Tract Bleeding Research Articles

Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration. To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo. A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies. A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery. LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

Sorafenib plus partial splenic embolism for treatment of hepatocellular carcinoma Barcelona stage C combined with hypersplenism: a case series.

BackgroundSorafenib is mainly used to treat patients with hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer (BCLC) stage C, many of whom also have severe cirrhosis. However, hypersplenism and digestive tract hemorrhage are common complications of cirrhosis, which increase the risk and difficulty of treatment.MethodsNineteen patients with HCC BCLC stage C with hypersplenism were treated with sorafenib plus partial splenic embolism at Chongqing University Cancer Hospital, Chongqing, China, between January 2015 and June 2018. We analyzed the therapeutic effect and clinical safety of this treatment in these patients.ResultHypersplenism was rectified in all patients. The incidence rates of hemorrhage and myelosuppression were 0%, and the mean survival time was 11.2 months.ConclusionSorafenib plus partial splenic embolism could relieve hypersplenism and prolong survival in patients with BCLC stage C HCC.

Effectiveness of a Standardized External Ventricular Drain Placement Protocol for Infection Control

Placement of an external ventricular drain (EVD) is a common procedure routinely completed at bedside by neurosurgical residents. A standardized protocol for placement and maintenance of an EVD is potentially useful. This single-institution retrospective review analyzed all patients who underwent placement of an EVD over a 5-year span using a standardized protocol. A total of 428 EVDs in 381 patients were placed as per this protocol. Overall compliance with the practice protocol was 98.7%. Overall, our infection rate was 1.86% (8 external ventricular drain-related infection [ERIs] over 428 EVDs). There was no difference in age for the ERI cases (median 55, range (50.5-60.5), compared with the non-ERI cases (median of 53, range [38-65]) (P= 0.512). Indications for placement of EVD were hemorrhage (51.9%, n= 198), tumor (16.2%, n= 62), trauma (12.8%, n= 49), hydrocephalus (11.5%, n= 44), cerebellar stroke (2.8%, n= 11), infection (3.1%, n= 12), unknown (1.3%, n= 5). Most EVDs (77.6%, n= 296) were placed bedside by second-year residents (median PGY level 2, interquartile range 1-2.75). Computed tomography confirmed placement in the ipsilateral frontal horn in 72% (n= 277) of EVDs. EVD-related complications were noted in 8.3% of EVDs (n= 32, with 8 infections and 24 tract hemorrhages). The median EVD duration was 10 days; duration of EVD had no statistically significant impact on the risk of an ERI (P= 1). Only replacement of an EVD was associated with an increased risk of infection. Adherence to a standard EVD placement protocol is useful in maintaining a low risk of ERI regardless of the duration of catheter utilization. Replacement of the catheter through the same access hole as the original catheter is associated with an increased risk of ERI.

Web-Based Educational Intervention for Patients With Uninvestigated Dyspepsia Referred for Upper Gastrointestinal Tract Endoscopy

