Source Of Bleeding Research Articles

THU537 A Case Of Aggressive NET With Extensive Bone Marrow Metastasis Presenting With Hypercalcemia

Abstract Disclosure: G. Kela: None. A.S. Gill: None. F. Kussaga: None. O. Olarinmoye: None. Introduction: A metastatic cancer that has no identifiable site of origin despite a thorough workup is termed cancer of unknown primary (CUP). Neuroendocrine tumors of unknown primary (NUP) are rare, making up less than 5% of all CUPs. This case demonstrates a rare presentation of a well-differentiated neuroendocrine tumor (NET) of an unclear primary site with extensive metastasis to the bone that initially presented with hypercalcemia of unclear cause. Case: We report a case of a 76-year-old-female with a history of depression and hypertension who was initially admitted for evaluation of hypercalcemia with a corrected calcium of 11.9, low normal PTH of 14.2, and PTHrP of 18, treated with zoledronic acid who presented again 3 months later with a 30lb weight loss for 2 months and bright red blood per rectum for one day. The patient had petechiae and flat dry purpura across her upper and lower extremities, lymphadenopathy, hepatosplenomegaly, and jaundice. Labs revealed a hemoglobin of 8.4g/dl (normocytic normochromic) and platelet count of 61,000/cm3, compared to 14.5g/dl and 269,000/cm3 respectively 4 months before admission. Colonoscopy and barium enema revealed internal hemorrhoids as the bleeding source. Laboratory workup for thrombocytopenia revealed no distinct etiology. Further workup with a right iliac bone marrow biopsy revealed a well-differentiated NET. The tumor cells expressed keratin 7, chromogranin, and synaptophysin, & variably expressed INSM1. CT scan of the chest, abdomen, & pelvis revealed a left thyroid nodule measuring 2.4 cm, suspicious for a NET on an octreotide scan. Biopsy of the left thyroid nodule, however, revealed follicular neoplasm which is not a NET. The patient was started on Lanreotide with no significant improvement. She remained severely anemic requiring multiple blood transfusions despite undergoing a hemorrhoidectomy. A repeat CT scan and MRI of the head done for increased confusion and disorganized speech 2 months later showed extensive metastatic disease involving the brain and skull. The patient could not tolerate further workup or cytotoxic chemotherapy and wished to proceed with hospice care. Discussion: NETs can arise from neuroendocrine cells located in any part of the body, most commonly in the gastrointestinal tract, lungs, or pancreas, and on extremely rare occasions from the bone. Conventionally, these tumors are indolent and accompanied by carcinoid symptoms. In this case, the bone biopsy was positive for tumor markers suggesting various primary sites including small bowel, stomach, and pancreas. However, despite extensive workup, the primary localization of the tumor was unsuccessful. The combination of the absence of a site of origin, the predominance of hematologic pathology (pancytopenia), and the highly invasive nature of this patient’s malignancy are suggestive of a well-differentiated NET with extensive metastasis into the bone. Presentation: Thursday, June 15, 2023

Epidemiology of Trauma-Related Hemorrhage and Time to Definitive Care Across North America: Making the Case for Bleeding Control Education.

Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury. The purpose of this investigation was to evaluate the types of trauma associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion. A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care. Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage. Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.

Thrombocyte transfusion and rebleeding rate in patients using antiplatelet agents before aneurysmal subarachnoid hemorrhage.

