Minor Gastrointestinal Bleeding Research Articles

Outcomes of meso-Rex bypass for prehepatic portal hypertension in pediatric patients

Portal hypertension in pediatric patients is often associated with prehepatic portal hypertension (PHPH), frequently linked to thrombosis and cavernomatous degeneration of the portal vein (CDVP). This study evaluates the efficacy of the MesoRexBypass (MRB) in managing PHPH and associated thrombosis. MethodsA retrospective prognostic cohort design was employed to analyze the clinical outcomes of nine pediatric patients who underwent MRB between 2020 and 2022. Clinical and surgical variables were examined, including graft type, surgical time, and complications. Postoperative follow-up confirmed MRB functionality. ResultsThe MRB proved highly successful, with improved clinical parameters observed in all patients. Significant reductions in gastrointestinal bleeding, esophageal varices, and hypertensive gastropathy were observed postoperatively. Thrombocytopenia and liver enzyme levels showed substantial improvement, indicating enhanced liver function and amelioration of hypersplenism. The MRB's adaptability was demonstrated using autologous grafts and various graft sources.One patient experienced shunt thrombosis, another experienced minor gastrointestinal bleeding, and another died. The MRB exhibited a high success rate and few complications. ConclusionThe MRB is an effective and versatile surgical technique for managing PHPH in pediatric patients. This study emphasizes its promising outcomes and suggests its potential for enhancing treatment approaches and quality of life in this patient population. Further research with larger cohorts is needed to strengthen the evidence presented. The MRB holds promise as a valuable addition to the management of PHPH in children. Level of Evidence IV.

Impact of bleeding event for new cancer diagnosis in patients with antiplatelet therapy after percutaneous coronary intervention

BackgroundBleeding is a frequent event in coronary artery disease (CAD) patients treated with antiplatelet therapy after percutaneous coronary intervention (PCI). The impact of bleeding in CAD patients with antiplatelet therapy for cancer diagnosis remains unclear. Methods and resultsConsecutive 1565 CAD patients treated with antiplatelet therapy after PCI, without anticoagulation therapy, were enrolled. We aimed to investigate the relationships between bleeding events and the incidence of new cancer diagnosis. Among 1565 patients, 178 (11.3 %) experienced any bleeding events defined as Bleeding Academic Research Consortium (BARC) type 1, 2, 3, or 5 bleeding and 75 (4.7 %) experienced minor bleeding events defined as BARC 1 or 2 bleeding, and 116 (7.4 %) were diagnosed with new cancer during a mean follow-up period of 1528 days. Among 178 patients with any bleeding and 75 patients with minor bleeding events, 20 (11.2 %) and 13 (17.3 %) were subsequently diagnosed with new cancer, respectively. The proportion of new cancer diagnosis was higher in patients with any bleeding and minor bleeding events than in those without bleeding events (3.3 versus 1.6 per 100 person-years, p < 0.001 and 6.2 versus 1.6 per 100 person-years, p < 0.001, respectively). Multivariate Cox proportional hazard analysis revealed that any bleeding and minor bleeding events were associated with higher rate of new cancer diagnosis [hazard ratio (HR) 2.27, p = 0.003 and HR 3.93, p < 0.001, respectively]. Additionally, any gastrointestinal bleeding and minor gastrointestinal bleeding events were associated with higher rate of new gastrointestinal cancer diagnosis (HR 8.67, p < 0.001 and HR 12.74, p < 0.001, respectively). ConclusionsIn CAD patients with antiplatelet therapy after PCI, any bleeding and minor bleeding events were associated with subsequent new cancer diagnosis. Even minor bleeding events may be the first manifestation of underlying cancer during antiplatelet therapy after PCI.