Diagnostic yield of upper gastrointestinal (GI) tract endoscopy for uninvestigated dyspepsia is low, and its clinical implications are limited. There is an unmet need for better strategies to reduce the volume of upper GI tract endoscopic procedures for dyspepsia. To study the effectiveness of a web-based educational intervention as a tool to reduce upper GI tract endoscopy in uninvestigated dyspepsia. This open-label, multicenter, randomized clinical trial enrolled participants between November 1, 2017, and March 31, 2019, with follow-up 52 weeks after randomization, at 4 teaching hospitals in the Netherlands. Participants included patients with uninvestigated dyspeptic symptoms who were referred for upper GI tract endoscopy by their general health care clinician without prior consultation of a gastroenterologist. A total of 119 patients, aged 18 to 69 years, were included. Patients were excluded if any of the following red flag symptoms were present: (indirect) signs of upper GI tract hemorrhage (hematemesis, melena, hematochezia, or anemia), unintentional weight loss of 5% or higher of normal body weight during a period of 6 to 12 months, persistent vomiting, dysphagia, or jaundice. Patients were randomly assigned (1:1) to education (intervention) or upper GI tract endoscopy (control). Education consisted of a self-managed web-based educational intervention, containing information on gastric function, dyspepsia, and upper GI tract endoscopy. Difference in the proportion of upper GI tract endoscopy procedures between those who received access to the web-based educational intervention and those who did not at 12 weeks and 52 weeks after randomization, analyzed in the intention-to-treat population. Secondary outcomes included quality of life (Nepean Dyspepsia Index) and symptom severity (Patient Assessment of Gastrointestinal Disorders Symptom Severity Index) measured at baseline and 12 weeks. Of 119 patients included (median age, 48 years [interquartile range, 37-56 years]; 48 men [40%]), 62 were randomized to web-based education (intervention) and 57 to upper GI tract endoscopy (control). Significantly fewer patients compared with controls underwent upper GI tract endoscopy after using the web-based educational intervention: 24 (39%) vs 47 (82%) (relative risk, 0.46; 95% CI, 0.33-0.64; P < .001). Symptom severity and quality of life improved equivalently in both groups. One additional patient in the intervention group required upper GI tract endoscopy during follow-up. Findings of this study indicate that web-based patient education is an effective tool to decrease the need for upper GI tract endoscopy in uninvestigated dyspepsia. ClinicalTrials.gov Identifier: NCT03205319.

Dieulafoy’s lesion of the upper GI tract: a comprehensive nationwide database analysis

We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States. UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables. The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P= .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P< .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P< .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P< .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P< .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P< .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P< .05) readmissions. The rate of successful endoscopic treatment was 96.81%. UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.

Plasma Exchange to Treat Cytokine Release Syndrome and Immune Effector Cell-Associated Neurotoxicity Syndrome after Anti-CD19 Chimeric Antigen Receptor-T Cell Infusion: A Case Report

Adoptive cell immunotherapy with chimeric antigen receptor-T (CAR-T) cells has shown remarkable clinical outcomes. However, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are the two most significant toxicities during this therapy and can be life-threatening. We described a 12-year-old juvenile who had been diagnosed with relapsed and refractory B-cell acute lymphocytic leukemia (r/r B-ALL). The patient was recruited into our phase I clinical trial concerning ssCAR-T-19 (anti-CD19 CAR-T cells with shRNA targeting IL-6), and 5*106 /kg of engineered ssCAR-T-19 cells were administered. After infusion, the patient underwent a typical CRS reaction, with fever and increased cytokine levels. He was treated with antipyretic drugs, methylprednisolone, and tocilizumab, but the effect was limited. He developed coagulation abnormalities, multiple organ dysfunction, lung infection and ICANS. Apart from the necessary supportive and symptomatic treatment, plasma exchange was performed three times in four days while methylprednisolone pulse was performed for two consecutive days. After that, the body temperature, heart rate, and especially the cytokine levels declined. But digestive tract hemorrhage occurred to him and he was transferred to intensive care unit. To make things worse, he developed acute respiratory failure and received intubation and mechanical ventilation. In addition, symptomatic treatment such as suppression of stomach acid and anti-infection was given. The bleeding was controlled, and his respiratory function improved, and the CRS and ICANS-related symptoms were relieved. He received extubation and was transferred back to the general ward. Additionally, abone marrow smear showed no lymphoblast cells, and minimal residual disease in bone marrow was negative on day +22 and day +30. The patient was eventually discharged in a normal condition. In conclusion, CRS and ICANS as two most common toxicities after CAR-T therapy, which often cause patient death. Several methods such as anti-IL-6 therapy and/or corticosteroids have been adopted in the management guidelines of CRS and ICANS except plasma exchange. This case shows the validity of plasma exchange in a patient with severe CRS and ICANS after receiving ssCAR-T.

