Symptoms Of Gastrointestinal Bleeding Research Articles

Upper gastrointestinal hemorrhage after nonresponsive thoracic spine pain: a case report

Objective This case study reports the findings of an upper gastrointestinal hemorrhage in a patient with thoracic spine pain reporting to a chiropractic clinic. The purpose of this article is to highlight the importance of identifying a patient's medication history as well as reviewing the signs and symptoms of gastrointestinal bleeding from a nonvariceal lesion. Clinical Features A 61-year–old woman presented with worsening middle thoracic spine pain of 3 months' duration along with recent abdominal pain. Medications, physical therapy, and spinal manipulation did not provide considerable improvement. The patient was taking ibuprofen daily to cope with her back pain. Intervention and Outcome The initial physical examination demonstrated mild increased tissue tension in the thoracic paraspinal muscles with mild restriction of thoracic spine range of motion secondary to the patient's pain. There was pain on palpation of the T4-5 and T7-8 spinal segments. The physical examination findings did not correlate to the patient's pain presentation, and she was referred back to her primary care physician. Two days after the initial examination, the patient experienced an upper gastrointestinal hemorrhage and underwent emergency surgery. It was determined postoperatively that she had a medication-induced duodenal ulcer that subsequently ruptured. Conclusion An upper gastrointestinal bleed should be considered in the differential diagnosis of a patient with a history of prolonged aspirin or nonsteroidal anti-inflammatory drug use with nonspecific abdominal symptoms.

Renal cell carcinoma metastatic to the stomach: single‐centre experience and literature review

To investigate the incidence, clinical presentation and therapy of gastric metastases, an uncommon finding, in a large group of patients with renal cell carcinoma (RCC). We systematically searched the computerized RCC database of our institute, covering 2082 patients (1180 men and 902 women) who had surgery between January 1984 and September 2005, to identify those with a synchronous and/or metachronous diagnosis of cancer in gastric biopsies or resection specimens. The histopathological slides of both renal and gastric cancer probes, and the clinical presentation, treatment and outcome of affected patients, were reassessed. Twelve patients with primary gastric cancer, one with local RCC recurrence affecting the antrum and five with clear cell RCC (three men and two women; mean age 73 years, range 65-83) with haematogenous cancer spread to the stomach were detected. The mean (range) time to gastric metastasis was 6.9 (1.7-13.1) years. There were metastases to other organs, most often the lung, in all patients. Three patients presented with symptoms of gastrointestinal bleeding, which was successfully controlled by local endoscopic therapy. Four patients died from disease at 3-19 months after diagnosis. One patient is still alive with disease after approximately 2 years. Gastric metastasis in patients with RCC appears to be a late event in the course of the disease. Most patients show concomitant tumour spread to other organs, and the outcome is generally poor. The use of targeted drugs might offer a new perspective for affected patients.

Self Assessment of Warning Symptoms in Upper Gastrointestinal Bleeding

Alcohol addicted patients are at increased risk of upper gastrointestinal bleeding. Delay to endoscopy is mainly determined by patients' self assessment. The authors asked 417 patients with high alcohol consumption from Leipzig (n = 277) and Munich (n = 140) with an average alcohol consumption of 660 g/week about their behavior when faced with symptoms of acute upper gastrointestinal bleeding. 71% or 51% said they would call the emergency physician if they were to vomit blood or black liquid. Only 32% would call emergency medical aid if they were to pass black stools, and only 25% of those surveyed thought urgent medical attention necessary in any of the three scenarios. Patients with regular contact with health care providers, and women, were more likely to consider these three scenarios as medical emergencies. The authors found no differences by age, educational level, marital status and alcohol consumption. Knowledge concerning the impact of symptoms of gastrointestinal bleeding was poor, in our study. Patients with high alcohol consumption and infrequent contact with health care providers, in particular, should be informed about symptoms such as melena and hematemesis, as delayed presentation significantly affects prognosis and resource consumption.

CAPSULE ENDOSCOPY: A SURGICAL PERSPECTIVE

Capsule endoscopy (CE) is gaining acceptance as an accurate method of imaging the small bowel. However, it is still being assessed for its use in successfully changing management and improving outcomes. We report the initial experience of CE in Tasmania. Findings were collected retrospectively for the first 55 consecutive CE carried out in Tasmania from May 2003 to June 2005. One surgeon had carried out and reported on these tests. Findings included indication, previous tests, abnormalities detected, subsequent change in management and outcomes. The median age was 68 years (range 33-87). Fifty-two CE were carried out for obscure gastrointestinal bleeding (23 for overt and 29 for occult bleeding) and 3 for abdominal pain without bleeding. Fifty-six per cent of tests had an abnormal result. Seven laparotomies were carried out to treat the abnormal findings of three suspected small bowel angiodysplasias, two suspected small bowel tumours, one patient with slow small bowel transit and abdominal pain and one patient with suspected Crohn's disease. Two patients died of cardiac arrest within 1 week of surgery, three patients showed improvement of their symptoms of gastrointestinal bleeding, one patient had resection and definitive diagnosis of Crohn's disease and another had excision of a bleeding Meckel's diverticulum. CE is an effective investigation for diagnosis of small bowel diseases amenable to medical or surgical management. However, the most appropriate use of this test to achieve an improvement in outcome is yet to be determined.