Preoperative bleeding requiring transfusion: An under-reported indication for hemorrhoidectomy

BackgroundThough hemorrhoids commonly cause minor gastrointestinal bleeding, major hemorrhage requiring blood transfusion is believed to be rare. We sought to identify the prevalence and risk factors for preoperative transfusion in surgical hemorrhoidectomy patients. MethodsPatients undergoing surgical hemorrhoidectomy at a single institution (2012–2017) were evaluated for preoperative bleeding requiring transfusion. Bivariate analysis compared patients requiring transfusion to those who did not, and multivariable analysis evaluated for independent risk factors for transfusion. ResultsOut of 520 patients, 7.3% experienced hemorrhoidal bleeding requiring transfusion, and 80.6% reported bleeding. On multivariable analysis, the use of either an anticoagulant or non-aspirin antiplatelet agent was associated with transfusion (OR 3.08, p = 0.03). Patients requiring transfusion had extensive preoperative workups, including colonoscopy (94.7%), flexible sigmoidoscopy (7.89%), upper endoscopy (50%) and capsule endoscopy (26.3%). ConclusionsBleeding requiring transfusion is an under-reported complication of hemorrhoids. Increased recognition could lead to expeditious surgical treatment and less costly diagnostic workup.

Catheter-directed therapy for acute pulmonary embolism in children.

Acute pulmonary embolism is a life-threatening condition and rarely occurs in children. In adults, catheter-directed therapy emerges as a potentially safer and effective therapeutic option. However, there is a paucity of data on the safety and efficacy of catheter-directed therapy for pulmonary embolism in children. We report a single-centred experience of catheter-directed therapy for acute pulmonary embolism in children. This is a retrospective study of children who had no CHD and underwent catheter-directed therapy at Detroit Medical Center during a 12-year period from 2005 to 2017. Demographic and clinical data associated with pulmonary embolism were collected along with the outcome. A total of nine patients of median age 16 years with the range from 12 to 20 received catheter-directed therapy for sub-massive (n = 6) and massive pulmonary embolism (n = 3). Among nine patients, one patient received Angiojet thrombectomy and balloon angioplasty, whereas eight patients received catheter-directed thrombolysis using tissue plasminogen activator through infusion catheters (n = 3) or EkoSonic ultrasound-accelerated thrombolysis system (n = 5). In four out of five patients treated with EkoSonic, significant clinical improvement was noticed within 24 hours. Among seven patients who survived, two patients had minor gastrointestinal bleeding with median hospital stay of 8 days with the range from 5 to 24 days, and two patients with massive pulmonary embolism died possibly due to delayed institution of catheter-directed therapy. Catheter-directed therapy with/without EkoSonic is an emerging alternative therapy for sub-massive and massive pulmonary embolism in children. A timely institution of catheter-directed therapy appeared important to improve the outcome.

Aortoenteric Fistula: A Rare Cause of Gastrointestinal Bleed Requiring Emergent Surgical Intervention

Introduction Aortoenteric fistula is a rare life-threatening diagnosis that may initially present as a minor gastrointestinal bleed, but will inevitably become a surgical emergency. This case highlights the need for a high clinical index of suspicion of aortoenteric fistulas in patients with a history of prior aortic surgery to avoid diagnostic delay, which is often fatal. Case A 81-year-old male with a past medical history significant for an abdominal aortic aneurysm repair and partial colon resection who presented to the Emergency Department complaining of bright red blood per rectum over the past 24 hours. Upon arrival, his blood pressure was 133/60, pulse 101, RR 18, temperature 97.7, and O2 saturation of 98% on room air. On physical exam, he had no abdominal tenderness. He was found to have a hemoglobin of 7.8 from a baseline of 10.2. The patient was started on pantoprazole and an emergent upper endoscopy was performed, which showed evidence of necrotic tissue in the D2 portion of the duodenum. Surgery was consulted. An emergent exploratory laparotomy was done, which revealed a fistula between the duodenum and the aorta. GI surgery mobilized the duodenal fistula by removing adhesions, and vascular surgery transected the aorta and removed the graft. The patient was stable after the excision of aorto-duodenal fistula and oversewing of the aorta. Discussion Aortoenteric fistulas (AEFs) are uncommonly encountered but are important to consider in the differential diagnosis of gastrointestinal bleeding in patients who have had prior aortic surgery. Primary AEFs arise de novo between the aorta and bowel, while secondary AEFs (SAEFs) are usually caused by prosthetic vascular grafts eroding into the intestine as in this patient. Pulsation of vascular grafts against the intestine may cause erosion of the duodenal wall, leading to hemorrhage. Any part of the gastrointestinal tract may be involved, but most commonly it is the third part of the duodenum. SAEFs may present as gastrointestinal bleeding and occasionally as sepsis. Patients initially have “herald bleeding” - intermittent episodes of bleeding due to thrombus formation -followed by massive hemorrhaging. A CT abdomen with contrast is the best diagnostic test if an AEF is suspected; AEFs may also be detected on endoscopy as in this patient. Emergency exploratory laparotomy is warranted immediately upon diagnosis, as mortality is 100% if not surgically treated.