The reason for a rebleed after an initial hemorrhage in patients with aneurysmal subarachnoid hemorrhage (aSAH) is considered multifactorial. Antiplatelet use is one of the factors that has been related to early rebleed and worse outcome after aSAH. Thrombocyte transfusion overcomes the inhibitory effects of antiplatelet agents by increasing the number of functional thrombocytes, but its impact on the rebleed rate and clinical outcome remains unknown. The aim of this study was to assess the effect of thrombocyte transfusion on rebleeding and clinical outcome in patients with aSAH and prehemorrhage antiplatelet use, considering confounding factors. Data were prospectively collected at a single tertiary reference center for aSAH in Zurich, Switzerland. Patients with aSAH and prehemorrhage antiplatelet use were divided into "thrombocyte transfusion" and "nontransfusion" groups based on whether they did or did not receive any thrombocyte transfusion in the acute stage of aSAH after hospital admission and before the exclusion of the bleeding source. Using multivariate logistic regression analysis, the impact of thrombocyte transfusion on the rebleed rate and on clinical outcome (defined as Glasgow Outcome Scale score 1-3) was calculated. One hundred fifty-seven patients were included, 87 (55.4%) of whom received thrombocyte transfusion. Eighteen (11.5%) of 157 patients had a rebleed during the hospital stay. The rebleed risk was 6.9% in the thrombocyte transfusion group and 17.1% in the nontransfusion group. After adjusting for confounders, thrombocyte transfusion showed evidence for a reduction in the rebleed rate (adjusted OR [aOR] 0.29, 95% CI 0.10-0.87). Fifty-seven patients (36.3%) achieved a poor outcome at 6 months' follow-up. Among those 57 patients, 31 (54.4%) underwent at least one thrombocyte transfusion. Thrombocyte transfusion was not associated with poor clinical outcome at 6 months' follow-up (aOR 0.91, 95% CI 0.39-2.15). Thrombocyte transfusion in patients with aSAH and prehemorrhage antiplatelet use is independently associated with a reduction in rebleeds but shows no impact on clinical outcome at 6 months' follow-up. Larger and randomized studies are needed to investigate the impact of thrombocyte transfusion on rebleed and outcome.

S3359 Varices at Choledochojejunostomy Site as the Elusive Gastrointestinal Bleeding Source in a Post-Whipple Patient

S3359 Varices at Choledochojejunostomy Site as the Elusive Gastrointestinal Bleeding Source in a Post-Whipple Patient

Endovascular embolization of persistent liver injuries not responding to conservative management: a narrative review.

Trauma remains a significant healthcare burden, causing over five million yearly fatalities. Notably, the liver is a frequently injured solid organ in abdominal trauma, especially in patients under 40 years. It becomes even more critical given that uncontrolled hemorrhage linked to liver trauma can have mortality rates ranging from 10% to 50%. Liver injuries, mainly resulting from blunt trauma such as motor vehicle accidents, are traditionally classified using the American Association for the Surgery of Trauma grading scale. However, recent developments have introduced the World Society of Emergency Surgery classification, which considers the patient's physiological status. The diagnostic approach often involves multiphase computed tomography (CT). Still, newer methods like split-bolus single-pass CT and contrast-enhanced ultrasound (CEUS) aim to reduce radiation exposure. Concerning management, nonoperative strategies have emerged as the gold standard, especially for hemodynamically stable patients. Incorporating angiography with embolization has also been beneficial, with success rates reported between 80% and 97%. However, it is essential to identify the specific source of bleeding for effective embolization. Given the severity of liver trauma and its potential complications, innovations in diagnostic and therapeutic approaches have been pivotal. While CT remains a primary diagnostic tool, methods like CEUS offer safer alternatives. Moreover, nonoperative management, especially when combined with angiography and embolization, has demonstrated notable success. Still, the healthcare community must remain vigilant to complications and continuously seek improvements in trauma care.