Endoscopic Findings and Their Clinical Relevance in 208 Diagnostic Esophagogastroduodenoscopies Made at Guadalajara’s Regional Military Specialty Hospital From September 2018 to March 2020

This technical review provides practical and basic information on the clinical relevance of proximal diagnostic digestive endoscopy in relation to pre- and post-endoscopic diagnoses, anatomopathological diagnosis of biopsies, choice of appropriate treatment and improvement of patients studied. It also highlights the importance of the prevention of esophageal-gastric cancer by previous macroscopic findings and its timely diagnosis, based on 208 reports of Esophagogastroduodenoscopies recorded in the general file database of the Guadalajara Regional Military Specialty Hospital between September 2018 and March 2020. Of the 208 selected reports, the most common pre-endoscopic diagnoses were dyspepsia, gastro-esophageal reflux disease, high digestive tract hemorrhage and dysphagia, which were mostly associated with endoscopic diagnosis of chronic gastropathy being the crucial anatomopathological diagnosis by demonstrating that the bacterium Helicobacter Pylori is primarily responsible for this gastropathy and in initiating

The Congenital Absence of the Portal Vein

Congenital absence of the portal vein (CAPV) is a rare defect often accompanied by other abnormalities such as heart defect, skeletal anomalies and / or liver tumors [1]. We describe here a case of CAPV revealed by an upper gastrointestinal tract hemorrhage in a child aged 02 years and 8 months. The esogatro-duodenal fibroscopy revealed the presence of Esophageal varices grade II, abdominal ultrasound revealed a large liver with no visualization of the spleen. Subsequent abdominal computed tomography revealed the presence of a spleno-mesaraic trunk measuring 7 mm in anteroposterior diameter receiving the inferior and superior mesenteric vein and a small splenic vein draining by dilated peri-gastric and peri-esophageal leads. Associated with splenic hypoplasia and portal trunk atresia. The rest of the malformative assessment was negative

Tranexamic acid for upper gastrointestinal bleeding

Background. In patients with trauma and significant bleeding or risk of significant bleeding it is advised to administer tranexamic acid (TXA) intravenously as early as possible at a loading dose of 1 g for 10 minutes, followed by 1 g for 8 hours. The effectiveness of TXA has been proven in various pathological conditions in large trials. TXA has been shown to reduce the need for blood transfusions.&#x0D; Objective. To describe the use of TXA for upper gastrointestinal tract (GIT) bleeding.&#x0D; Materials and methods. Analysis of literature sources on this topic.&#x0D; Results and discussion. The mechanism of TXA action is to inhibit plasminogen activation and reduce fibrin degradation, however, its features are not clear. With the use of TXA, the strength of the blood clot and its resistance to lysis increases. The use of TXA in gastrointestinal bleeding was analyzed in the Cochrane Review (2012) of seven randomized controlled trials involving 1,654 patients. TXA was compared with placebo, lansoprazole or cimetidine. There was a lower mortality in the TXA group, however, after taking into account possible bias, this trend did not persist. A randomized placebo-controlled study of HALT-IT included 12,009 patients with gastrointestinal bleeding who were prescribed TXA (loading dose of 1+3 g for 24 hours) or placebo. The primary endpoint was death from bleeding within 5 days. There were no differences in mortality or re-bleeding. The TXA group had a higher frequency of deep vein thrombosis and pulmonary embolism. One of the reasons for the lack of benefits of TXA in gastrointestinal bleeding is that the onset of such bleeding is difficult to detect immediately, and to achieve the effect of TXA as early as possible administration is necessary. In this case, &gt;80 % of patients sought medical help &gt;3 hours after the onset of bleeding. In addition, in 50 % of patients, the bleeding was due to esophageal varices due to liver disease. It is known that most coagulation factors are synthesized in the liver, so liver failure is a common cause of coagulopathies. When the liver is affected, the levels of vitamin-K-dependent procoagulants (coagulation factors II, VII, IX and X), coagulation factor V, as well as anticoagulants (proteins C and S, antithrombin) decrease. Levels of fibrinogen and acute phase proteins remain normal or increase. In case of liver failure, hyperfibrinolysis occurs and at the same time the risk of thrombosis increases significantly. In such patients there is a decrease in hemostatic blood reserve. In general, contraindications to the use of TXA include severe renal failure, seizures, disseminated intravascular coagulation without bleeding, arterial or venous thromboembolism, active bleeding from the upper urinary tract.&#x0D; Conclusions. 1. TXA is effective for most types of bleedings, however, there are some exceptions. 2. One should remember the side effects of TXA and follow the recommended method of administration. 3. TXA is not suitable for the treatment of gastrointestinal bleeding.

