab dosages every 14 days. During the first week of treatment, hemoglobin levels increased to 14g/dl and the condition was stabilized.Conclusions: The findings reported here suggest that bevacizumab may be a therapeutic choice to be considered when treating patients with recurrent and refractory GI bleeding caused by HHT. However, a larger sample is required to determine if administering this medication is safe for these patients, as well as the appropriate dosage.

Clinical case of a repeated life-threatening upper gastrointestinal bleeding due to previously unknown primary hyperparathyroidism

Clinical case of a repeated life-threatening upper gastrointestinal bleeding due to previously unknown primary hyperparathyroidism

Partially Covered Transjugular Intrahepatic Portosystemic Shunt Endograft for Repair of a Primary Aortoenteric Fistula

Aortoenteric fistulae (AEF) are a rare cause of life-threatening gastrointestinal hemorrhage. AEF are divided into primary and secondary types. Secondary fistulae are more common and occur after prior aortic interventions, namely aneurysm repairs. Less common is primary aortoenteric fistulae (PAEF), which most commonly arise de novo from trauma or underlying neoplastic, infectious, or rheumatologic conditions. Although PAEF are associated with high mortality and morbidity, there have been several case reports documenting temporization of PAEF with stent grafts. These measures are effective in acute settings, often with unstable patients. This approach also provides time for the patient, family and their care team to decide on definitive treatment. This is especially important as many of these patients have serious underlying pathology, or will need to undergo extensive treatment for definitive care. Here, we present a case of PAEF in a patent with Stage IV renal malignancy. The bleed was controlled with the use of a 12 mm VIATORR endoprosthesis (W. L. Gore and Associates, Inc., Flagstaff, Arizona, USA), typically used in transjugular intrahepatic portosystemic shunts. The report demonstrates how an endoprosthesis originally designed for hepatic interventions can serve as an endovascular stent graft in extenuating circumstances. This report also aims to highlight the importance of following endovascular principles and the post-treatment care of patients with PAEF.

Ileal Dieulafoy Lesion: a rare case report

BackgroundDieulafoy lesion, also known as calibre persistent artery is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). Commonest location is in proximal stomach while occurrence in small intestine, especially ileum is extremely rare.Case presentationA 26 year old female presented with lower gastrointestinal bleeding. Preliminary investigations failed to locate the exact source of bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.8 cm in diameter was identified in distal ileum. Histology revealed it to be Dieulafoy lesion.ConclusionAlthough uncommon, ileal dieulafoy is one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.

Prescribing Warfarin to a Patient with Oesophageal Varices—A Case Report and Review of the Literature

We describe the case of a 42-year old man who presented with melaena. He was found to have bleeding varices during endoscopic investigation. Subsequent investigation revealed the aetiology to be a portal vein thrombosis (PVT) due to an underlying pro-coagulable state (Factor V Leiden). He was managed with cautious anticoagulation but suffered a life-threatening upper gastrointestinal bleed that was not amenable to endoscopic treatment or transjugular intrahepatic portosystemic shunting (TIPS). As such, the only therapeutic option involved the pursuit of surgical shunt operations. We review the literature regarding this atypical cause of GI-bleeding and discuss medical and surgical considerations for the management of such patients.

Terminal Ileac Ulcers Mimicked Post-transplantation Lymphoproliferative Disorder in a Heart Recipient Treated With Everolimus: A Case Report

Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized and potentially fatal complication of cardiac transplantation that commonly involves the gastrointestinal tract. Herein, we report a case of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers mimicking PTLD in a heart recipient treated with everolimus (EVL). A 40-year-old man underwent heart transplantation for dilated cardiomyopathy 3 years prior to the current admission and was treated with tacrolimus and EVL. He was admitted to a local hospital because of fever, abdominal pain, and diarrhea. His symptoms persisted and, 3 weeks later, hematochezia occurred; thus, he was transferred to our hospital. As computed tomography and 18F-fluorodeoxyglucose positron emission tomography showed bowel-wall thickening of the terminal ileum, gastrointestinal PTLD was initially suspected. However, although colonoscopy— performed after switching EVL to mycophenolate mofetil (MMF)—showed terminal ileac ulcers, the histologic examination revealed no findings corresponding to PTLD. As EVL may delay ulcer healing, MMF was maintained for 3 months. After repeated colonoscopy showed ulcer healing, MMF was switched back to EVL for cardiac allograft vasculopathy prevention. Three weeks later, he was emergently admitted to a local hospital for life-threatening gastrointestinal bleeding from a recurrent terminal ileal ulcer, which required hemostatic forceps hemostasis. As EVL is suspected to be associated with recurrent ileal ulcers, EVL was again switched back to MMF. The ileal ulcers resolved, without recurrence in 3 months of clinical follow-up. This case demonstrates that cases of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers can mimic PTLD in a heart recipient treated with EVL.

Administration of four-factor prothrombin complex concentrate for a life-threatening bleed in a Jehovah's Witness patient.

: Life-threatening bleeds are medical emergencies that require time-sensitive decision making. Patients of the Jehovah's Witness faith can present a challenging conundrum when their beliefs conflict with modern treatment options for haemorrhage. Providers may not be aware of the grades of acceptance of the newer products outside of packed red blood cells. Researchers present a case of using four-factor prothrombin complex concentrate in a Jehovah's Witness patient in a life-threatening gastrointestinal haemorrhage along with a brief review of the literature.

CARDIOVASCULAR AND GASTROINTESTINAL COMMUNICATION: PREDICTIVE VALUE FOR COMORBID PATIENT

The article provides the description of the clinical importance of comorbidity, its epidemiology, the attention is focused on the highest prevalence and prognostic significance of cardiovascular and gastrointestinal pathogenetic relations complicating the course of the cardiovascular pathology by development of erosive-ulcerative lesions of stomach and duodenum, the first manifestation of which are often life-threatening gastrointestinal bleeding. Symptomatic gastroduodenal ulcer lesions (SGUL) are described in detail including their modern definition, classification, epidemiology, clinical manifestations and diagnosis with a detailed analysis of features of pathogenesis and course of patients with cardiovascular diseases. SGUL induced by nonsteroidal anti-inflammatory drugs are analyzed including those induced by low-dose acetylsalicylic acid (NDA), risk factors for their occurrence and prevention in groups at high and moderate gastrointestinal risk are considered. The need for further scientific research of topical issues of «comorbidity» to improve diagnosis and treatment of comorbid pathology in public health practice are stressed.

CARDIOVASCULAR AND GASTROINTESTINAL COMMUNICATION: PREDICTIVE VALUE FOR COMORBID PATIENT

The article provides the description of the clinical importance of comorbidity, its epidemiology, the attention is focused on the highest prevalence and prognostic significance of cardiovascular and gastrointestinal pathogenetic relations complicating the course of the cardiovascular pathology by development of erosive-ulcerative lesions of stomach and duodenum, the first manifestation of which are often life-threatening gastrointestinal bleeding. Symptomatic gastroduodenal ulcer lesions (SGUL) are described in detail including their modern definition, classification, epidemiology, clinical manifestations and diagnosis with a detailed analysis of features of pathogenesis and course of patients with cardiovascular diseases. SGUL induced by nonsteroidal anti-inflammatory drugs are analyzed including those induced by low-dose acetylsalicylic acid (NDA), risk factors for their occurrence and prevention in groups at high and moderate gastrointestinal risk are considered. The need for further scientific research of topical issues of «comorbidity» to improve diagnosis and treatment of comorbid pathology in public health practice are stressed.

Gastrointestinal causes of sudden unexpected death: A review.

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.