Akut Üst Gastrointestinal Kanama İle Başvuran Hastaların Endoskopi Yapılma Zamanının Hastaların Mortalitesine Etkileri

Background: Endoscopy is recommended in acute upper gastrointestinal bleeding (AUGIB) to detect the bleeding source and stop the bleeding. The optimal timing of endoscopy in AUGIB is controversial. We aimed to investigate the time of endoscopy and the factors affecting it.
 Materials and methods: Retrospective, single-center study. The patients were divided into four groups: endoscopy after discharge, 0-12 hours endoscopy, 12-24 hours endoscopy and 24 hours later. Age, sex, vital signs, laboratory findings were recorded. Glasgow-Blatchford Score (GBS) and Charlson comorbidity index (CCI) were calculated. The obtained data were compared between these four groups. All-cause mortality for 30 days was recorded.
 Results: A total of 318 patients were included. In the comparison of endoscopy times, the parameters found to be statistically significant between the four groups are Hb, BUN, and INR levels, GBS and CCI. As a result of CHAID analysis, the most crucial variable affecting the timing of endoscopy was found to be the Hb value of the patients (χ2=66.528; adjusted p=0.000). Mortality occurred in 10.69% of the patients. The timing of endoscopy did not affect mortality. In binary logistic regression analysis, low systolic BP (0.967 times increase), high CCI (86,402 times increase) were found to affect mortality.
 Conclusion: The factors affecting the timing of endoscopy are the signs of bleeding. A thorough follow-up of vital signs in patients presenting to the emergency department with acute gastrointestinal bleeding, particularly an evaluation of systolic blood pressure and detailed questioning of additional comorbid conditions, is critical to reduce mortality.

Gastrointestinal bleeding in children: diagnosis, analysis, and structure

The incidence of gastrointestinal bleeding is a significant concern among adult patients with gastrointestinal tract (GIT) disorders, as it is a leading cause of mortality. However, there is growing evidence of changes in the pattern of gastrointestinal pathologies among children, primarily attributed to an increasing number of cases related to peptic ulcer disease (PUD) and erosive processes of the GIT. Purpose - to investigate the prevalence and analyze changes in the structure of GIT diseases in children complicated by upper gastrointestinal bleeding (GIB), based on esophagogastroduodenoscopy (EGD) data. Materials and methods. Based on the clinic’s records, a total of 4,457 children underwent EGD at the Regional Medical Center of Family Health in Dnipro. Among them, 1,393 (31.25%) patients were admitted to the surgical department with suspected GIB. In 201 (14.4%) cases, EGD was performed during active bleeding to determine its origin. The utilization of EGD during the acute phase in patients with suspected GIB is considered highly effective for both diagnosing the bleeding source and initiating early-stage treatment. The data were processed using the methods of variation statistics using the Statistica v 6.1 software package. To compare the relative indicators, the Pearson Hi-quadrat test (χ2) and the two-sided Fisher’s exact test (TCF) were used. The critical level of statistical significance (p) was accepted as <0.05. Results. To conduct a comparative analysis of diagnosed cases of GIB, two groups of children with endoscopically confirmed GIB were formed: the Group I (n=125) representing the period of 2012-2013, and the Group II (n=201) - the period of 2020-2021. The results revealed an increase of 1.6 times in the number of patients with upper GIT diseases accompanied by bleeding in the Group II. Additionally, a significant rise in the frequency of GIT diseases, specifically erosive esophagitis, was observed. The number of patients with erosive esophagitis tripled in the Group II compared to the Group I. Conclusions. In recent years, there has been a notable rise in GIT diseases accompanied by upper GIB. The number of such cases increased by 1.6 times, from 125 to 201 patients. Notably, there is a pronounced increase in the incidence of erosive esophagitis, particularly among children in the early and younger age groups. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Eroded small-bowel phlebectasia: clipping of an uncommon bleeding source by using motorized spiral enteroscopy

Eroded small-bowel phlebectasia: clipping of an uncommon bleeding source by using motorized spiral enteroscopy