S3542 Ulcerative Roux Limb Jejunitis: Unusual Finding on Endoscopy

INTRODUCTION: Obesity is a common health issue in the United States. Roux-en-Y Gastric Bypass (RYGB) is most frequently performed in the US. Although, it has promising effects on weight loss but overall complication rate is 21% (1). We present a unique case of ulcerative roux limb jejunitis. CASE DESCRIPTION/METHODS: 38 y/o female with a history of RYGB 13 yrs ago presented with LUQ abdominal pain and dark stools of one day's duration. She took Motrin and drank a large quantity of alcohol 4 days prior to presentation. Subsequently, she began been having intermittent LUQ abdominal discomfort with loss of appetite and nausea. She had no history of GI bleed. Her last endoscopy and colonoscopy in 2015 were normal. She smokes cigarettes 1 PPD, is a social drinker, and has no history of IVDA. Abd exam was positive for LUQ tenderness but no rebound tenderness. DRE was negative for melena. Labs showed Hb 14.8, BUN/Cr 5/0.5, AST/ALT 153/121, lipase 1053, lactic acid 2.3, vit B12 169, ANA/ASMA/ESR/viral hepatitis panel/EtOH/fibrin split products/UDS normal. CT abdomen pelvis with IV contrast showed bowel wall thickening and inflammatory change surrounding the loop of bowel emanating from the bypass. Esophagogastroduodenoscopy (EGD) showed inflammation involving the gastric pouch and extending from the gastrojejunal anastomosis (at 45 cm) to involve almost the entire roux limb (about 35 – 40 cm in length). It was characterized by marked edema, erythema, friable mucosa with erosion and ulceration. There was a short afferent limb with inflammation. The jejunojejunal anastomosis was normal at about 90cm. Biopsies were taken and histopathology showed acute inflammation. Based on the EGD findings, ischemia was a concern but CTA abdomen and pelvis were unremarkable. Her Hb remained stable during the hospital course and she was discharged with outpatient follow up with GI and surgery. DISCUSSION: RYGB is associated with early and late postoperative complications which include anastomotic leak, ileus, GI tract hemorrhage, anastomotic stricture, bowel obstruction, intussusception, and marginal ulceration. However, extensive jejunitis both involving the entire roux limb and confined to the roux limb has rarely been reported. NSAID and heavy alcohol consumption were thought to be the culprit in light of negative CTA abdomen.Figure 1.: GastroJejunal Anastomosis showing friable mucosa, ulceration, erosions, and extensive inflammation.Figure 2.: Roux limb showing extensive inflammation and hemorrhagic appearance.Figure 3.: Roux limb showing extensive inflammation.

Magnesium and Risk of Bleeding Complications From Ventriculostomy Insertion.

Hemorrhages are a serious complication of brain surgery, and magnesium has shown hemostatic properties in hemorrhagic stroke and non-neurological surgeries. External ventricular drain (EVD) insertion is an advantageous model of emergency neurosurgical hemorrhage risk because it is common, standardized, and the operator is blinded to the outcome during the procedure. We tested the hypothesis that low magnesium is associated with risk of hemorrhagic complications from EVD insertion. Patients with spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage were enrolled in a prospective, observational study. Demographic and clinical variables were prospectively recorded, including serum magnesium measurements. Catheter tract hemorrhage (CTH) was measured on postoperative head computed tomography within 48 hours of EVD insertion. We observed 50 CTH among 327 EVD procedures (15.3%) distributed similarly among intracerebral hemorrhage (21/116 [18.1%]) and subarachnoid hemorrhage (29/211 [13.7%]). Magnesium was lower in patients with CTH compared with those without (median 1.8 versus 2.0 mg/dL, P<0.0001). Higher magnesium was associated with lower odds of CTH (odds ratio 0.67 per 0.1 mg/dL magnesium [95% CI, 0.56-0.78], P<0.0001) after adjustment for other risk factors, with similar effect in the intracerebral hemorrhage and subarachnoid hemorrhage subgroups. Preprocedural increase in magnesium (odds ratio 0.68 [0.52-0.85]) and dose of preprocedural magnesium sulfate (odds ratio 0.67 [0.40-0.97]) were associated with reduced CTH risk after adjustment for initial magnesium and other risk factors. Lower magnesium at the time of EVD insertion was an independent predictor of hemorrhagic complications. Baseline risk was attenuated by preprocedural increases in magnesium, suggesting a therapeutic opportunity.

