Overt Gastrointestinal Bleeding Research Articles

The role of capsule endoscopy in etiological diagnosis and management of obscure gastrointestinal bleeding.

Background/AimsTo investigate the various etiologies, yields, and effects of capsule endoscopy (CE) on management and complications, along with follow up of patients with obscure gastrointestinal (GI) bleeding.MethodsThe study group of patients included those having obscure, overt, or occult GI bleeding. The findings were categorized as (A) obvious/definitive, (B) equivocal, or (C) negative. Any significant alteration in patient management post CE in the form of drug or surgical intervention was noted.ResultsTotal patients included in the study were 68 (48 males and 20 females). The ratio of male:female was 2.4:1. The age ranged between 16 years to 77 years. Mean age for males was 62±14 years, for females 58±16 years. The total yield of CE with definitive lesions was in 44/68 (65.0%) of patients. In descending order (A) angiodysplasia 16/68 (23.53%), (B) Crohn's disease 10/68 (14.70%), (C) non-steroidal anti-inflammatory drug enteropathy 8/68 (11.76%), (D) small bowel ulcers 4/68 (5.88%), (E) jejunal and ileal polyps 2/68 (2.94%), (F) intestinal lymphangiectasis 2/68 (2.94%), and (G) ileal hemangiomas 2/68 (2.94%) were followed. Equivocal findings 12/68 (17.65%) and negative study 12/68 (17.65%) was found. Complications in the form of capsule retention in the distal ileum were noted in 2/68 (2.94%) subjects. Statistically, there was a higher probability of finding the etiology if the CE was done during an episode of bleeding.ConclusionsCE plays an important role in diagnosing etiologies of obscure GI bleeding. Its role in influencing the management outcome is vital.

What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

The aim of this study was to investigate the efficacy of capsule endoscopy (CE) performed on patients who presented to emergency room with clinically evident gastrointestinal (GI) bleeding from unknown source and were hospitalized for follow-up. Total of 38 patients who underwent CE and were followed-up for evaluation of clinically perceptible GI bleeding with no obvious etiology in Istanbul Medical Faculty emergency surgery department were included in the study. Patient data, which were collected between January 1, 2007 and June 1, 2015, were reviewed retrospectively. Of the 38 patients included in this study, 12 (32%) patients were women and 26 (68%) were men. Average age was 55.57 years (range: 20-88 years). Nine patients were using anticoagulants. Ten patients were followed-up in intensive care, and 7 patients underwent angiography. Angioembolization was performed for 1 patient who was diagnosed as having active bleed with CE. Average erythrocyte suspension replacement was 20.7 units. Total of 13 patients underwent surgery for bleeding found with CE. Eleven (34%) patients underwent double-balloon endoscopy, during which 5 patients were treated with cauterization and sclerotherapy was performed on 2. Four (18%) patients died during the study period: 2 died as result of bleeding from unknown source, 1 died of cholangiocarcinoma recurrence, and 1 died of anastomotic leakage. One patient was readmitted to hospital due to recurrence of bleeding. Nineteen (50%) patients were treated successfully based on CE findings. Diagnostic yield of CE was determined to be 78.9%. Average length of hospital stay was 32.68 days (range: 3-153 days). CE is an effective tool to detect source of GI bleeding. CE should be first choice of evaluation method for patients admitted to emergency room with obscure overt GI bleeding once radiological imaging determines absence of obstruction.

Splenic infarction as a pitfall on labeled red blood cell imaging

Patient with a history of overt gastrointestinal bleeding, diabetes mellitus, hypertension, polycythemia vera, and choledocojejunostomy was hospitalized because of hematemesis and melena. An area of Technetium-99m labeled red blood cells accumulation at the splenic flexure similar to an overt bleeding area, was observed on gastrointestinal bleeding scintigraphy (GIBS). In case of underlying malignancy, abdominal computed tomography was performed and demonstrated the infarction area placed laterally in spleen, appearing as a cold region on sctintigraphic image, separating the inferomedial and upper part of splenic uptake. Splenic variants and pathologies can complicate interpretation of GIBS.