Small bowel enteropathy associated with chronic low-dose aspirin therapy

In April, 2005, a 79-year-old Chinese man presented with severe iron defi ciency anaemia (haemoglobin 67 g/L). He had no history of peptic ulcer disease and there were no signs or symptoms of gastrointestinal bleeding or disease. He had had a myocardial infarction in 1999, and had been taking aspirin 80 mg daily since then; he was not using any non-steroidal anti-infl ammatory drugs (NSAIDs) or herbal preparations. Upper and lower gastrointestinal endoscopy failed to identify any bleeding lesions. He was supportively transfused, and misoprostol 400 μg daily was empirically added. In the subsequent 7 months, he had a progressive drop in haemoglobin from 106 g/L (post-transfusion) to 54 g/L. He developed bilateral ankle oedema, with serum albumin concentration dropping from 39 g/L to 23 g/L. There was no proteinuria and the cause of hypoalbuminaemia was suspected to be loss from the gastrointestinal tract. A technetium-99m-labelled human serum albumin scan, which is purported to be a sensitive test for a protein losing enteropathy, was normal. Small bowel capsule endoscopy (Olympus, Tokyo, Japan), however, showed multiple small bowel ulcers, particularly in the ileal region (fi gure A and B). In view of the possible link between aspirin therapy and small bowel enteropathy, aspirin was withheld. A repeat capsule endoscopy 3 months later showed a few small healing erosions only (fi gure C and D). When last seen in July, 2006, our patient remained asymptomatic with no oedema or anaemia (haemoglobin 122 g/dL), and his serum albumin was 41 g/L. Small bowel injury is increasingly recognised to be an important complication of NSAID therapy. NSAIDs cause varying degrees of small bowel injury from increased intestinal permeability, intestinal infl ammation, protein loss, blood loss, and ulcerations, to perforation and diaphragm-like strictures. In our study, comparing the gastrointestinal tolerability of celecoxib with diclofenac and a proton pump inhibitor, we found that 30% of the serious gastrointestinal events were distal to the duodenum with one death due to small bowel perforation. Post-hoc analysis of a large-scale clinical outcome trial showed that lower gastrointestinal events accounted for 40% of all serious gastrointestinal events in patients on NSAIDs. The diffi culty in assessing the severity of NSAIDenteropathy was previously hampered by the lack of reliable tests for examining the small bowel. With the advent of capsule endoscopy and double balloon enteroscopy, small bowel injury can now be directly visualised. Capsule endoscopy corroborates the high prevalence of NSAID-enteropathy demonstrating that about 70% of regular NSAID users have small bowel erosions and ulcers. Here we illustrate a case of severe enteropathy induced by low-dose aspirin that has many striking similarities with NSAID-enteropathy. Although aspirin at anti-infl ammatory drug doses can cause stomach and duodenal ulcers, it is generally believed that aspirin does not cause any small bowel damage based on intestinal permeability and faecal infl ammatory marker studies. Our observation not only challenges the safety of aspirin on small bowel mucosa but also raises questions about the effi cacy of misoprostol as a prophylactic treatment against enteropathy. Low-dose aspirin, used for cardiovascular prophylaxis, is one of the most commonly prescribed medications worldwide. The demonstration of a severe form of enteropathy with this drug suggests the need to defi ne the extent of this potential problem. Increasing clinical awareness and appropriate early investigation are needed to establish the proper diagnosis.

MYCOPHENOLATE MOFETIL-INDUCED COLONIC ULCERATIONS IN RENAL TRANSPLANT PATIENTS

Introduction: Mycophenolate mofetil (MMF) is a common immunosuppressive agent used to prevent rejection in renal transplant patients. We report two cases of colonic ulcers associated with MMF in renal transplant recipients. Case Reports: Case #1: A 48-year-old Caucasian man who received a renal transplant in December 2002. His maintenance immunosuppression regimen included prednisone, sirolimus and mycophenolate mofetil (2 gm/day). After 8 months of immunosuppressive therapy he presented with melena and anemia. Patient denied use of aspirin and other non-steroidal anti-inflammatory medications. Colonoscopy with biopsy was performed which revealed a large solitary ulcer in the ascending colon. Pathology revealed necrotic debris and was negative for malignancy. Immunochemical stains and serology for cy-tomegalovirus (CMV) and herpes simplex virus (HSV) were also negative. The anemia resolved after discontinuation of MMF. Repeat colonoscopy two months later revealed complete resolution of the colonic ulcer. Case #2: A 51-year-old African American man who underwent renal transplant in 2002. His immunosuppressive regimen included tacrolimus, sirolimus, prednisone and MMF (2 gm/day). Two years later patient underwent colonoscopy for anemia and weight loss. Patient did not report overt symptoms of gastrointestinal bleeding. Colonoscopy revealed a medium sized ulcer in the cecum. Pathology showed acute ulceration with inflammation and no evidence of malignancy or viral infection. MMF dose was reduced to 1 gm/day with improvement of patient's anemia. Discussion: MMF is associated with various gastrointestinal (GI) side effects including nausea, vomiting and diarrhea. Gastro duodenal ulceration with bleeding has also been reported with the use of MMF, however development of colonic ulcers is rare and limited to case reports. The actual mechanism of MMF induced colonic ulcer is unknown. It has been hypothesized that colonic ulcers develop due to high levels of active MMF metabolites in the colon in patients with renal transplant. While infection, especially CMV colitis, remains the more common cause of colonic ulceration and lower GI bleeding in immunosuppressed renal transplant patients, MMF-induced colonic ulceration should be included in the differential diagnosis. Healing of the ulcer can occur with dose-reduction or discontinuation of the drug.