Clinical profile and colonoscopic findings in patients with lower gastrointestinal haemorrhage: a descriptive cross-sectional study

Background: Most of the bleeding in the lower gastrointestinal tract are usually located in the rectum, colon and terminal ileum. Colonoscopy is an invasive procedure used for both diagnostic and therapeutic purposes for detection of lower gastrointestinal (GI) tract pathologies and haemorrhage.&#x0D; Aims and Objective: The purpose of the study was to understand the clinical profile and colonoscopic findings in patients with lower gastrointestinal haemorrhage.&#x0D; Materials and Methods: Seventy-two patients presenting with lower GI haemorrhage were included in the study. All patients underwent colonoscopy after achieving hemodynamic stability and bowel preparation. Clinical profile and colonoscopic findings were studied.&#x0D; Results: The common aetiologies of lower GI haemorrhage were haemorrhoids followed by nonspecific colitis, colorectal polyp and carcinoma of colon. Rectum followed by sigmoid harbored majority of pathologies that presented with lower GI haemorrhage.&#x0D; Conclusions: The diagnosis of the pathological lesion and management of underlying cause not only prevents another episode of lower GI haemorrhage but also help in reducing morbidity and mortality. Colonoscopy or at least sigmoidoscopy is strongly recommended for evaluation, diagnosis and management of lower GI haemorrhage.

Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: A report of 11cases

Objective: This study aims to summarize a clinical experience on the diagnosis and treatment of acute graft-versus-host disease (aGVHD) after liver transplantation.Methods: Between April 2005 and August 2016, 11 recipients who underwent OLT developed aGVHD with clinical symptoms of fever, rash, diarrhea and pancytopenia. T lymphocyte chimerism was detected though STR-PCR. These patients were treated with immunosuppressant adjustment, methylprednisolone, basiliximab, etc. All the results were recorded and summarized.Results: We demonstrated the diagnostic criteria of aGVHD based on our experiences: 1 aGVHD occurred from two weeks to two months after the liver transplantation. Fever, rash, digestive tract symptoms and bone marrow suppression were the four symptoms that appeared in any orde, All the percentages of donor T lymphocytes of aGVHD patients were more than 10%. All 11 recipients underwent treatments including immunosuppressant adjustment, glucocorticoids, IVIG and organ function support. Among these recipients, two survived due to successful treatment, while nine recipients died due to infection and cerebral and digestive tract hemorrhage. It is noteworthy that the occurrence of aGVHD was related to the dose of immunosuppressive agents, and we suggest the concept of “aGVHD induced by immunosuppression”.Conclusions: The diagnostic criteria of aGVHD is mainly based on time, clinical symptoms, T-lymphocyte chimerism and histopathology. The concept of “aGVHD induced by immunosuppression” provides important guidance in immunosuppressant management, control, and prevention of infection. Support treatment is very important in the treatment of aGVHD.

Conventional angiography findings in hemodynamically unstable patients with acute abdominal hemorrhage and a negative CT bleeding study