Development of a Simple Clinical Risk Score for Early Prediction of Severe Dengue in Adult Patients.

We aimed to develop and validate a risk score to aid in the early identification of laboratory-confirmed dengue patients at high risk of severe dengue (SD) (i.e. severe plasma leakage with shock or respiratory distress, or severe bleeding or organ impairment). We retrospectively analyzed data of 1184 non-SD patients at hospital presentation and 69 SD patients before SD onset. We fit a logistic regression model using 85% of the population and converted the model coefficients to a numeric risk score. Subsequently, we validated the score using the remaining 15% of patients. Using the derivation cohort, two scoring algorithms for predicting SD were developed: models 1 (dengue illness ≤4 days) and 2 (dengue illness >4 days). In model 1, we identified four variables: age ≥65 years, minor gastrointestinal bleeding, leukocytosis, and platelet count ≥100×109 cells/L. Model 1 (ranging from −2 to +6 points) showed good discrimination between SD and non-SD, with an area under the receiver operating characteristic curve (AUC) of 0.848 (95% confidence interval [CI], 0.771–0.924). The optimal cutoff value for model 1 was 1 point, with a sensitivity and specificity for predicting SD of 70.3% and 90.6%, respectively. In model 2 (ranging from 0 to +3 points), significant predictors were age ≥65 years and leukocytosis. Model 2 showed an AUC of 0.859 (95% CI, 0.756–0.963), with an optimal cutoff value of 1 point (sensitivity, 80.3%; specificity, 85.8%). The median interval from hospital presentation to SD was 1 day. This finding underscores the importance of close monitoring, timely resuscitation of shock including intravenous fluid adjustment and early correction of dengue-related complications to prevent the progressive dengue severity. In the validation data, AUCs of 0.904 (95% CI, 0.825–0.983) and 0.917 (95% CI, 0.833–1.0) in models 1 and 2, respectively, were achieved. The observed SD rates (in both cohorts) were <3% for patients with a score <1 point, but >50% for those with a score of ≥2 points, irrespective of the day of illness onset, suggesting that our simple risk score can be easily implemented in resource-limited countries for early prediction of dengue patients at risk of SD provided that they have rapid dengue confirmed tests. For patients with other acute febrile illnesses or bacterial infections usually have SD risk score of >1. Thus, these scoring algorithms cannot totally replace good clinical judgement of the physician, and most importantly, early differentiating dengue from other febrile illnesses is critical for appropriate monitoring and management.

Phenprocoumon in HeartWare venrticular assist device patients - a new regimen for early postoperative anticoagulation