The Role of Emergency Endoscopy in Small Bowel Bleeding: A Review

There is no consensus on the timing and management of emergency overt obscure gastrointestinal bleeding. Emergency capsule endoscopy and balloon-assisted enteroscopy have a high diagnostic and therapeutic yield in these situations. Most lesions detected by small bowel endoscopy are amenable to endoscopic haemostasis, although some lesions still require surgery or interventional radiology. The management of these patients is varied, and doubt persists about which technique should be preferred as first-line treatment. This narrative review analyses the usefulness and impact of small bowel endoscopic techniques in the emergency setting for severe overt obscure gastrointestinal bleeding.

Hookworm infestation is not an uncommon cause of obscure occult and overt gastrointestinal bleeding in an endemic area: A study using capsule endoscopy.

Obscure gastrointestinal bleeding (OGIB), particularly occult, has been reported to be caused by hookworm infestation rarely from tropical countries, particularly India. Hence, we undertook a retrospective study evaluating frequency, clinical spectrum, and outcome of patients with OGIB associated with worm infestation. Data of consecutive patients with OGIB undergoing capsule endoscopy in a multilevel university hospital in northern India were retrospectively analyzed. Twenty-one out of 163 (13 %) patients with OGIB had hookworm infestation detected on capsule endoscopy. Of 21 patients (median age 65 years [range 19-82], 17 [81 %] male), 16 had overt and 5 had occult OGIB. Another lesion that could explain OGIB was present in 8/21 patients, 3/5 with OGIB occult, and 5/16 overt (p = ns). All the patients received treatment with albendazole and appropriate measures for the associated lesion, if any. Patients with hookworm infestation with another lesion experienced recurrent bleeding more often than those with worm infestation only. Hookworm infestation is an important cause of occult as well as overt OGIB and may be present even in association with another lesion. Those with additional lesion had recurrent bleeding more often than those with worm infestation alone.

Varied Clinical Manifestations of Amebic Colitis.

Invasive amebiasis is common worldwide, but infrequently observed in the United States. It is associated with considerable morbidity in patients residing in or traveling to endemic areas. We review the clinical and endoscopic manifestations of amebic colitis to alert physicians to the varied clinical manifestations of this potentially life-threatening disease. Copyright ©Most patients present with watery or bloody diarrhea. Less common presentations of amebic colitis include abdominal pain, overt gastrointestinal bleeding, exacerbation of inflammatory bowel disease, or the incidental association with colon cancer. Amebic liver abscesses are the most frequent complication. Rectosigmoid involvement may be found on colonoscopy; however, most case series have reported that the cecum is the most commonly involved site, followed by the ascending colon. Endoscopic evaluation should be used to assist in the diagnosis, with attention to the observation of colonic inflammation, ulceration, and amebic trophozoites on histopathological examination.

Video capsule endoscopy as the initial examination for overt obscure gastrointestinal bleeding can efficiently identify patients who require double-balloon enteroscopy.

BackgroundBoth double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) have similar diagnostic yields for patients with overt obscure gastrointestinal bleeding (OGIB). However, the choice of initial modality is still controversial. The aim of this study was to show the clinical outcome of the strategy of initial VCE, followed by DBE.MethodsEighty-nine consecutive overt OGIB patients who had undergone VCE as the initial examination were analyzed. The interpreters of VCE evaluated the necessity of performing DBE, and the antegrade or retrograde route was chosen, depending on the transit time of the capsule.ResultsThirty-seven patients (42 %) underwent DBE depending on the findings of VCE. Of these, bleeding sites in the small bowel were identified in 29 patients with the initially selected route (21 antegrade and 8 retrograde). The remaining 8 later underwent DBE by the other route, but 7 had no bleeding lesion, which was confirmed by second-look VCE. One remaining patient had a jejunal varix found by VCE, but DBE from either side could not reach the lesion. The sensitivity and negative predictive value of VCE were 100 %, both for the presence of small bowel lesions and the requirement of hemostasis in the small bowel; this indicated that VCE never misses relevant findings in the small bowel, and that negative VCE findings correspond to the lack of necessity for further examination.ConclusionsVCE as the initial examination can efficiently identify overt OGIB patients who require DBE. The strategy of initial VCE for overt OGIB appears to be reasonable.

