Massive Melena Research Articles

Systemic lupus erythematous presenting with hemorrhagic shock caused by gastric penetration of pancreatic pseudocyst: a case report

BackgroundSystemic lupus erythematous that causes various organ damage is rarely associated with pancreatic lesion. To the best of our knowledge, no cases presenting with hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis have been reported. Herein, we report a case of hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis.Case presentationA 53-year-old Japanese man with a history of systemic lupus erythematous, pancreatic pseudocyst, and chronic pancreatitis complained of epigastric pain and had hematemesis. He visited our emergency room and was admitted in our hospital. Upper endoscopy showed that hemostasis was obtained; however, computed tomography scan was performed since he was suspected to have gastric penetration into hollow viscera. The computed tomography revealed accumulation of fluid around the pancreas and gastric penetration of pancreatic cyst. Blood test showed increased serum amylase level. These results suggest that the exacerbation of chronic pancreatitis causes the penetration. Surgery was considered; however, we took a wait-and-see approach since hemostasis was obtained. After that, he was in stable condition, although he suffered from fever and accumulation of left pleural effusion was observed by computed tomography. However, he had massive hematemesis and melena 9 days after hospitalization and died in spite of several treatments including blood transfusion. Autopsy revealed that he actually had pleural thickening, which is not caused by accumulation of left pleural effusion but by severe pleural inflammation. We therefore performed additional blood and urinary tests on the same day. The test results showed that he had a high titer of anti-double-stranded deoxyribonucleic acid (DNA) antibody, hypocomplementemia, and erythrocyturia, indicating that he had systemic lupus erythematous with high disease activity considering his fever and pleural inflammation.ConclusionsPatients who have systemic lupus erythematous with high disease activity have the potential to develop fatal complications due to pancreatitis, so appropriate treatments are required for such patients.

Recurrent massive bleeding from a small intestinal arteriovenous malformation after surgery for biliary atresia in an infant: a case report and literature review

BackgroundSmall intestinal arteriovenous malformation (AVM) can cause bleeding. Most small intestinal AVMs occur during adulthood, rarely in infancy. We report a case of an infant with hemorrhage due to small intestinal AVM early and recurrently after Kasai portoenterostomy (PE) for biliary atresia (BA).Case presentationA 51-day-old male infant was admitted to our institution for obstructive jaundice. Laparotomic cholangiography revealed BA (IIIb1μ), and Kasai PE was performed at 60 days of age. On postoperative day 17, he developed massive melena and severe anemia. Contrast-enhanced computed tomography (CT) revealed that the jejunum around the PE site was strongly enhanced with enhancing nodules in the arterial phase, and a wide area of the Roux limb wall was slightly enhanced in the venous phase. As melena continued, emergency laparotomy was performed. There were no abnormal macroscopic findings at the PE site except for a clot in the Roux limb 5 cm away from the PE site, and the Roux limb was resected 5 cm. On further investigation, a red spot was detected on the jejunal serosa 30 cm away from the Roux-en-Y anastomosis site. PE and wedge resection for the red spot were performed. Histopathologically, both specimens indicated AVM. He was jaundice-free 65 days after the first surgery. However, at 7 months of age, he developed massive melena again. Contrast-enhanced CT and upper gastrointestinal endoscopy revealed no bleeding lesions. Hemorrhagic scintigraphy showed a slight accumulation at the hepatic hilum prompting an emergency surgery. Intraoperative endoscopy detected a bleeding lesion at the PE site, and the Roux limb was resected (approximately 6 cm). Intraoperative frozen section analysis of the stump of the resected jejunum revealed no abnormal vessels. PE was performed, and permanent section analysis revealed an AVM in the resected jejunum. The postoperative course was uneventful without re-bleeding.ConclusionsWe experienced a case of recurrent massive bleeding from small intestinal AVM in an infant after surgery for BA. Intraoperative endoscopy and frozen section analysis helped identify the bleeding lesion and perform a complete resection of the small intestinal AVM, even after surgery, in the infant.