Objective: Implantation of a mechanical circulatory support system is one of the surgical options for end-stage heart failure. The new HeartWare ventricular assist device system (HVAD), a magnetically levitated centrifugal blood pump, shows a low complication rate. Advantages of this new system are less hemolysis, reduced neurological and thromboembolic events, simplified implantation procedure and less bleedings based on lower levels of anticoagulation compared to pulsatile assist devices. Due to these facts we evaluated a new regimen for early postoperative anticoagulation for HVAD implantation. Methods: Between 01/2010 and 07/2013 41 patients underwent HVAD implantation for left-, right-, or biventricular support. Indications were dilated cardiomyopathy in 16 (39.0%) patients, ischemic cardiomyopathy in 14 (34.1%) cases, cardiogenic shock or acute myocardial infarction in 7 (17.0%) patients, myocarditis in 3 (7.3%) patients as well as right heart failure in one (2.4%) long-term heart transplant recipient. No anticoagulation was given for the first twelve hours postoperatively. Then, oral phenprocoumon was started according to INR. Intravenous heparin bridging was performed in 6 (14.6%) patients only. The INR course was monitored from postoperative day one to five and early postoperative complications such as mortality, stroke, thrombosis and bleeding were recorded. Results: Mean patients age was 58.48 ± 12.10 years, 36 (87.8%) patients were male, five (12.1%) female. When patients were transferred to ICU, an anticoagulation profile was taken. The first INR on arrival was 1.39 ± 0.57 (1.0-3.1). Mean dosage of the first phenprocoumon administration was 6.0 ± 2.1 mg, given on postoperative day one. Mean INR level was 1.43 ± 0.77 (1.1-5.0) on postoperative days 1 and 2.18 ± 1.03 (0.9-5.0) on day 5. The average time needed to reach target INR levels of 2-3 was 3.8 ± 1.8 days. Two (4.8%) patients did not survived the early postoperative period and died of multi organ failure. No stroke, thrombosis or major bleeding complication occurred. One (2.4%) patient required re-thoracotomy for bleeding and minor gastrointestinal bleeding occurred in 1 (2.4%) patient. Conclusion: Early postoperative anticoagulation regimen without heparin bridging can be performed safely, thereby avoiding potential bleeding complications due to the additive effects of phenprocoumon and heparin. Despite lower anticoagulation levels, no stroke or thrombosis occurred in any of the patients.

Review of Economics and Cost-Effectiveness Analyses of Anticoagulant Therapy for Stroke Prevention in Atrial Fibrillation in the US

To summarize the available evidence on the issues in health economics related to oral anticoagulation for stroke prevention in atrial fibrillation (AF) in the US. A literature review was performed using PubMed, EMBASE, Cochrane Library, and International Pharmaceutical Abstracts, as well as the websites of professional organizations. The search was conducted according to a prespecified protocol, limiting articles to those published in English from 2001 to October 2012 and focused on the economics associated with AF and AF-related stroke in the US. Data from 27 studies were extracted and included in the review. Strokes in patients with AF are more debilitating and have higher recurrence rates and mortality compared with strokes unrelated to AF. However, data describing the long-term cost of AF-related stroke and stroke subtypes remain limited. The costs of major gastrointestinal (GI) bleeding and intracranial bleeding related to warfarin are significant, whereas the costs of the more frequent minor GI bleeding are relatively low. Overall, the cost-effectiveness of warfarin versus aspirin or no treatment in patients with at least 1 risk factor for stroke is well established. Economic evaluations based on results from randomized controlled clinical trials generally found that new anticoagulants were a cost-effective alternative to warfarin for stroke prevention in AF. However, these cost-effectiveness results are highly sensitive to how well optimal international normalized ratio control is maintained (within target of 2.0-3.0) for warfarin and the time horizon used for analysis. Time in therapeutic range for warfarin in routine clinical practice was lower than in clinical trials, as shown by previous studies. This review identified several areas of uncertainty regarding the economic benefit of anticoagulants. The generalizability of cost-effectiveness results of anticoagulant therapy in AF based on clinical trial data must be confirmed by comparative effectiveness research conducted in the real-world setting.

All-cause and bleeding-related health care costs in warfarin-treated patients with atrial fibrillation.