Intravenous Access in Acute Gastrointestinal Bleeding: A Quality Improvement Project to Assess Adherence to Guidelines and Effect on Outcomes

Introduction: Gastrointestinal bleeding (GIB) carries a substantial morbidity and economic burden, and are frequently encountered in clinical practice. Aggressive initial management can improve outcomes. Textbooks and literature suggest placement of 2 large bore IV lines (2LBIV) in every patient presenting with GIB. There is paucity of literature on adherence to this guideline, and effect on outcomes in patients who get 2LBIV versus those who don't, has not been reported before. Methods: We conducted a quality improvement project to assess whether patients presenting to our hospital with GIB had 2LBIV. Our secondary outcomes included length of stay, mortality, transfer to higher level of care, and number of transfusions received. We conducted a prospective, observational study; looking at all patients who presented to our emergency department with overt GIB over a 2 month period. Forty-six consecutive patients who met the inclusion criteria were included in the study. Results: Only 9 (19.5%) of the 46 patients were found to have 2LBIV. All-cause, in-hospital mortality was 6.5% (1/9 in the 2LBIV group vs 2/37 in the group without). Length of stay was 5.7 days in the 2LBIV group and 5.6 days in those without. Zero patients in the 2LBIV group required transfer to a higher level of care, versus 22% (7/31) of those without 2LBIV. However, 44% (4/9) of patients with 2LBIV were admitted directly to the intensive care unit (ICU), versus 14% (5/36) of patients without 2LBIV. The 2LBIV group received more blood transfusions (1.89 vs 1.56 Units pRBC/patient). Drop in hemoglobin from baseline was 1.7g/dl in the 2LBIV group compared to 0.8g/dl in those without 2LBIV. Patients with 2LBIV also had a higher rate of anticoagulant/antiplatelet use (44% vs 19%), lower initial systolic blood pressure (114mmHg vs 131mmHg) and lower initial creatinine level (0.73 vs 1.44mg/dL). Conclusion: The relatively simple and cheap intervention of placing 2LBIV lines is not often executed. Our initial investigation suggests that only sicker GIB patients (higher rate of anticoagulant use, higher initial ICU disposition, lower baseline blood pressure, and lower presenting hemoglobin) receive 2LBIV. We plan to conduct an intervention consisting of a nursing and physician education, and an algorithm for protocolized care, to increase our compliance with this guideline. Data collection will be done postintervention to assess the success of this intervention, with regards to adherence and patient outcomes.