Varicose veins of the jejunum as a rare source of recurrent bleeding

Ectopic varices are any pathologically dilated collaterals in diff erent areas of the gastrointestinal tract, developing as a result of portal hypertension. When localized in the digestive system, varicose veins can be the cause of approximately 5% of cases of bleeding, with a high (up to 40%) fatality rate due to the diffi culty in diagnosing and treating them. The aim of this study is to present a rare clinical observation of recurrent gastrointestinal bleeding from varicose veins of the small intestine. Materials and methods: this article presents a clinical case of recurrent bleeding from ectopic varicose veins of the small intestine in a 65-year-old female patient. The patient was admitted to our hospital with complaints of tarry stools and weakness. She had undergone esophagogastroduodenoscopy (EGD) and colonoscopy (CS) at her place of residence, but no pathology was detected. She was referred to the surgical department of the State Budgetary Healthcare Institution “City Clinical Hospital No. 2” to determine the treatment strategy. In the conditions of the City Clinical Hospital No. 2 in Krasnodar, comprehensive endoscopic diagnostics of the digestive system were performed on the patient, including EGD, CS, video capsule endoscopy (VCE), and balloon-assisted enteroscopy (BAE). Results: erosions of the prepyloric part of the stomach were detected during EGD. Data indicating bleeding from the upper parts of the digestive system were found during colonoscopy. After appropriate preparation, video capsule endoscopy (VCE) was performed on the patient, which revealed signs of ongoing bleeding. Balloonassisted enteroscopy (BAE) was performed on the patient under endotracheal anesthesia in the operating room. Multiple bluish varicose veins, protruding into the lumen up to a distance of 4–5 mm, were visualized throughout the examined length of the small intestine (80 cm from the Treitz ligament). The patient underwent surgical intervention — resection of the aff ected segment of the small intestine. Conclusions: the presented modern methods of small bowel examination — capsule endoscopy and balloon-assisted enteroscopy — provide the opportunity for highly informative endoscopic examination, which signifi cantly aff ects the timeliness of diagnosis and early detection of small bowel diseases.

Endoscopic Evaluation among Patients Presenting with Upper Gastrointestinal Tract Bleeding

Background: Bleeding from the upper gastrointestinal tract is a critical medical condition that requires prompt diagnosis and management. Endoscopic evaluation plays a pivotal role in identifying the source of bleeding, determining its severity, and guiding appropriate interventions. Objective: The objective of this study was to conduct a comprehensive endoscopic evaluation in patients who have presented with bleeding originating from the upper gastrointestinal tract. Study Design: Descriptive cross-sectional study. Settings: Department of Gastroenterology, Islamic International Medical College, Rawalpindi Pakistan. Duration: Study duration was 7 months from November 2021 to April 2022. Methods: Patients who were 18 years of age or older and presented with active or recent upper gastrointestinal bleeding, regardless of gender, and were scheduled for endoscopic examination, were incorporated into the study. Upper gastrointestinal endoscopies were performed. The procedure was involving the direct visualization of the esophagus, stomach, and duodenum using an endoscope. Any visible lesions or bleeding sources were documented. Data regarding the location and nature of bleeding sources and the endoscopic diagnosis were recorded in a standardized data collection form and analyzed by SPSS version 26. Results: The study included 59 patients with a mean age of 52.27 years. Esophageal endoscopic findings revealed "Grade I to III Esophageal varices (EV) being less common (3.4%, 11.9%, and 13.6% respectively). LAX LEs, esophagitis and Hiatus hernia were observed in 10.2%, 3.4%, and 6.8% of cases. Rarer findings, including Venules, Ecstatic vein, Candidiasis, and various combinations, each accounted for 1.7% of cases. Portal hypertension gastropathy was the most prevalent condition (20.3%), followed by Antral gastritis (45.8%), Erosive gastropathy (10.2%), and other less frequent conditions, such as fundal varices, GOVI varices, diffuse gastritis and Ulcer. Grade II and III EV, and PHTN gastropathy, were significantly more prevalent among males, while Antral gastritis was notably higher among females (p < 0.05). Although the endoscopic findings did not show any statistically significant differences based on gender (p > 0.05). Conclusion: PHTN gastropathy, antral gastritis, grade III EV and erosive gastropathy were the most common conditions among patients with Hematemesis, along with less frequent findings like grade I to III Esophageal varices, Venules, Ecstatic vein, Candidiasis, and combinations of these conditions.

