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Upper gastrointestinal bleeding is most commonly caused by lesions in the oesophagus, stomach or duodenum. In a minority of cases the bleeding originates from the pancreatic duct, and is known as haemosuccus pancreaticus. In many cases it is associated with chronic pancreatitis. Diagnostic strategies and therapeutic options are discussed.
Upper gastrointestinal bleeding is one of the commonest emergencies encountered by general physicians. Once haemodynamic stability has been achieved, therapeutic endoscopy is vital in control and arrest of bleeding. Various methods are available and the evidence is reviewed as to the most optimal approach. Clinical parameters including timing of endoscopy, risk stratification, and predictors of failure will also be discussed together with a summary of recommendations based on current available evidence.
Diffuse gastrointestinal bleeding in an immunodeficient patient is presented. Two hours after in vivo erythrocyte labeling, abnormal activity was observed in the wall of a distended colon. If this abnormal concentration had been luminal, a focal, surgically treatable lesion could not have been excluded. This pattern of hemorrhagic colonic lesions has been described pathologically, but not scintigraphically, in immune deficient patients.
Upper gastrointestinal bleeding from peptic ulcers is common. Advances in prognostication, therapeutic endoscopy, and medical management have evolved rapidly. Patients most likely to rebleed after therapy can now be identified and monitored more closely, and patients with ulcers of low risk for rebleeding can be managed on an outpatient basis. High-risk patients include those with ulcers containing a visible vessel or who are actively bleeding. Endoscopic therapy is mandatory in high-risk patients and involves at least two hemostatic techniques. Second-look endoscopy and repeated hemostasis should be performed promptly in patients who rebleed. Adjunctive treatment includes intravenous proton pump inhibitor administered in high doses for the first 72 hours after endoscopic therapy. Further studies are needed to determine the optimal combination of hemostatic techniques to better target patients who are at risk for ulcer rebleeding.
Lower gastrointestinal bleeding after aspirin intake was reported in a 64-year-old woman. Gastroscopy, colonoscopy and selective mesenteric angiography failed to reveal the source of hemorrhage; only a midgut malrotation was suggested by angiography. Small bowel enema finally demonstrated a blind sac on the antimesenteric border of the ileum, corresponding to a Meckel's diverticulum. This embryological remnant of the vitelline duct was associated with a mesenterium commune. Laparoscopy confirmed the small bowel study, and resection of the diverticulum was easily carried out. It is, to our knowledge, the first time that these developmental abnormalities have been preoperatively diagnosed together.
Occult gastrointestinal bleeding is diagnosed by using one of the commercially available fecal occult blood tests (FOBTs). Guaiac-based slide tests are most frequently used, although the more specific immunochemical methods are promising. The guaiac tests are inexpensive, nonspecific, qualitative measures of stool blood, and their use requires dietary and drug restrictions. Clinicians need to be aware of the causes of false-positive and false-negative test results. Although specific for the presence of human blood, immunochemical tests are more expensive and tend to react also to physiological quantities of blood in fecal specimens. Whichever test is chosen, it must be processed and read correctly. Annual FOBT screening for colorectal cancer, combined with periodic flexible sigmoidoscopy, is a cost-effective method of detecting early, curable colorectal cancer.
Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.
BACKGROUND: Lower gastrointestinal bleeding is a frequent cause of hospitalization, but diagnostic methods for this condition are not fully established. Transabdominal ultrasound is a widely accepted diagnostic tool in bowel diseases. AIM: To evaluate the usefulness of transabdominal ultrasound for lower gastrointestinal bleeding. METHODS: We reviewed the medical records of consecutive patients who underwent transabdominal ultrasound as the first diagnostic procedure for acute haematochezia during the period June 1999 to June 2004. The study group comprised 111 patients and all underwent colonoscopy thereafter. Detection and diagnosis of lower gastrointestinal bleeding by ultrasonographic examination were evaluated by comparing the ultrasound diagnosis with the colonoscopic findings and final diagnosis. RESULTS: The bleeding site was localized by colonoscopy in 90 of the 111 patients (81%). The bleeding site was localized by ultrasound in 59 of the 90 patients (66%). When the bleeding site was in the rectum, ultrasonographic detectability was 30% (10/33); ultrasonographic detectability was 82-100% when the bleeding site was elsewhere. Rectal bleeding and diverticular bleeding were difficult to diagnose by ultrasound, but for the other diseases, diagnosis by ultrasonographic examination was possible in 91-100% of cases. CONCLUSIONS: Ultrasonographic examination may be an effective screening method for lower gastrointestinal bleeding.