Recurrent Gastrointestinal Bleeding From a Rare Source

Blue rubber bleb nevus syndrome (BRBNS) is a rare condition that is characterized by multiple vascular malformations that involve mainly skin & gastrointestinal (GI) tract. We report a case of a 33 year-old female with long standing history of BRBNS with persistent iron deficiency anemia and GI bleeding. Case Report: Our patient is a 33 year-old female who was diagnosed with BRBNS as an infant. She has had multiple GI bleeds since childhood. She underwent snare cautery and removal of a large bleb in her colon which then bled leading to immediate surgical resection when she was 14 years old. She continues to have a drop in her hemoglobin and intermittent melena. Her most recent colonoscopy showed a large bleb in the ascending colon & had a capsule endoscopy showing multiple blebs with active bleeding in her distal duodenum. She therefore underwent single balloon enteroscopy, which showed a bleeding 1.5 cm bleb in the distal duodenum. She had clips placed at the base of the bleb and sclerotherapy with sodium tetradecyl sulfate which helped in achieving hemostasis. Despite the extensive treatment she had another episode of bleeding several weeks later and underwent a repeat capsule endoscopy that showed additional blebs in her distal small bowel. She therefore was referred to surgery for possible treatment. Discussion: Since the first described in 1860, about 200 cases of BRBNS have been reported. The etiology of this syndrome is still unknown. Most of the cases are sporadic, although autosomal dominant mode of inheritance has been reported. Clinical manifestations are variable. Skin lesions range from asymptomatic to painful & tender. GI involvement is variable with small intestine involvement 100% of the time. Symptoms include abdominal pain, iron deficiency anemia, intussusception, intestinal infarction, volvulus & overt gastrointestinal bleed. Brain involvement can present with infarction or hemorrhage. Bone & joint involvements are rare & include skeletal bowing & pathological fractures. Lesions in the vertebrae can cause spinal cord compression. Treatment of BRBNS is controversial as it is currently limited to case reports. Conservative treatment such as blood transfusions & iron supplement are recommended for minor or intermittent bleeding. For more severe or recurrent bleeding surgical intervention is required. Surgical intervention ranges from laser photocoagulation, sclerotherapy & band ligation to surgical resection. Pharmacologic agents such as antiangiogenic agents have been used for treatment of BRBNS. Recently, Sirolimus has been reported as an effective treatment in 3 case reports. It has also been reported that using Octreotide subcutaneously could decrease the need for blood transfusions. Our patient is currently undergoing surgical evaluation for further treatment.Figure 1Figure 2Figure 3

Gastic Mucosal Calcinosis Associated With Gastrointestinal Bleeding

Purpose: Gastric mucosal calcinosis (GMC) is a rare cause of gastrointestinal bleeding, and usually an incidental finding on endoscopy. Histopathology characteristically reveals deposits of irregular, amorphous microcalcifications in the gastric mucosa. GMC is classified as metastatic, dystrophic or idiopathic. Metastatic calcinosis is the most common, occurring in the setting of abnormal calciumphosphate metabolism, and resulting in deposition of calcium salts. We report a case of gastric mucosal calcinosis associated with overt gastrointestinal bleed. Case: A 59 year old Hispanic man presented with 1 week of black stools. Past medical history included end stage renal disease on hemodialysis for 8 years, atrial fibrillation on anticoagulation, diabetes, and coronary artery disease. He denied nausea, vomiting, hematemesis, or abdominal pain. No NSAID use other than daily aspirin was reported. Vital signs on presentation were unremarkable. Physical exam was notable for pale conjunctiva, soft, non-tender abdomen, and melena on rectal exam. Laboratory tests revealed hemoglobin of 5.9 g/dL (baseline 10 g/dL), creatinine 5.87 mg/dL, corrected calcium 9.3 mg/dL, phosphorus 3.4 mg/dL, calcium-phosphate product 31, and INR 2.8. The patient received 2 units of packed red blood cells and 4 units of fresh frozen plasma with appropriate response. EGD showed thickened antral folds (Figure 1), which were further evaluated with endoscopic ultrasound showing hyperechoic foci and shadowing with intact gastric layers (Figure 2). Histopathology of thickened folds showed foveolar hyperplasia and histiocytes in the lamina propria containing calcium deposits. Von Kossa stain confirmed calcium deposition (Figure 3). Steiner stain was negative for Helicobacter pylori. No other source of bleeding was identified on repeat EGD, colonoscopy, and capsule endoscopy. At 4 months follow up, patient has had no further bleeding.Figure 1Figure 2Figure 3Conclusions: The presentation above is suggestive of upper GI bleed secondary to gastric mucosal calcinosis in the setting of end stage renal disease. GMC has been rarely reported as a cause of GI bleeding. This case emphasizes that gastric mucosal calcinosis should be considered as a possible GI bleeding source especially in the clinical setting of chronic kidney disease.