Incidence, Predictors, and Prognostic Impact of Bleeding Events After TAVR According to VARC-3 Criteria

BackgroundThe updated Valve Academic Research Consortium (VARC) definition for bleeding events after transcatheter aortic valve replacement (TAVR) lacks of clinical validation. ObjectivesThe aim of this study was to determine the incidence, predictors, and clinical impact of bleeding events following TAVR as defined by recent VARC-3 criteria. MethodsA total of 2,384 consecutive patients with severe symptomatic aortic stenosis undergoing TAVR were included. Early (at index hospitalization) and late (after hospital discharge) bleeding complications were defined according to VARC-3 criteria as type 1, 2, 3, or 4. Baseline, procedural, and follow-up (24 [IQR: 12-43] months) data were prospectively collected. ResultsBleeding events occurred in 761 patients (31.9%): types 1, 2, 3, and 4 in 169 (22.2%), 399 (52.4%), 149 (19.6%), and 44 (5.8%) patients, respectively. The primary vascular access site and gastrointestinal locations were the most common bleeding sources among early and late bleeding events, respectively. Female sex, thoracotomy access, larger (14-F) sheath use, and dual antiplatelet therapy determined an increased risk of early bleeding events (P < 0.02 for all). The use of the radial artery for secondary access was associated with a significant risk reduction of early bleeding (P < 0.001). Type 2 and type 3 events were associated with an increased mortality risk at 30-day (HR: 2.94 [95% CI: 1.43-6.03; P = 0.003] and HR: 4.91 [95% CI: 2.19-11.03; P < 0.001], respectively) and 1-year (HR: 1.86 [95% CI: 1.28-2.69; P = 0.001] and HR: 2.28 [95% CI: 1.41-3.66; P = 0.001], respectively) follow-up. A similar prognostic pattern was observed when applying VARC-2 criteria but with a much lower global incidence of early bleeding events (19% vs 27%; P < 0.001). ConclusionsBleeding events after TAVR were associated with poorer short- and long-term survival. The magnitude of this correlation was proportional to bleeding severity defined according to VARC-3 criteria. Further studies on bleeding prevention following TAVR are warranted to improve procedural safety and patient prognosis.

Bleeding alert map (BAM): The identification method of the bleeding source in real organs using datasets made on mimicking organs

Bleeding alert map (BAM): The identification method of the bleeding source in real organs using datasets made on mimicking organs

Usefulness of intraoperative transesophageal echocardiography for hemodynamic management of liver transplantation in a patient with massive polycystic liver disease: a case report

BackgroundHemodynamic management during anesthesia in liver transplantation for patients with polycystic liver disease (PLD) can be more challenging because of the bleeding and hemodynamic alterations due to the markedly enlarged liver. We hereby report a case of PLD wherein transesophageal echocardiography (TEE) was employed for optimal hemodynamic monitoring during liver transplantation.Case presentationA 61-year-old man was scheduled to undergo liver transplantation for massive PLD. Hemodynamic instability was associated with mechanical displacement of the giant cystic liver. TEE results revealed the collapse of the inferior vena cava due to liver displacement. TEE also detected intrathoracic hemorrhage triggered by detachment from the markedly enlarged liver.ConclusionTEE is a valuable monitoring tool for sharing information with surgeons and diagnostic modality for finding the source of bleeding in liver transplantation for PLD and may contribute majorly to the quality of perioperative management.

Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study.

Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Spontaneous middle meningeal arteriovenous fistula without cortical venous reflux presenting with acute subdural hematoma: illustrative case.