OBJECTIVE: To differentiate, among patients presented at the emergency department with acute upper gastrointestinal bleeding, those who need early urgent upper gastrointestinal endoscopy from those who do not. METHODS: Seventeen variables for each patient presenting with upper gastrointestinal bleeding were prospectively recorded and considered in a multivariate analysis. We used the presence of active bleeding during early urgent upper gastrointestinal endoscopy within 12 h from admission as the end point. The derived score was validated with data from the next consecutive patients presenting with upper gastrointestinal bleeding. RESULTS: Among 190 consecutive patients (mean age 63.7 +/- 16 years; 64.7% men), active bleeding was observed in 51 patients (26.8%). Four variables were identified as independent predictors (P < 0.05) of active bleeding in early urgent upper gastrointestinal endoscopy and were used for the derivation of the following integer-based scoring system: number of points = 6 (fresh blood in nasogastric tube) + 4 (haemodynamic instability) + 4 (haemoglobin < 8 g/dl) + 3 (white blood cell count > 12 000/microl). The validation study consisted of 110 patients (71 men; mean age 66.1 +/- 14 years; 28 patients [25.5%] with active bleeding). In this study, a cut off of < 7 points indicated absence of active bleeding and >/= 11 points indicated presence of active bleeding; this gave a sensitivity of 96%, specificity of 98%, positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS: Simple clinical and laboratory variables available at presentation can be used to differentiate patients with upper gastrointestinal bleeding who do not need an early urgent upper gastrointestinal endoscopy from those who do.
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OBJECTIVE: Obscure gastrointestinal bleeding from jejunal and ileal lesions remains undiagnosed using traditional imaging techniques (radiologic, endoscopic). This prospective study compares the diagnostic detection rate of small-bowel lesions using wireless video capsule endoscopy (VCE) with the detection rate using double-balloon enteroscopy (DBE) in patients with obscure gastrointestinal bleeding (OGIB). Tolerance, adverse events, endoscopic interventions, and prognosis were described as secondary aims. METHODS: Thirty-five consecutive patients with obscure gastrointestinal bleeding were evaluated (22 males and 13 females; mean age 63.2 yr; range, 19-86 yr). The detection rates of the Given M2A wireless VCE and DBE were compared. RESULTS: Small-bowel abnormalities were detected using VCE in 28 (80%) of the 35 patients with OGIB, compared with 21 (60%) of the 35 patients using DBE (p = 0.01). Both examinations were well tolerated, but VCE was more acceptable to patients. No major adverse event occurred after either examination. Biopsies (n = 27), argon plasma coagulation (n = 19), tattoo injection (n = 8), and polypectomy (n = 2) were feasible with DBE when indicated in 27 of the 35 patients (77%). During a median (range) follow-up period of 5 (2-12) months, 26 (74%) patients remained clinically stable and did not require blood transfusions after DBE procedures. Eighteen (51%) of those who remained clinically stable had received APC therapy. CONCLUSIONS: High detection rates of the causes of OGIB are feasible with VCE and DBE. Although the detection rate of VCE was superior, our results indicate that the procedures are complementary; an initial diagnostic imaging employing VCE might be followed by therapeutic and interventional DBE.
Upper-gastrointestinal bleeding may be related to tension or fear, which are commonly aggravating factors in digestive diseases. A survey was made of patients living in and around Hadera (located in Israel's central coastal region) during the Gulf War (January 18 through February 28, 1991) who suffered from upper-gastrointestinal bleeding; they were compared with patients seen during 1990 and 1992-1993 at the same time of the year. We found no appreciable difference in the rate of upper-gastrointestinal bleeding during the analogous periods covered in the survey.
BACKGROUND: Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy. PURPOSE: This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome. METHODS: Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed. RESULTS: The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding. CONCLUSION: Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.