Factors Determining Diagnostic Yield of Wireless Capsule Endoscopy

Introduction: Wireless capsule endoscopy (WCE) has emerged as an important diagnostic work up for evaluation of patients with anemia. The predictive factors for a positive yield of WCW in patients with anemia with or without overt gastrointestinal bleeding are unclear. The aim of the study was to determine factors predicting a positive diagnostic yield of WCE. Methods: We conducted a single-center retrospective chart review of 174 adult patients age 18 and above at a community hospital center who underwent WCE study for unexplained anemia from 2009-2014. Clinical data including prospective laboratory data were reviewed. All patients had negative esophagogastroduodenoscopy (EGD) and colonoscopy. Fisher exact test and logistic regression models were used. Results: Total of 174 patients were reviewed, 87 were male and 87 were female. The mean age was 57.5 years. 78 patients had positive WCE results, 96 were negative. Age was a significant risk factor for a positive WCE result. Patients with a positive study were 6.6 years older than patients with a negative result (61.2 vs 54.6, p=0.015). Each decade of life increased the relative risk of a positive result by 8%. Lower hemoglobin (Hgb) level was also a risk factor for a positive WCE result. Patients with a positive study had a 1.0 mg/dL lower Hgb level than patients with a negative study (9.8 vs 8.8, p=0.01). In comparison to patients with Hgb > 10, those with Hgb < 7mg/dL had a 3.6 fold increased risk of positive WCE (p- value=0.0005), and those with Hgb between 7-10mg/dL had a 1.7 fold increase in the likelihood of a positive WCE (p=0.09) (Fig 2). There was a weak association with coronary artery disease (CAD) or diabetes mellitus (DM) with a having an abnormal finding on a WCE study (OR=2.1, 1.6, p=0.04, 0.09 respectively). There was no association between gender, race, MCV, MCH, and RDW with positive study results. A multivariate analysis revealed age to be the lone significant independent predictor.Figure 2Conclusion: Anemia is a predictor for having a positive WCE study. Diagnostic yield of WCE is higher when the study is conducted for anemic patients. A hemoglobin below 10 mg/dl is a cutoff for positive results and Hgb < 7 mg/dl has a 3.6 fold increased risk of a positive test result. Age is an independent strong risk factor for having a positive WCE result. CAD and DM were also associated with increased risk, but this may be confounded by higher age in this patient group. There was no evidence for association with gender, race, MCV, MCH and RDW.Figure 1

Gastrointestinal Bleeding: A Rare Presentation of Gastrointestinal Metastases From Primary Carcinoma of the Lung