Dural arteriovenous fistula (AVF) without cortical venous reflux (CVR) has a relatively benign course. Here, the authors describe a patient presenting with subdural hematoma due to a middle meningeal AVF without CVR. A 17-year-old male was admitted to the emergency department with acute headache without an episode of head trauma. Computed tomography demonstrated a left acute subdural hematoma (SDH). Because the nontraumatic SDH raised the suspicion of vascular pathology, emergent angiography was performed, which demonstrated an AVF fed by the middle meningeal artery and draining to the diploic vein via the serpentine meningeal vein without CVR. T2-weighted magnetic resonance imaging (MRI) revealed no signs of venous congestion. Given the proximity of the AVF to the SDH and the MRI findings, we suspected that the serpentine meningeal vein was responsible for the SDH. The patient was successfully treated with transarterial Onyx embolization. During the injection, Onyx migrated to the extravascular space following its penetration into the serpentine meningeal vein, suggesting the meningeal vein was a bleeding source of the subdural hematoma. Despite the absence of cortical venous reflux, serpentine meningeal venous drainage of middle meningeal AVF can be a source of subdural hemorrhage.

Recurrent upper gastrointestinal bleeding in chronic pancreatitis since childhood: a case report

Chronic pancreatitis is a progressive inflammatory disease of the pancreas. Causes of gastrointestinal (GI) bleeding in chronic pancreatitis are bleeding into the pseudocyst, pseudoaneurysm of peripancreatic vessels, and thrombosis of portal vein and splenic vein. We are presenting a rare case presentation of recurrent GI bleed in chronic pancreatitis since childhood and its management. A seventeen-year-old female patient presented with recurrent attacks of upper abdominal pain, hematemesis, bleeding per rectum, and melena since 1 month of age. She was diagnosed with a case of chronic calcific pancreatitis with pseudoaneurysm of common hepatic artery, and portal vein thrombosis with splenomegaly at the age of 2 years. She underwent angioembolization of the common hepatic artery pseudoaneurysm at the age of 2 years. However, she continued to have recurrent episodes of upper GI bleeding which required multiple hospital admissions and blood transfusions in the past. Contrast-enhanced computed tomography of abdomen was suggestive of chronic calcific pancreatitis with status post coil embolization of common hepatic, gastroduodenal, and proper hepatic arteries. She underwent modified Frey’s procedure in view of recurrent symptoms. Currently, the patient is doing well after 18 months of follow-up, with no further episodes of GI bleed. Angioembolization or surgical ligation of pseudoaneurysm of involved vessels in chronic pancreatitis can control GI bleed. However, in cases where the source of bleeding is not localized by imaging/ endoscopy, drainage of pseudocyst or local resection of pancreatic tissue can reduce inflammation in and around the pancreas and prevent further GI bleed in chronic pancreatitis.

One in four patients with gastrointestinal bleeding develops shock or hemodynamic instability: A systematic review and meta-analysis.

Hemodynamic instability and shock are associated with untoward outcomes in gastrointestinal bleeding. However, there are no studies in the existing literature on the proportion of patients who developed these outcomes after gastrointestinal bleeding. To determine the pooled event rates in the available literature and specify them based on the bleeding source. The protocol was registered on PROSPERO in advance (CRD42021283258). A systematic search was performed in three databases (PubMed, EMBASE, and CENTRAL) on 14th October 2021. Pooled proportions with 95%CI were calculated with a random-effects model. A subgroup analysis was carried out based on the time of assessment (on admission or during hospital stay). Heterogeneity was assessed by Higgins and Thompson's I2 statistics. The Joanna Briggs Institute Prevalence Critical Appraisal Tool was used for the risk of bias assessment. The Reference Citation Analysis (https://www.referencecitationanalysis.com/) tool was applied to obtain the latest highlight articles. We identified 11589 records, of which 220 studies were eligible for data extraction. The overall proportion of shock and hemodynamic instability in general gastrointestinal bleeding patients was 0.25 (95%CI: 0.17-0.36, I2 = 100%). In non-variceal bleeding, the proportion was 0.22 (95%CI: 0.14-0.31, I2 = 100%), whereas it was 0.25 (95%CI: 0.19-0.32, I2 = 100%) in variceal bleeding. The proportion of patients with colonic diverticular bleeding who developed shock or hemodynamic instability was 0.12 (95%CI: 0.06-0.22, I2 = 90%). The risk of bias was low, and heterogeneity was high in all analyses. One in five, one in four, and one in eight patients develops shock or hemodynamic instability on admission or during hospitalization in the case of non-variceal, variceal, and colonic diverticular bleeding, respectively.