S2158 Fundic Gland Polyp Causes Massive Melena During Induction Chemotherapy With R-EPOCH for DLBCL

INTRODUCTION: Fundic Gland Polyps (FGPs) are hamartomatous cystic lesions in the gastric mucosa, and mostly occur sporadically. Bleeding from an FGP is very rare but has been reported in the setting of long-term PPI use and rare hematologic conditions. Overall, these polyps are considered quite benign. CASE DESCRIPTION/METHODS: A 71-year-old gentleman presented to the hospital in active tumor lysis and was subsequently diagnosed with Diffuse Large B Cell Lymphoma of the non-germinal center type, in a background of 3B follicular lymphoma. He was started on induction chemotherapy with the R-EPOCH regimen (without rituximab given unknown HBV status) and a day later, developed massive melena resulting in hemorrhagic shock. His chemotherapy regimen was stopped and he was resuscitated, requiring multiple transfusions. Once in stable condition, an EGD was performed which found only a benign FGP in a background of chronic atrophic gastritis as a source of the bleed (Figure 1). The pathology revealed pyloric and intestinal metaplasia, consistent with autoimmune gastritis (Figure 2), with no evidence of dysplasia or malignancy. Mesenteric angiography was subsequently performed to identify any other source of GI bleed for IR embolization, but no contrast extravasation was observed to suggest one. The patient's clinical status improved during the procedure, suggesting that the hemorrhage had ceased. DISCUSSION: The development of FGPs is a rare phenomenon. When they do form, they may form sporadically, or may be associated with hypergastrinemia seen in patients taking proton pump inhibitors, in those with Zollinger-Elison syndrome, and in those with autoimmune metaplastic atrophic gastritis (AMAU). Interestingly, our patient was found to have AMAU on pathology and there have been multiple reports of a bidirectional association between lymphocytic malignancies, like DLBCL, and autoimmune manifestations. Our patient's GI bleed was likely the result of a combination of factors, including his AMAU and his DVT prophylaxis (enoxaparin), but the most significant of these factors is the gastrointestinal side effects of his chemotherapeutic R-EPOCH (Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide and Doxorubicin Hydrochloride) regimen. Many of the drugs used in this regimen are known to cause mucositis, and prednisone in particular has been historically associated with GI bleeds due to mechanisms such as impaired wound healing. As seen in this case, when his chemotherapeutic regimen was stopped, his bleeding also ceased.Figure 1.: Endoscopic photograph of the fundic gland polyp.Figure 2.: The biopsy of the fundic gland polyp demonstrates cystically dilated glands arising in oxyntic-type mucosa.Figure 3.: The biopsy of the background fundic mucosa shows atrophic mucosa with loss of oxyntic glands, pseudopyloric metaplasia, and chronic inflammation in the lamina propria, compatible with autoimmune gastritis.

Dieulafoy lesion: two pediatric case reports

BackgroundMassive gastrointestinal bleeding in children is uncommon. Dieulafoy lesion is an uncommon disease which may lead to massive and repeated upper gastrointestinal hemorrhage. We report two cases of gastric Dieulafoy lesion successfully treated with either band ligation or endoscopic hemoclipping.Case presentationFirst case report: A previously healthy 18-month-old female infant with E. coli sepsis, pneumonia and respiratory failure with bilateral pneumothorax requiring chest drainage. Over a few days, the patient presented hematemesis and melena with progressively worsening anemia. The esophagogastroduodenoscopy revealed an arterial vessel with eroded apex located between the body and the fundus of the stomach. Two elastic bands were applied which resulted in resolution of hematemesis and melena and improvement of the anemia.Second case report: A 8-year-old male was admitted to our department with sudden massive hematemesis and melena. Clinical examination revealed anemia (hemoglobin, 6.8 g/dl). Esophagogastroduodenoscopy revealed a mucosal erosion with visible vessel located along the small curvature, close to the antrum. Three hemostatic clips were placed on the Dieulafoy lesion and hemostasis was obtained.Conclusionswe showed that, similar to gastric DL in adult patients,, gastric DL in pediatric patients can be successfully treated with endoscopic therapy, and both hemoclipping and band ligation are suitable techniques.