BackgroundCT bleeding study (CTA) is regularly requested in acute abdominal haemorrhage (AAH) with haemodynamic instability by clinical teams and interventional radiologists because CTA can; detect arterial bleeding at low rates of hemorrhage, accurately localize the bleeding point and characterize the etiology.How best to manage an unstable patient who has an AAH with a haematoma and no acute vascular findings on CTA represents a difficult clinical scenario for treating physicians and Interventional Radiologists.PurposeTo review the conventional angiography (CA) findings and clinical outcome of hemodynamically unstable patients with AAH who had a preceding negative CTA.Materials and methodsAll patients who were hemodynamically unstable and underwent CTA and CA for acute arterial abdominal hemorrhage at our institution between 01/01/2010 and 31/12/2017 were identified. Patients with obstetric, penetrating trauma, abdominal aortic or venous sources of hemorrhage were excluded. Patients who had a negative CTA before CA were included. Patient medical records were reviewed for clinical outcome.ResultsIn the study period 160 hemodynamically unstable patients underwent 178 CA procedures. 155 CA procedures were preceded by CTA. 141 CTAs demonstrated active bleeding or an abnormal artery. 14 CTAs in 13 patients demonstrated hematoma but no acute bleeding (mean age = 56-years; M:F, 12:1). Eight of the 14 CA studies demonstrated: active bleeding (n = 4), pseudoaneurysm (n = 1) or a truncated artery (n = 3). Cases of renal hemorrhage demonstrated a significantly higher proportion of false negative CTA studies (36%). Selective (n = 8) or empiric (n = 4) embolization was performed in twelve cases. All patients stopped bleeding and there were no mortalities.ConclusionIn a cohort of hemodynamically unstable patients, 57% (8/14) of cases with no acute vascular findings on CTA demonstrated a source of hemorrhage on CA. The false negative rate of CTA was significantly higher for renal tract hemorrhage compared to other sites of bleeding.

Cápsula endoscópica para el diagnóstico de metástasis de melanoma en intestino delgado, reporte de dos casos y revisión de la literatura

Malignant melanoma is the neoplasm that most frequently produces metastasis at the gastrointestinal tract. Metastatic lesions can be found in the small bowel in 50 to 60% of the necropsies of patients who die due to malignant melanoma; however, the diagnosis of metastasis in vivo is achieved in less than 10% of patients with this clinical entity. The capsule endoscopy is considered an excellent non-invasive diagnostic method for the evaluation of the small bowel in this group of patients. All patients with melanoma history and gastrointestinal tract hemorrhage, iron deficiency anemia, abdominal pain and / or unexplained weight loss should perform an capsule endoscopy to rule out small bowel involvement. We present two patients with cutaneous melanoma with apparent remission who develop iron-deficiency anemia, without a history of evident gastrointestinal bleeding with negative endoscopic examinations and capsule endoscopy findings of intestinal metastasis due to melanoma.

Surgical Treatment of Tensile Effusion in Postoperative Cavity after Glioma Resection

Objectives: To explore the clinical surgical methods for the treatment of tensile effusion in postoperative cavity after glioma resection. Methods: Clinical data of 26 cases of tensile effusion in postoperative cavity after glioma resection were analyzed retrospectively. All 26 patients underwent surgical treatment, including 16 cases who underwent puncture and drainage (P&amp;D), and 10 cases who underwent craniotomy decompression (CD). Among the cases of P&amp;D, postoperative cavity in 7 cases were punctured through the burr hole for creating the skull flap for intraoperative resection of glioma, and postoperative cavities in 9 cases were punctured through a burr hole for the dura mater suspended under the skull flap. Glasgow Coma Scale (GCS) was used to evaluate the consciousness status of the two groups of patients before and after surgery. Moreover, time of operation, intraoperative blood loss, postoperative hospital duration, and postoperative complications were also adopted for evaluation of the merits of the two methods for treatment of tensile effusion in postoperative cavity after glioma resection. Results: The consciousness of the patients in both groups improved within 24 hours after the operation, and there were no death cases. In the P&amp;D group, the GCS score within 24 hours after surgery was (14.38±0.20), the time of operation time was (7.81±0.64) mins, intraoperative blood loss was (6.25±0.56) ml, and postoperative hospital duration was (6.69±0.54) days. There were 3 cases with postoperative complications (1 case of puncture tract hemorrhage, 1 case of subdural hematoma and 1 case of intracranial infection) in the P&amp;D group. All of the puncture tract hemorrhage and subdural hematoma did not require surgical treatment, and the intracranial infection was cured after antibiotic treatment and lumbar puncture for cerebrospinal fluid replacement. In the CD group, the GCS score within 24 hours after surgery was (13.70±0.21), the time of operation was (124.10±8.96) mins, intraoperative blood loss was (260±30.55) ml, and postoperative hospital duration was (11.30±0.60) days. There were 2 cases with postoperative complications (both of them were with subdural hematoma), none of which required surgical treatment. The GCS score, time of operation, intraoperative blood loss and postoperative hospital duration in the P&amp;D group were better than those in the CD group (P &lt; 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P &gt;0.05). Conclusion: The P&amp;D and CD for tensile effusion in postoperative cavity after glioma resection can both achieve ideal results, but P&amp;D in line with the concept of micro-invasive neurosurgery was better than CD in terms of postoperative GCS score within 24 hours, duration of operative, intraoperative blood loss, and postoperative hospital duration.