Bleeding is a major complication of warfarin therapy. Assessing the cost of warfarin-associated bleeding may more fully describe the costs associated with warfarin use. To assess health care costs related to warfarin-associated bleeding in patients with newly diagnosed atrial fibrillation (AF). Medical and pharmacy claims were analyzed for patients with AF (ICD-9-CM code 427.31) in the Medstat MarketScan database from January 2003 to December 2007. Eligible patients had no warfarin pharmacy claim or AF diagnosis in the 4 months prior to AF index date, a warfarin pharmacy claim within 30 days of AF diagnosis, and 12 months follow-up data after the index warfarin claim. Subjects were categorized based on the first type of bleeding event observed during follow-up, and only bleeding events occurring within 30 days following a warfarin claim were considered. Intracranial hemorrhage (ICH) and gastrointestinal (GI) events were assessed based on primary or secondary ICD-9-CM codes, and major GI bleeding was defined as a GI bleed associated with hospitalization. Annual total all-cause allowed charges in patients with and without bleeding events after the index warfarin claim were compared using generalized linear model (GLM) regression with gamma distribution and log link, controlling for demographics, insurance status, and comorbidities. Costs for claims with a primary or secondary diagnosis of bleeding were calculated separately. Of the 47,437 patients who were analyzed, 194 (0.4%) had an ICH, 919 (1.9%) had a major GI bleed, and 1,804 (3.8%) had a minor GI bleed within 30 days after a warfarin claim during follow-up. Compared with patients who had no bleeding events after a warfarin claim (n = 44,520, 93.9%) during the study period, patients with at least 1 bleeding event were older and had more comorbidities (P < 0.01). Patients with at least 1 ICH or major GI bleed had more all-cause hospitalizations (P < 0.05) and hospital days (P < 0.01) than patients without bleeding events. Patients with at least 1 ICH, major GI bleed, or minor GI bleed had more all-cause emergency room visits (P < 0.01) than patients without bleeding events. Mean (SD) unadjusted all-cause health care costs in the 12 months after the warfarin index claim were $41,903 ($56,654), $40,586 ($65,164), and $24,347 ($56,488) for patients with at least 1 ICH, major GI bleed, and minor GI bleed, respectively, compared with $24,129 ($36,425) for patients with no bleeding events. Claims with a primary or secondary diagnosis of bleeding accounted for 49.6%, 30.2%, and 2.6% of annual cost in patients with ICH, major GI bleeding, and minor GI bleeding, respectively. On average, 50.9%, 33.5%, and 10.8% of annual all-cause costs occurred within 30 days after the first ICH, major GI bleeding event, and minor GI bleeding event, respectively. GLM regression showed that annual all-cause costs were 64.4% and 49.0% higher (P? less than ?0.001) for patients with ICH and major GI bleeding, respectively, than for patients with no bleeding events. ICH and major GI bleeding associated with warfarin therapy are rare but costly.

Multiple aneurysm repair: hybrid approach to chronic dissection around visceral branches

The present case report details our experience with the hybrid approach for multiple aneurysms in the aortic arch, thoracoabdominal aorta, and around the aortic bifurcation. Total arch replacement for the arch aneurysm under hypothermic cardiopulmonary bypass with antegrade cerebral perfusion was the first stage of aneurysm repair. Five months later, bifurcated graft replacement with debranching of four abdominal branches was undertaken as the second stage of treatment. Finally, stent-graft repair for chronic dissection of the thoracoabdominal aorta was performed utilizing a Gore-Tex Tag endovascular prosthesis. Over 7 months of treatment, all aneurysms were excluded from the aortic blood flow and pressure without abdominal organ dysfunction except a transiently elevated total bilirubin level. Although the patient had an episode of minor gastrointestinal bleeding after discharge, he is currently leading a normal life without limitations at home 5 months after the stent-graft repair.