Aortoenteric fistula following overlap esophagojejunal anastomosis using linear staplers for cancer of the esophagogastric junction: a case report

BackgroundAortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy.Case presentationA 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site.ConclusionsTo our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

Non Peptic Ulcer Upper Gastrointestinal Bleeding in Patients Treated with Non-Steroidal Anti-inflammatory Drugs for Musculo-articular Disorders

Introduction: Complications in the evolution of digestive tract benign pathology leads to symptoms: hemorrhagic, occlusive or perforative syndrome. Method: We present three cases of gastrointestinal (GI) hemorrhage with a different pathology and rarely seen in clinical practice in patients treated with non-steroidal anti-inflammatory drugs for muscular-articular pathology. Cases’ presentation: (1) A 47 years old man known with recurrent episodes of upper GI bleeding was admitted for a new massive hemorrhage; the emergency laparotomy revealed a splenic arteriovenous fistula penetrating the Wirsung duct. A splenopancreatectomy was performed with uneventful recovery. (2) A 57 years old woman with chronic anemia, nausea, weight loss and vomiting was admitted for intermittent recurrent episodes of melena. The exploratory laparotomy revealed several jejunal diverticulum with active bleeding; a segmental enterectomy was performed with uneventful recovery. (3) A 24 year old patient was admitted for massive inaugural melena. The upper GI tract endoscopy was negative; due to hemorrhagic shock an emergency exploratory laparotomy was performed and revealed a jejunal GIST. The resection was performed with uneventful recovery. The histo-pathologic exam confirmed a benign GIST. Conclusions: During Non-Steroidal Anti-inflammatory Drugs (NSAID) therapy anemia and upper GI bleeding are usually considered as common disorders related with peptic ulcer. However NSAID therapy can hide another more complex causes of bleeding. In majority of cases the bleeding is brutal and surgical approach remains the only alternative to perform the diagnosis and to cure the patient.

Nonocclusive Mesenteric Ischemia Resulting from Acute MyocardialInfarction of Left Main Trunk after the Recovery from Cardiac Arrest by Percutaneous Cardiopulmonary System: A Case Report

A 77-year old male was ambulated to our institution after he had been found unconsciousness in the street. On admission, he complained about severe chest pain. His systolic blood pressure was 58 mmHg; therefore, he was diagnosed to be in cardiogenic shock. A 12-lead electrocardiography (ECG) revealed ST elevation in the lead II, III, aVf, and V1 - V5. The episode of chest pain and abnormal ECG findings led to the diagnosis of AMI. Coronary angiography revealed severe stenosis in the left main trunk (LMT) and the left anterior descending artery (LAD). LMT was considered as the culprit lesion in this case. During the examination, the monitoring ECG revealed cardiac arrest; therefore, cardiac resuscitation was immediately performed using percutaneous cardiopulmonary system. Ventricular fibrillation was evident; following cardiac defibrillation at 360J restored sinus rhythm. Subsequently, intraaortic balloon pumping was placed, and percutaneous coronary intervention was performed; coronary stents were successfully placed in LMT and LAD. Postoperative course was uneventful; however, he emerged with massive melena on day 13. Colonoscopy revealed cast-like stripped mucosa from the ascending to the cecum, which was suggesting of severe intestinal ischemia. Non contrast computed tomography suggested a lower intestinal perforation. Because of his circulatory condition and anticoagulant therapies after AMI, he didn’t become a candidate for surgical treatment. After provided with conservative therapy, he died of multiple organ failure resulting from panperitonitis.

Therapeutic Effects of Lenalidomide on Hemorrhagic Intestinal Myeloma-associated AL Amyloidosis

A 74-year-old woman with refractory IgG-κ multiple myeloma developed massive melena caused by hemorrhagic submucosal tumors in the duodenum and middle jejunum. A biopsy revealed the tumor to be marked AL amyloid deposition. Treatment with bortezomib did not improve the melena or the underlying disease. The patient also developed multiple amyloidomas in the bilateral femoral heads, which caused a fracture in the left femoral head. Treatment with lenalidomide, as the final therapeutic option, resolved the intractable melena and improved both the intestinal lesions and myeloma. This case shows that successful treatment of multiple myeloma leads to marked improvement of accompanying AL amyloidosis.

An unusual case of jejunal choriocarcinoma detected by single-balloon endoscopy

A 41-year-old woman was admitted to our institution because of massive melena and symptomatic anemia (Hb 5.3 g/dL). The patient had previously undergone a cesarean section and tubal ligation 3 years ago while giving birth to her second child.

Microballoon Occlusion Test to Predict Colonic Ischemia After Transcatheter Embolization of a Ruptured Aneurysm of the Middle Colic Artery

A 76-year-old woman presented with sudden massive melena, and superior mesenteric arteriography showed an aneurysm in the middle colic artery (MCA). Because she had a history of right hemicolectomy and ligation of the inferior mesenteric artery (IMA) during open abdominal aortic aneurysm repair, embolization of the MCA aneurysm was considered to pose a risk comparable to that of colonic ischemia. A microballoon occlusion test during occlusion of the MCA confirmed retrograde visualization of the IMA branches through the collateral arteries by way of the left internal iliac artery, and embolization was successfully performed using microcoils. No colonic ischemia or aneurysm rupture occurred after embolization.