Postpartum Haemorrhages: Targeting Mid-Genital Tract Anatomy

Mid-genital tract has some disadvantages in terms of both anatomy and physiology for controlling postpartum haemorrhage. The aetiology of postpartum haemorrhage is classified as 4Ts (tonus, tissue, trauma and thrombin). However, in 4T classification, different anatomic and physiologic characteristics of the genital tract are not taken into consideration. This critique suggests a modified nomenclature by adding specific anatomic location to etiologic information and aims to focus on postpartum mid-genital tract haemorrhages for the advanced learning. We have also discussed our approach to the mid-genital tract bleedings in an attempt to contribute to an improved management. Keywords: Postpartum haemorrhage; uterine atony; placenta previa; placenta adhesion spectrum; genital trauma Special Issue of Health Sciences DOI: 10.7176/JSTR/6-03-26

Protocolo diagnóstico y terapéutico de la hemorragia digestiva alta en urgencias

Upper digestive tract hemorrhage is a common emergency appearing as hematemesis or melena. Peptic ulcer disease and digestive gastrointestinal bleeding secondary to portal hypertension (PHT) are the commonest causes. The main goals of initial management are: to achieve hemodynamic stability, to stage the risk, to determine the most likely etiology and to begin medical treatment according with suspicion. In order to confirm diagnosis and to perform therapeutic maneuvers, early endoscopy has to be carried out (in less than 24hours). If etiology is a peptic ulcer, treatment will be based on high-doses of proton pump inhibitors, and therapeutic endoscopy in presence of injuries at high risk for rebleeding. Vasoactive and antibiotic drugs as well as endoscopic band ligation are mandatory in the cases of esophageal varices caused by PHT; intrahepatic portosystemic shunt will be taken for refractory cases.

Letter: Ventricular Catheter Tract Hemorrhage as a Risk Factor for Ventriculostomy-Related Infection.

Letter: Ventricular Catheter Tract Hemorrhage as a Risk Factor for Ventriculostomy-Related Infection.

The Use of Haemostatic Agents in Percutaneous Nephrolithotomy: A Systematic Review

Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large renal and ureteric stones. A nephrostomy tube is often inserted post-operatively to reduce complications such as tract haemorrhage and infection. However, nephrostomy tubes cause significant discomfort, increasing both analgesic requirements and length of inpatient stay. Whilst tubeless PCNL has been shown to be safe in low-risk patients, the risk of above complications remains. To address these concerns, clinicians have trialled applying haemostatic agents (HA) to the tract, with varied results. We aim to determine if HA are safe and clinically beneficial in PCNL. Systematic review of literature yielded 97 original research articles. Seventeen papers were deemed suitable after abstract screening and eligibility criteria application. These 17 research studies compared either tubeless PCNL vs PCNL with HA or PCNL with nephrostomy tube vs PCNL with HA. Within these studies a wide range of HA with differing mechanisms were used. Outcomes compared, where available, included bleeding (as determined by Hb drop or transfusion rates), pain scores, analgesic requirements, length of hospital stay and complication rates. We conclude that low-risk patients undergoing tubeless PCNL are unlikely to benefit from HA. However, potential remains in using HA to complement or replace nephrostomy tube in patients with significant intraoperative bleeding. Further studies are required to determine the optimal patient demographic who may benefit from HA, with a focus on cost-benefit analysis. Whilst HA were found to be safe, concerns remain regarding inadvertent collecting system injection and long-term effects, as well as increased cost.