Stress ulcer prophylaxis in pediatric intensive care units

To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units (PICUs) in Porto Alegre, Brazil. This was a multicenter, prospective, cross-sectional observational study. PICUs were visited on randomly defined days between April 2006 and February 2007, and the medical records of admitted patients were reviewed. Patients whose records had been previously assessed were excluded, as were those with upper gastrointestinal bleeding on admission. Data were collected on age, gender, admission diagnosis, severity of illness, administration of stress ulcer prophylaxis, rationale for prophylaxis, and first-line prophylactic agent of choice. Variables were described as absolute and relative frequencies, mean and standard deviation, or median and interquartile range as appropriate. Pearson's chi-square test for linear trend or Fisher's exact test were used to assess possible associations. The level of significance was set at 5% (p ≤ 0.05). 398 patients (57% male) were assessed [median age, 16 months (IQR 4-65); median length of PICU stay, 4 days (IQR 1-9)]. Respiratory illness was the main reason for admission (32.7%). Most patients received stress ulcer prophylaxis (77.5%; range, 66-91%). Mechanical ventilation (22.3%) was the most common rationale provided, followed by informal routine use of prophylaxis (21.4%). Only one of the participating PICUs had a specific care protocol for use of stress ulcer prophylaxis. Ranitidine was the most commonly used drug (84.5% of cases). Evidence of minor gastrointestinal bleeding was found in 3% of patients; none had clinically significant bleeds. Administration of stress ulcer prophylaxis is a common practice in the participating PICUs, with ranitidine the most commonly used drug. Among the various rationales provided, mechanical ventilation and informal routine use were the most prevalent.

Profilaxia para úlcera de estresse em pacientes internados em UTI pediátrica

OBJECTIVE: To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units (PICUs) in Porto Alegre, Brazil. METHODS: This was a multicenter, prospective, cross-sectional observational study. PICUs were visited on randomly defined days between April 2006 and February 2007, and the medical records of admitted patients were reviewed. Patients whose records had been previously assessed were excluded, as were those with upper gastrointestinal bleeding on admission. Data were collected on age, gender, admission diagnosis, severity of illness, administration of stress ulcer prophylaxis, rationale for prophylaxis, and first-line prophylactic agent of choice. Variables were described as absolute and relative frequencies, mean and standard deviation, or median and interquartile range as appropriate. Pearson's chi-square test for linear trend or Fisher's exact test were used to assess possible associations. The level of significance was set at 5% (p < 0.05). RESULTS: 398 patients (57% male) were assessed [median age, 16 months (IQR 4-65); median length of PICU stay, 4 days (IQR 1-9)]. Respiratory illness was the main reason for admission (32.7%). Most patients received stress ulcer prophylaxis (77.5%; range, 66-91%). Mechanical ventilation (22.3%) was the most common rationale provided, followed by informal routine use of prophylaxis (21.4%). Only one of the participating PICUs had a specific care protocol for use of stress ulcer prophylaxis. Ranitidine was the most commonly used drug (84.5% of cases). Evidence of minor gastrointestinal bleeding was found in 3% of patients; none had clinically significant bleeds. CONCLUSIONS: Administration of stress ulcer prophylaxis is a common practice in the participating PICUs, with ranitidine the most commonly used drug. Among the various rationales provided, mechanical ventilation and informal routine use were the most prevalent.

Endovascular treatment for chronic cerebrospinal venous insufficiency: is the procedure safe?

The aim of this report is to assess the safety of endovascular treatment for chronic cerebrospinal venous insufficiency (CCSVI). Although balloon angioplasty and stenting seem to be safe procedures, there are currently no data on the treatment of a large group of patients with this vascular pathology. A total of 564 endovascular procedures (balloon angioplasty or, if this procedure failed, stenting) were performed during 344 interventions in 331 CCSVI patients with associated multiple sclerosis. Balloon angioplasty alone was performed in 192 cases (55.8%), whereas the stenting of at least one vein was required in the remaining 152 cases (44.2%). There were no major complications (severe bleeding, venous thrombosis, stent migration or injury to the nerves) related to the procedure, except for thrombotic occlusion of the stent in two cases (1.2% of stenting procedures) and surgical opening of femoral vein to remove angioplastic balloon in one case (0.3% of procedures). Minor complications included occasional technical problems (2.4% of procedures): difficulty removing the angioplastic balloon or problems with proper placement of stent, and other medical events (2.1% of procedures): local bleeding from the groin, minor gastrointestinal bleeding or cardiac arrhythmia. The procedures appeared to be safe and well tolerated by the patients, regardless of the actual impact of the endovascular treatments for venous pathology on the clinical course of multiple sclerosis, which warrants long-term follow-up.