Incidence and Prognostic Factors for Infectious and Hemorrhagic Death in Patients with Acute Myeloid Leukemia: A Single-Centre Study.

INTRODUCTION: Death is as a common cause of remission induction failure in patients with acute myeloid leukemia (AML), mainly due to hemorrhage and infection. The relative incidence and chronology of each of these categories of induction failure, as well as their prognostic factors, have been investigated critically and in detail in rare studies only.OBJECTIVES: We report the incidence, chronology, and prognostic factors for induction death, analyzing separately hemorrhagic and infectious death, in a large series of 946 patients with AML who received induction therapy in a single institution over the last 30 years.PATIENTS AND METHODS: Adult patients were consecutively diagnosed of AML and started first induction chemotherapy in our institution. AML was classified according to the FAB criteria. Induction therapy consisted of the classic combination of cytarabine and anthracyclines (with or without a third agent) in 50% of patients, cytarabine plus adriamicine and thioguanine or vincristine in 17%, ATRA with chemotherapy in 9%, monochemotherapy with anthracycline in 7%, high dose cytarabine in 7%, and other regimens in 10%. Causes of induction death include the following categories:1.Infection, when death was due to a clinical, radiological or microbiologically documented infection,2.Hemorrhage, when a major bleeding occured in a vital organ (central nervous system, lungs). Gastrointestinal hemorrhage required massive melena or hematemesis accompanied by fall in blood pressure, and3.Other, i.e., any other cause not classified as infection or hemorrhage.RESULTS: From 1977 to 2007, 946 consecutive patients with diagnosis of AML received induction chemotherapy, 24% in the period 1 (1977–1986), 28% in the period 2 (1987–1993), 28% in the period 3 (1994–2000), and 20% in the period 4 (2001–2007). Median age was 55 years (range 13–83 years). One hundred and sixty-seven patients (18%) had antecedents of myelodysplastic/myeloprolipherative disease (10%) or other neoplasia (8%). Two hundred and thirty-seven patients (25%) died during induction therapy, 13% due to infection, 7% due to hemorrhage, 2% due to hemorrhage and infection, and 3% due to other causes. The induction mortality rates decreased gradually over the 4 periods (31% vs 24% vs 18% vs 18%), due to reduction of both hemorrhagic and non-hemorrhagic deaths. Overall, 42% of hemorrhagic deaths occurred within the first 10 days of induction therapy, whereas 86% of infectious deaths occurred after 10 days. In multivariate analysis, the following characteristics had an unfavorable impact on overall induction mortality: age >60 years, WBC >50x109/L, Quick index <65%, ECOG >1, and albumin serum levels <3.5mg/dL. Multivariate analysis identified the following factors predicting for infectious mortality: albumin <3.5mg/dL, age >50 years, AML secondary to neoplasia, ECOG >1, and fever at presentation. The following factors were associated with hemorrhagic mortality: WBC >50x109/L, FAB-M3, age >60 years, de novo AML, and ECOG >1.CONCLUSIONS: The main causes of induction death in AML patients, infection and hemorrhage, shows a different chronologic pattern and can be separately predicted by their own specific prognostic factors.

Massive Melena Caused by a Carcinoid of the Small Intestine: Report of a Case

We report a case of massive melena caused by a carcinoid of the small intestine. A 28-year-old woman was admitted to our department after presenting with massive melena. The source of the bleeding could not be localized by upper or lower gastrointestinal endoscopy, computed tomography (CT), or labeled red blood cell scintigraphy. Enteroscopy allowed visualization only up to the jejunum, and we could not localize the lesion. The melena subsided with conservative treatment, but the patient was readmitted 4 months later when she suffered another episode of massive melena. A contrast CT scan performed immediately showed extravascular leakage and the retention of contrast medium in the ileum. Thus, she underwent an emergency surgery, during which endoscopy confirmed a small ileal tumor accompanied by pulsating bleeding from the exposed blood vessels at its center. The small intestine was partially resected, including the swollen lymph nodes, the size of small beans. Pathological examination confirmed a carcinoid tumor 1 cm in diameter, with an arterial rupture at its center and lymph node metastasis.