Risk Factors for Severe Clinical Course in Epistaxis Patients.

Purpose: Epistaxis is a common medical emergency that may require admission to the emergency department (ED) and treatment by an otolaryngologist. Currently, there are no widely accepted indications for hospitalization, and the decision is based on personal experience. Methods: A retrospective study of 1171 medical records of patients with epistaxis treated at our tertiary medical center ED from 2013 to 2018 with no age limit. The presence of recurrent epistaxis, a posterior source of bleeding, the need for hospitalization, the need for blood transfusion, or surgical intervention defined severe clinical course. Results: The 1171 admissions included 230 recurrent admissions for a total of 941 patients (60% males) who were treated by an otolaryngologist. The average age was 57.6 in the adult population (>15) and 6.6 in the pediatric population (≤15). Of all patients, 39% had hypertension; 39% took antiplatelet/anticoagulation therapy; 63% came during winter-a significant risk factor; 34 (2.9%) had reduced hemoglobin levels of >1gr%, but only 7 received a blood transfusion; 131 (11%) were hospitalized, and 21 (1.8%) required surgical control of the bleeding. Age (OR 1.02; CI 1.01-1.023), male sex (OR 2.07; CI 1.59-2.69), hypertension (OR 1.76; CI 1.27-2.45), and antiplatelet/anticoagulation therapy (OR 2.53; CI 1.93-3.33, OR 1.65; CI 1.11-2.44, respectively), were significantly correlated with severe clinical course. Conclusion: Epistaxis is significantly more common and severe in older male patients with hypertension or antiplatelet/anticoagulation therapy. However, few need a blood transfusion or surgical intervention. In borderline cases with no definitive indication for hospitalization, we suggest adopting these factors as indications for hospitalization due to their marked influence on the clinical course. Routine coagulation tests are indicated in patients treated with warfarin or combined antiplatelet + anticoagulation therapy.

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience.

Postoperative epistaxis is a very rare but severe complication after endoscopic endonasal transsphenoidal surgery (EETS) that can lead to catastrophic consequences. However, the incidence, risk factors, management and prevention of postoperative epistaxis remain unclear. Consecutive patients with pituitary adenoma (PA), Rathke's cleft cyst, craniopharyngioma, or clival chordoma who received EETS in our department between September 2020 and November 2022 were retrospectively analyzed. The incidence, risk factors, management and prevention of postoperative epistaxis were investigated and analyzed. A total of 557 consecutive patients who received EETS were included in this study. Eight patients (1.4%) (7 PAs and 1 Rathke's cleft cyst) experienced severe postoperative epistaxis. The size of the PAs was 9.6 mm-46.2 mm, with a median size of 22.1 mm. Epistaxis occurred 4 h to 30 days (median 14.5 days) postoperatively. Bleeding was stopped in 3 patients after nasal packing with iodoform gauze. The remaining 5 patients for whom nasal packing was insufficient were all sent to the operating room, and posterior nasal septal artery (PNSA) bleeding was identified and successfully treated with endoscopic bleeding artery electrocauterization under general anesthesia. In the EETS, all 8 patients had downward extension of the septal mucosal incision, in which 6 had intraoperative bleeding of PNSA that were cauterized by bipolar diathermy. Four patients had causative factors, including administration of antiplatelet agents, Valsalva-like manoeuvre, nose blowing and removal of nasal packing, respectively. No patients had recurrent epistaxis during the follow-up period. Post-EETS epistaxis is a rare but severe complication that could lead to catastrophic consequences, and one of the most common bleeding sources is the PNSA. Endoscopic bleeding artery electrocauterization under general anesthesia may be a safe, economic and effective measure for epistaxis refractory to nasal packing. Avoiding excessive downward extension of the septal mucosal incision could contribute to the prevention of postoperative epistaxis.