Same Day Bidirectional Outpatient Endoscopy for Suspected Gastroenterology Bleeding at Veterans Affairs Tertiary Referral Center

Purpose: Patients (Pts) with minor gastrointestinal (GI) bleeding are often scheduled for expedited outpatient EGD and colonoscopy on the same day at our institution. Our aim was to determine the diagnostic yield of scheduling bidirectional outpatient procedures for minor GI bleeding and to determine if the pre-test data can predict the test yield to conclude whether this practice should continue or be modified. Methods: We reviewed all records of outpatients who had EGD and colonoscopy scheduled the same day in 2005 at Veterans Affairs Medical Center, Buffalo. Our study population included pts with minor GI bleed which was defined as occult GI bleeding with or without iron deficiency anemia or iron deficiency anemia alone. Pts with melena were also included if EGD/Colonoscopy were performed as outpatient. Base line laboratories including: CBC, INR, BUN, Creatinine, iron studies and Fecal Occult Blood Test (FOBT) status were recorded. GI symptoms, number of blood transfusion and hospital admission in one year prior to the procedure were obtained as well. Significant EGD findings include: ulcer (Duodenal, Gastric), portal Hypertension, gastropathy, varices, mild gastritis, superficial erosions, mild duodenitis, friable mucosa, Arterio-Venous Malformations and active bleeding. Non-significant findings include: normal study, candida infection, hiatal hernia, polyps, Barrett's esophagus, Schatzki's ring and lipomas. Multivariate regression analysis conducted. Results: Total of 91 pts (Male=88; Female=3) were included in the study. 81 were white and 10 African American. Median age was 68. Study indications were: Iron deficiency without anemia (n=4), Iron deficiency with anemia (n=42), FOBT positive without anemia (n=14), FOBT positive with anemia (n=28), and melena with anemia (n=2). Significant medications received within one month prior to the study were Aspirin (n=28), Nonsteroidal anti inflammatory drugs (n=14), Plavix (n=12) and Coumadin (n=12). Upper GI symptoms were reported by 25 pt including nausea, vomiting, dysphagia, abdominal pain or heartburn while 5 had lower GI symptoms as change in bowel movement habits. Only 17 pts had significant findings while 74 had non-significant ones (including 37 normal studies). Our analysis revealed no statistically significant correlation between any of the baseline labs mentioned above or the GI symptoms and the results of the EGD. Conclusion: In summary we were unable to find any pre-procedure predictive factor that can help in deciding the endoscopic procedure of choice in pts with minor GI bleed. The study is limited with sample size, recommend following prospective studies.

Gastrointestinal bleeding in infants and children

Gastrointestinal (GI) bleeding in infants and children is an alarming symptom to both the patient and parents. It can present orally and/or rectally. While minor GI bleeding is usually a self-limited condition, requiring only minimal intervention, it can certainly be a life-threatening condition at times. An initial focused review of the history and physical examination, followed by a detailed history, investigations and management, is necessary to identify the etiology of the bleeding and aid in its treatment. This article reviews the different etiologies, investigation and therapeutic options for management of GI bleeding in infants and children.