Clinical challenges and images in GI

Question: A 25-year-old, previously healthy American man was in Taiwan for 3 months and presented with massive melena and bloody stool for 1 day. He visited another hospital where upper endoscopy and colonoscopy disclosed no bleeding. Because of ongoing bleeding, he was referred to our hospital for enteroscopy the next day. His medical history was unremarkable. He also denied excessive alcohol consumption. Physical examination was remarkable for a pale conjunctiva. There were no spider angioma, palm erythema, or splenomegaly.

Hemobilia Complicating a Liver Abcess

We present the case of an 11-year-old female, with a history of colicky pain abdomen fever, and episode of massive hematemesis and melena. The child was presented to the medical emergency with features of shock. Coagulation profile of the child was normal. Ultrasonography demonstrated multiple liver abscess. Repeated endoscopies ruled out the possibility of gastric or upper gastrointestinal causes of bleed where in the possibility of hemobilia, was considered. Endoscopic retrograde cholangiography demonstrated the presence of bleeding from the biliary tract. Angiography demonstrated the presence of the communication of the biliary radicles with the hepatic vessels and also aided with therapeutic embolization. Hemobilia is a rare cause of upper gastrointestinal hemorrhage with an increasing incidence because of the widespread use of invasive hepatobiliary procedures and improved recognition. In the majority of cases the cause is iatrogenic and those associated with the liver abscess are scantily reported in the English literature. Persistent bleeding sometimes requires urgent therapeutic intervention, such as angiography or surgery.

Influence of Leukocytapheresis Therapy for Ulcerative Colitis on Anemia and Hemodynamics

In Japan, leukocytapheresis (LCAP) therapy has been carried out for ulcerative colitis as an effective therapy with a low incidence of side-effects. In the present study, we serially investigated the influence of LCAP therapy on anemia and hemodynamics in patients with ulcerative colitis using a non-invasive method with a Crit-Line monitor (CLM) (Hema Metrics Inc., Salt Lake City, UT and Boston, MA, USA). We carried out LCAP on 10 patients with ulcerative colitis using a CS-100 Cellsorba EX LCAP filter in 34 courses of LCAP. The mean hematocrit value, which was measured using the Crit-Line monitor, was 21.8 +/- 0.2% (21.0-22.4%), which showed no significant changes after each LCAP therapy. The actual erythrocyte count, hemoglobin and hematocrit values decreased by 244 000/mm3, 0.7 g/dL and 2.1%, respectively, however, the differences were insignificant. These values corresponded to 7.8, 8.0 and 7.6% of the values before LCAP, respectively. There were no significant changes in systolic blood pressure, diastolic blood pressure, or heart rate during LCAP. The results of this study suggest that one course of LCAP does not exacerbate anemia, and it does not influence hemodynamics. However, considering the exacerbation of anemia in patients with severe ulcerative colitis caused by massive melena, monitoring with a less invasive Crit-Line monitor and a vital information monitor might be useful.

Epstein–Barr virus‐associated enteritis with multiple ulcers after stem cell transplantation: First histologically confirmed case

The present case involves unique enteritis forming multiple ulcers associated with Epstein-Barr virus (EBV). A 57-year-old man had undergone a reduced intensity allogeneic stem cell transplantation for a relapse of multiple myeloma following sequential autologous peripheral blood stem cell transplantation. The ileum, resected for massive melena, showed multiple irregular ulcers with occasional cobblestone-like appearance. There was inflammation including numerous plasma cells in the ulcer bases and surrounding areas, where many EBV-infected plasma cells were detected by double staining with EBV-encoded small RNA-1 (EBER-1) in situ hybridization and CD79a, while EBV-infected epithelial cells were not noted. The number of EBER-1-positive cells in the ileum (mucosa, 1451 cells/mm(2); submucosa, 465 cells/mm(2)) was much larger than in control samples (malignant lymphoma or leukemia after allogeneic stem cell transplantation, n = 4, range 0-113 cells/mm(2); malignant lymphoma after chemotherapy, n = 14, range 0-0.89 cells/mm(2); colon cancer, n = 12, range 0-3.5 cells/mm(2)). In the mucosa near the ulcers, EBER-1-positive cells often surrounded and involved the glandular epithelium, forming lymphoepithelial-like lesions. The histological findings differ from post-transplant lymphoproliferative disorders or intestinal thrombotic microangiopathy, and this is the first case of EBV-associated enteritis with ulcers characterized by numerous plasma cells and lymphoepithelial-like lesions after stem cell transplantation.