Automated algorithm for diagnosing gastrointestinal bleeding

BACKGROUND: Gastrointestinal bleeding (GIB) is a complication of many diseases of the gastrointestinal tract (GIT), including erosive and ulcerative lesions, vascular malformations, diverticula, and tumors. In developed countries, the GIB mortality rate ranges from 5% to 15%, reaching 30%40% in the group of patients with severe recurrent bleeding.&#x0D; AIM: The study aimed to develop an automated diagnostic algorithm for patients with GIB.&#x0D; METHODS: Knowledge engineering is used to extract terms and their relationships from the scientific literature related to the GIT. After agreement with the experts, information on the diagnosis and treatment of patients with GIB was arranged using a MS Excel spreadsheet editor. For building GIB localization rules, the study included data from histories of 280 patients aged 2094 years (61 [44; 74]); of these, 47.5% were women, while all others were men. The patients were diagnosed and treated at the Municipal Clinical Hospital No. 31 between 2008 and 2021. For testing the algorithm, data from histories of 514 patients aged 2096 years (62 [46; 74]) were used; of these, 57% were men, while the rest were women. The patients under study were diagnosed and treated at the Municipal Clinical Hospital No. 17 and the Municipal Clinical Hospital No. 31 between 2008 and 2022. For each study subject, data were available on 37 signs, including 19 clinical, 3 laboratory, and 15 endoscopic signs. Statistical data analysis was performed using the Statistica 13 software package, R Project programming language, and GraphPad online calculator. The software implementation of the algorithm was performed using the JavaScript programming language.&#x0D; RESULTS: Using polynomial logistic regression, an algorithm for differential diagnosis of GIB according to the preliminary localization of the bleeding source was developed. Having the data from 8 clinical and laboratory parameters with probability, a preliminary localization of the bleeding source may be determined. Thus, the probability of bleeding localization in the upper, middle, and lower GIT accounts for 84% (95% CI [78%; 89%]), 84% (95% CI [74%; 91%]), and 75% (95% CI [69%; 80%]), respectively. A final algorithm to support clinical decision-making in the management of patients with GIB (sergisa.smrtp.ru/medical/edit.html) was developed and implemented as a web-service, working with 92.2% efficiency.&#x0D; The sequence of operations of the algorithm for diagnosing GIB is as follows:&#x0D; &#x0D; Obtaining clinical and laboratory signs of a patient with suspected GIB.&#x0D; Determining the nature of bleeding (overt/occult) using literature data, assessing the severity of bleeding (mild/medium/severe) based on Gorbashko classification, and detecting the preliminary localization of bleeding (upper/middle/lower GIT) by regression equation.&#x0D; Providing recommendations for selecting a research method based on production rules and expert opinions.&#x0D; Obtaining endoscopic signs.&#x0D; Determining the localization and source of bleeding using the production rules.&#x0D; Providing recommendations for stopping/preventing GIB based on literature and expert opinions.&#x0D; &#x0D; CONCLUSIONS: An algorithm to support clinical decision-making for the management of patients with GIB, considering the nature of clinical manifestations and the severity and the cause of bleeding based on expert opinions, production rules, and polynomial logistic regression, which allows to assume a preliminary localization of the source of bleeding, was developed for the first time in the Russian Federation. The developed algorithm is implemented as a web-service and may be integrated into the medical information system at the automated workstation of a surgeon, an endoscopist, and a gastroenterologist to support clinical decision-making in the management of patients with GIB.