Lung cancer has the highest mortality rate amongst any other cancer. About half of patients with primary lung cancer have metastases at the time of diagnosis. Metastases to the gastrointestinal tract (GI) are rare but when they do occur manifestations from bowel perforation are common and GI hemorrhage is exceedingly rare. We present two cases of patients who presented with overt gastrointestinal bleeding secondary to metastatic lung cancer involving the proximal small bowel. Case1: A 54-year-old male and active smoker presented to the emergency department with complaints of fatigue and black stool for 1 week. The patient also noted 20 pound unintentional weight loss in the last 4 months. Denied any prior endoscopies. Physical exam remarkable for melena on digital rectal exam. Labs notable for anemia with hemoglobin of 6.0 gm/dL. An emergent esophagogastroduodenoscopy (EGD) revealed a 10 millimeter, doughnut-shaped, ulcerated nodule in the duodenum with dried blood (see Figure 1). Pathology showed a metastatic poorly differentiated pulmonary adenocarcinoma. Colonoscopy was unremarkable. A Computed Tomography (CT) scan of the chest showed a large mass in the left upper lung lobe and pathology revealed poorly differentiated pulmonary adenocarcinoma. Case 2: A 78-year-old Chinese male and active smoker, presented to the emergency department with generalized weakness, dark stools, and 15 pound unintentional weight loss over the last 2 months. Normal EGD and virtual colonoscopy 3 months prior. Physical exam remarkable for melena on digital rectal exam. Labs notable for anemia with hemoglobin of 6.2gm/dL. An EGD and a colonoscopy were performed and were unremarkable. Capsule endoscopy revealed a bleeding jejunal mass. A push enteroscopy showed a circumferential, necrotic mass in the proximal jejunal that was partially obstructing the lumen and actively oozing blood. An exploratory laparotomy found a necrotic mass in the proximal jejunum that was penetrating the serosa and adherent to the mid transverse colon (see Figure 2). A segmental resection of the penetrating small bowel mass and mid transverse colon was performed. Pathology revealed metastatic, poorly differentiated pulmonary adenocarcinoma with neuroendocrine differentiation. A CT scan of chest showed a large mass in the left upper lung lobe and pathology revealed a non-small-cell undifferentiated carcinoma of the lung with neuroendocrine expression. This was consistent with the jejunal lesions being metastases from primary lung carcinoma. Our cases are unique since this is the first reported case series of undiagnosed metastatic lung cancer involving the proximal small bowel in patients admitted with overt gastrointestinal bleeding. In both cases diagnosis of lung cancer was made by histological examination of the gastrointestinal lesions, which prompted further pulmonary work-up.Figure 1Figure 2

Chronic Superior Mesenteric Venous Thrombosis Complicated With Protein-Losing Enteropathy and Massive Duodenal Bleeding in a Patient With HIV Infection: A Case Report

Chronic superior mesenteric vein thrombosis (SMVT) is a rare condition with favorable prognosis. We report a patient with HIV infection and chronic SMVT who presented with chronic diarrhea associated with protein-losing enteropathy (PLE) and subsequently he developed massive overt gastrointestinal bleeding (OGIB). A 46-year-old man had been diagnosed as HIV infection for 24 years. Ten years earlier, he had disseminated mycobacterial avium complex (MAC) associated with intra-abdominal lymphatic obstruction. As a consequence, SMVT without evidence of cirrhosis was detected by CT scan of the abdomen. He received antiretroviral agents. CD4 level was 213 cells/mm3 (17%CD4) and his viral load was 318 copies/ml. In addition, a long-standing of oral estrogen was used for inducing his female characteristics. He was referred to our hospital because of chronic watery diarrhea, hypoalbuminemia, and generalized edema for 6 months. Physical examination showed ascites and legs swelling. During hospitalization, he developed massive hematochezia. After blood transfusion, gastroscopy, colonoscopy, and CT angiography were performed. The bleeding source was not identified. CT scan of the abdomen revealed SMV obliteration with increased collateral vessels and bowel wall thickening (Figure 1). Subsequently, ectopic varices were suspected. Push enteroscopy was performed and showed varices at the third part duodenum with blood clot on top and endoscopic therapy with glue injection was successfully done (Figure 2). 99mTc-human serum albumin scan showed radiotracer accumulation in small bowel (Figure 3). Stool microbiology, histopathology of small bowel and colon were negative for mycobacterium, parasites and malignancy. Therefore chronic SMVT secondary from intra-abdominal infection complicated with PLE and massive bleeding of duodenal varices was diagnosed.Figure 1Figure 2Figure 3The cause of SMVT in this patient was due to intra-abdominal inflammation from the previous disseminated MAC infection combined with acquired thrombophilia by estrogen. The chronic obliteration of SMV raised mesenteric venous pressure and the development of dilated venous collaterals, these in turns resulted in variceal formation as ectopic varices. We speculate that SMVT could further block lymphatic drainage; and cause intestinal lymphangiectasia and PLE from lymphatic leakage.