Primary Nonresponse to Anti‐Cd20 Therapy in Gastrointestinal Posttransplant Lymphoproliferative Disorder

Primary Nonresponse to Anti‐Cd20 Therapy in Gastrointestinal Posttransplant Lymphoproliferative Disorder

ANCA-negative pauci-immune crescentic glomerulonephritis complicated with recurrent massive gastrointestinal hemorrhage

On April 25, 2003, a 62-year-old Japanese man had been admitted to a hospital because of heavy proteinuria and elevated serum creatinine level, and purpura on the lower extremities. On May 15, 2003, he was referred to our hospital for evaluation and treatment. Serum immunoglobulin and complements were within normal ranges. Immune serology was negative for antinuclear antibody, antiglomerular basement membrane antibody, and antineutrophil cytoplasmic antibodies. Histological examination of a percutaneous renal biopsy specimen revealed that all of the glomeruli had severe crescent formation without deposits of immunoreactants. A diagnosis of antineutrophil cytoplasmic antibody-negative pauci-immune crescentic glomerulonephritis was made. The patient was treated with one cycle of steroid pulse therapy (1000 mg methylprednisolone daily, given on 3 consecutive days), and subsequently with prednisolone (60 mg/day). Despite this treatment, renal failure progressed rapidly and hemodialysis was started 1 month after the acute presentation. On May 30, 2003, he suddenly developed massive hematochezia. A technetium-targeted red-blood-cell scan suggested bleeding in the small intestine. On June 11, he presented with massive melena. A bleeding ulcer was found in the third part of the duodenum, and was treated successfully with endoscopy, using a heater probe. On June 19, he presented with massive hematochezia again. Mesenteric angiography revealed active bleeding from the iliac branch of the superior mesenteric artery. He was treated with continuous intraarterial vasopressin infusion by a catheter seated in the branch artery. The majority of patients with pauci-immune crescentic glomerulonephritis, one of the most common causes of rapidly progressive glomerulonephritis, have glomerular disease as part of a systemic vasculitis. Massive gastrointestinal bleeding, although rare, should be considered one of the serious complications in these patients.

Two cases of colonic tuberculosis presenting with massive melena

The clinical symptoms of colonic tuberculosis are variable, among which massive melena is extremely rare. Herein, we report two cases of colonic tuberculosis representing with massive melena, both of whom never had active pulmonary tuberculosis. The first case was a 55-year-old woman. Although her emergency colonoscopic setting suggested colonic tuberculosis, no evidence of tuberculosis could be found at that time. We performed a therapeutic trial and observed a drastic regression of the initial changes with 4-week treatment using antituberculous agents. The second case was a 37-year-old man. His emergency colonoscopy showed lesions mimicking colon carcinoma. However, the histological examinations did not indicate malignancy. The polymerase chain reaction of colonic biopsy specimen was positive for Mycobacterium tuberculosis. Similar to the first case, a significant improvement of the initial lesions was observed after 4-week treatment using antituberculous agents. Collectively, although the massive melena is a rare manifestation, tuberculosis of the colon should be suspected in the patients with such symptom.

COMPLICATIONS ASSOCIATED WITH ENDOSCOPIC MUCOSAL RESECTION: DEFINITION OF BLEEDING THAT CAN BE VIEWED AS ACCIDENTAL

ABSTRACTThe consensus reached during the meeting on complications associated with EMR entitled ‘The definition of bleeding that can be viewed as accidental’ was held at the third EMR Conference, December 20, 2003, in Tokyo is as follows. (1) The definition of complications associated with EMR as intraoperative bleeding is cases requiring special measures such as emergency surgery, intraoperative blood transfusion, or vasopressor therapy and cases where EMR has to be necessarily discontinued because of intraoperative bleeding; and (2) the definition of complications associated with EMR as postoperative bleeding is marked bleeding from the ulcer‐affected area after EMR, requiring special measures for hemostasis. Bleeding during or after EMR may be deemed as accidental if the Hb level falls by 2 g/dL or more in comparison with the last preoperative level, or if any of apparent bleeding or massive melena, etc. is seen. Providing a clear definition for ‘apparent bleeding’ and ‘massive melena’ was left open to debate.