Use of Imatinib Mesylate in Gastrointestinal Stromal Tumours: Pan-Birmingham Cancer Network Experience

Aims Imatinib mesylate, a selective tyrosine kinase receptor inhibitor of KIT and PDGFRα, is currently licensed for the treatment of unresectable or metastatic gastrointestinal stromal tumours (GISTs), which are KIT positive. Partial response rates in 65% of patients and stable disease in 20% of patients are typically seen. The aim of this study was to assess the effectiveness and toxicity of an unselected cohort of patients treated with imatinib mesylate and to compare these results with published data. Materials and methods A retrospective audit of the use of imatinib mesylate in GISTs within the Pan-Birmingham Cancer Network was carried out. In total, 39 patients were identified, the first commenced imatinib mesylate in September 2001. Results The most common primary tumour sites were small intestine (19 [49%]) and stomach (12 [31%]). Initial curative resection was carried out in 21 (54%), palliative resection in three (8%) and 15 (38%) were unresectable. Of those who had curative resection, the median time to recurrence was 13 months (range 2–276). Common sites of metastases were liver (19 [49%]) and peritoneum (12 [31%]). At 24 months 70% remained on imatinib. A partial response was reported in 23 (59%), stable disease in seven (18%) and disease progression in four (10%). Five patients (13%) have yet to be reassessed at 3 months. Imatinib was well tolerated with minor side-effects; peri-orbital oedema (nine [23%]), skin rash (four [10%]), minor gastrointestinal bleed (one [3%]). No significant toxicity was documented in 18 (46%). Conclusions The response rates achieved in this unselected cohort of patients are consistent with published data. The duration of tumour control is good, with most patients responding to imatinib mesylate for more than 2 years. Side-effects are mild and acceptable.

Complications associated with the use of the Celestin tube for benign oesophageal obstruction

Two cases are described in which disruption of a Celestin tube took place after being lodged in a benign oesophageal stricture for 14 months. One patient presented with apparent acute pancreatitis and the other with a minor gastrointestinal bleed.

The Indolent Natural History of Essential Thrombocythemia: A Challenge to New Drug Development

The Indolent Natural History of Essential Thrombocythemia: A Challenge to New Drug Development

The Indolent Natural History of Essential Thrombocythemia: A Challenge to New Drug Development

The Indolent Natural History of Essential Thrombocythemia: A Challenge to New Drug Development

Gastrointestinal disease control after histamine2-receptor antagonist dose modification for renal impairment in frail chronically ill elderly patients.

To determine whether histamine2-receptor antagonist (H2RA) dose modified for renal impairment affects gastrointestinal (GI) disease control. Concurrent medical record review. One hundred forty-six nursing facilities throughout the United States. Three hundred thirty-six patients aged 65 and older receiving H2RAs for GI disorders. H2RA dose modified for renal impairment or no dose change. Disease control (no H2RA dose increase for 6 months or longer, additional GI medication, hospitalizations, emergency room visits, and unscheduled physician visits for GI symptoms) was evaluated using chart review at 3, 6, 9, and 12 months in nursing home patients aged 65 and older with H2RA dose modified for decreased creatinine clearance (ClCr) according to manufacturer. Three hundred thirty-six patients, mean age +/- standard deviation 85.9 +/- 7.9, with mean ClCr of 33.6 +/- 10.4 mL/min, were recommended to receive lower H2RA doses based upon estimated renal function. Patients were analyzed in two groups: H2RA dose reduced (Group 1) and dose reduction not adopted or implemented (Group 2). There was no difference in baseline characteristics (age, weight, ClCr, or starting H2RA dose and indication) between the two groups. One hundred ninety-eight patients in Group 1 were taking 195.5 +/- 71.0 mg per day of nizatidine or equivalent, compared with 183.7 +/- 66.6 mg for 138 patients in Group 2. For patients with 90 days of follow-up, the mean H2RA dose in Group 1 was 100.2 +/- 44.3 mg, compared with 187.8 +/- 69.9 for Group 2 (P <.0001) The mean decrease in daily dose for Groups 1 and 2 after 365 days were 98.9 +/- 72.9 mg and 22.2 +/- 68.2 mg, respectively (P <.0001). Except for more physician visits in Group 2, disease control was similar for all groups. Major and minor GI bleeding events were similar across both groups and over time. The 12-month mortality rate was 12.1% and 21.7% for Groups 1 and 2, respectively. This difference was statistically significant (P =.02). The findings suggest that the dose of H2RAs may be decreased based upon renal function in frail elderly patients without compromising GI disease control.