Metastatic Melanoma to the Jejunum Presenting as Obscure Overt Gastrointestinal Bleeding

Metastatic Melanoma to the Jejunum Presenting as Obscure Overt Gastrointestinal Bleeding

Argon plazma koagülasyon ile tedavi edilen gastrik anjiodisplazi: İki olgu sunumu

Angiodysplasias are rare but important causes of gastrointestinal bleeding thtat are commonly seen in the colon but rarely in the stomach. Although various endoscopic modalities are used for the treatment of these lesions, argon plasma coagulation is the most commonly used approach. We present a report of two cases of gastric angiodysplasias leading to overt gastrointestinal bleeding, which were successfully treated with argon plasma coagulation. The procedure is a safe, effective and easy to use modality for the treatment of gastric angiodysplasias that present with overt gastrointestinal bleeding.

Long-Term Outcomes in Patients with Overt Obscure Gastrointestinal Bleeding After Negative Double-Balloon Endoscopy.

The long-term outcomes of patients after negative double-balloon endoscopy (DBE) for obscure gastrointestinal (GI) bleeding remain unclear. The aim of this study was to assess the long-term outcomes of patients with negative DBE and clarify the effect of repeat endoscopic work-up. A total of 42 patients with a negative DBE for overt obscure GI bleeding were enrolled, and their clinical data were retrospectively reviewed. The mean (± standard deviation) follow-up period is 5.4 (± 2.8) years. The outcome measurement was overt rebleeding witnessed by the patient after negative DBE. At the time of rebleeding, further endoscopic work-up and specific treatment were performed. Rebleeding occurred in 16 of 42 patients (38%). At the time of rebleeding, further investigations were made in 14 of 16 patients (88%), and the bleeding source was identified in 10 of 14 patients (71%). These 10 patients received specific treatment (endoscopic in five, surgical in two, medical in two, and angiographic in one). The bleeding source was in the small intestine in seven of 10 patients (70%). Blood transfusion before DBE and multiple bleeding episodes before DBE were significant predictive factors for rebleeding (odds ratio 5.056, 95% confidence interval 1.158-22.059, p = 0.031 and odds ratio 8.167, 95% confidence interval 1.537-43.392, p = 0.014, respectively). The rebleeding rate after a negative DBE is considerable. Careful long-term follow-up and repeat endoscopic work-up at the time of overt rebleeding are important.

A Case of Overt GI Bleeding from a Obscured Source in a Cirrhotic Patient

While esophago-gastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 70-year-old woman who had not previously undergone abdominal surgery, who had not diagnosed liver cirrhosis before. Emergency endoscopy revealed no esophageal varices but multiple nodular lesions with ulcerated tips with active oozing of blood and no bleeding focus was found at colonoscopy. She continued to produce recurrent melaena with hematochezia and received several units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. USG&amp;CT scan of abdomen reveals coarse liver with splenomegally with mild pelvic collection. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgeryBangladesh Crit Care J September 2014; 2 (2): 81-84

The outcome and role of drugs in patients with unexplained gastrointestinal bleeding

Objective. Studies on unexplained gastrointestinal bleeding (GIB) are lacking. We aimed to study the clinical outcomes of patients with unexplained GIB and to determine the incidence of obscure GIB. Material and methods. A population-based study on all patients undergoing endoscopy at the National University Hospital of Iceland in 2010. Indications, results of endoscopies and drug history were prospectively registered with a follow-up of 3 years. A national pharmaceutical database containing prescription data was utilized. Patients were categorized into unexplained overt and occult GIB and obscure GIB. Patients undergoing endoscopy and without GIB acted as controls. Results. Of 2471 patients undergoing endoscopy, 11% had unexplained GIB. Of those, 46% had unexplained overt GIB, 44% had unexplained occult GIB and 11% had obscure GIB. Multivariate analysis showed that patients with unexplained GIB and unexplained overt GIB had greater odds of NSAID use than controls, OR 1.8 (CI 1.03–3.03) and OR 2.0 (CI 1.01–3.77), respectively. Warfarin was strongly associated with all bleeder groups, OR 4–4.8. The incidence of obscure GIB was 10/100,000 inhabitants annually. Two (0.8%) patients were diagnosed with colon cancer 16 and 30 months after the index colonoscopy. Of patients with unexplained overt, unexplained occult GIB and controls, 5%, 6% and 3.5% (NS) had another overt bleeding episode, during the study period. Conclusions.NSAIDs and warfarin seem to play an important role in unexplained GIB. The incidence of obscure GIB is low and missed cancers are very rare. The probability of a repeat bleeding episode is similar to that of controls.

Occult vs. overt upper gastrointestinal bleeding - inverse relationship and the use of mucosal damaging and protective drugs.

While efforts have focused on the prevention of overt upper gastrointestinal bleeding (UGIB), little is known about occult GIB, which might also originate from sites not protected by acid inhibition. To measure the incidence and outcomes of both overt and occult GIB over a 6-year period (2007-2012), and to assess the use of NSAIDs, anti-thrombotic therapy (ATT), proton pump inhibitors (PPIs), and iron therapy. A sample of 300 patients (100 from each of three index years) with occult GIB was randomly selected and their outcomes were compared with those of patients with overt UGIB (N = 869). The incidence of overt UGIB fell from 140.1 per 100 000 population per annum in 2007 to 106.8 in 2010 and to 88.0 in 2012 (P < 0.001); while that of occult GIB rose from 243.1 to 263.6 and to 292.8 (P < 0.001) over the same period. The incidence of occult GIB was highly correlated with the number of prescriptions of PPIs per 1000 population (χ(2) trend = 11.80; P < 0.001). In the overt UGIB group, the median haemoglobin level on presentation was lowest (10.3) in patients taking NSAIDs/ATT plus PPIs compared with those taking PPIs alone (11.5), NSAIDs/ATT alone (10.4) or none of these drugs (12.7 g/dL) (P < 0.001, Kruskal-Wallis). An inverse trend seems to have formed in the incidence of overt vs. occult gastrointestinal bleeding in association with the wider use of PPIs and NSAIDs. An alternative approach to acid inhibition is needed to prevent gastrointestinal bleeding.

Impact of serum ferritin level on hepatocarcinogenesis in chronic hepatitis C patients.

To elucidate the impact of the serum ferritin level, a surrogate indicator of hepatic iron accumulation, on hepatocarcinogenesis in chronic hepatitis C patients. Serum ferritin was measured in 487 chronic hepatitis C patients without history of hepatocellular carcinoma (HCC) after excluding patients in phlebotomy, those with overt chronic gastrointestinal bleeding and those who achieved sustained virological response before enrollment. Patients were divided into four groups (G1-G4) by quartile points of serum ferritin, with sexes separated. The serum ferritin level was positively correlated with total bilirubin, aspartate aminotransferase, alanine aminotransferase (ALT), γ-glutamyltransferase, hemoglobin and AFP, and inversely correlated with prothrombin activity in both sexes. A significant difference in HCC incidence was observed only in male patients; the incidence was higher in G1 (≤80 ng/mL, n = 54) and G4 (≥323 ng/mL, n = 54) compared with that of G2 (81-160 ng/mL, n = 54) and G3 (161-322 ng/mL, n = 52). The spline curve indicating the relationship between the hazard ratio and serum ferritin level took the form of a J-shape for male patients. In multivariate analysis, G1 and G4 showed higher incidence of HCC among men with a hazard ratio of 2.19 (95% confidence interval, 1.02-4.70; P = 0.045) compared with G2 and G3, together with older age, lower serum albumin and ALT above the normal upper limit. The serum ferritin level is an independent risk factor for HCC development in male patients with chronic hepatitis C when the level is extremely high or low.