The purpose of this research was to look for a possible mechanism whereby NSAIDs, and particularly ASA, might cause gastrointestinal bleeding. A total of 34 hospitalized GI bleeders and 29 age- and sex-matched controls were studied. Skin bleeding time (SBT) was measured within 6 h of coming to hospital and before any blood products were given. All patients and controls were questioned regarding current NSAID use. This history was supplemented by estimation of serum salicylate and of platelet cyclooxygenase activity to detect unreported current aspirin (ASA) use. Various aspects of platelet function were also tested by lumiaggregation in 28 controls and, after recovery, in 27 of the bleeders. Of 34 bleeders, 26 bled from the upper GI tract, (13 from peptic ulcer) and eight from the lower GI tract, 30 (88%) had a current intake of NSAIDs and of these 22 (73%) used ASA, some in combination with other NSAIDs, whereas 12 of 29 controls were using NSAID's, 11 of which were ASA. SBT in the bleeders was 9.0 +/- 1.02 min versus 4.8 +/- 0.42 min in the controls (p < 0.001). SBT measured 6.6 days later in 28 bleeders was 4.7 +/- 0.22 min (p < 0.0006), and of those tested after recovery all but one had fallen to 6.5 min or less. None had any residual constitutional platelet abnormalities as tested by lumiaggregation. By logistic regression, NSAID intake was strongly associated with prolonged SBT to > 6 min (odds ratio [OR], 16.7; p < 0.0002), whereas NSAID intake (OR 14.6; p < 0.0003) and SBT > 6 min (OR 1.8; p < 0.005) contributed to a bleeding outcome. Almost 90% of GI bleeders had recently consumed NSAIDs, mostly ASA, on an average 15 h before onset of bleeding. Although most of the nonbleeders who had used NSAIDs did not have a prolonged SBT, most of the bleeders who used NSAIDs had an abnormal elevation of SBT, suggesting a possible mechanism for GI bleeding. Retesting approximately 7 days after recovery from bleeding showed normalization of the SBT, indicating that the defect was transient and spontaneously reversible.
BACKGROUND: In patients with hereditary bleeding disorders, upper gastrointestinal bleeding presents a life-threatening complication, while the role of Helicobacter pylori (H. pylori) infection in this group of patients has not been fully clarified in the literature. The aim of the present study was to evaluate the role of H. pylori infection and of dental status in upper gastrointestinal bleeding in patients with hereditary hemorrhagic disorders (HHD). METHODS: Thirty-seven patients with HHD (18 patients with and 19 without a history of upper gastrointestinal bleeding) and 26 control patients without HHD, who were admitted to our hospital for elective gastroscopy due to dyspeptic symptoms, were included in the study. Endoscopy was performed on all patients with gastrointestinal bleeding and on controls. ELISA was used to detect IgG, anti-CagA, and IgA antibodies to H. pylori in the serum and saliva of patients and controls. Moreover, dental status was examined using the decayed/missing/filled teeth index (DMFT) in all subjects. The chi(2)-test was used for statistical analysis. RESULTS: Some 64.8% of the patients and 65.4% of the controls had H. pylori IgG antibodies in serum (P>0.1, NS) while 54.05% of the patients and 34.6% of controls were anti-CagA-positive in serum (P=NS). However, 83 and 26.3% of the HHD patients with and without gastrointestinal bleeding, respectively, were serum anti-CagA-positive (P<0.01) while 72 and 58%, respectively, were serum IgG-positive (P=NS). H. pylori antibodies in saliva and the DMFT calculated index did not differ between the two subgroups. Subsequently, all serum anti-CagA-positive HHD patients received 1-week of triple H. pylori eradication therapy with omeprazole, clarithromycin, and amoxicillin orally. During a 2-year follow-up, none of these patients reported upper gastrointestinal bleeding. CONCLUSIONS: Although no statistically significant difference in H. pylori infection was found between HHD and controls, the CagA strain appeared more frequently in those HHD patients with a history of upper gastrointestinal bleeding. Given our results and the limited data available in the literature, we would recommend anti-CagA screening and therapy to all patients with HHD. However, further studies with a longer follow-up and a greater number of patients are necessary.
BACKGROUND: Clinical trials have suggested that cyclo-oxygenase-2-selective inhibitors are associated with a lower risk of upper gastrointestinal bleeding than are non-selective, non-aspirin, non-steroidal anti-inflammatory drugs. This has not yet been confirmed in studies of patients with an increased susceptibility to upper gastrointestinal bleeding. AIM: To examine the risk of upper gastrointestinal bleeding in high-risk patients who filled prescriptions for cyclo-oxygenase-2 inhibitors or other non-steroidal anti-inflammatory drugs. METHODS: A population-based case-control study was performed in the Danish county of North Jutland from 1 January 2000 to 31 December 2002. From the County Hospital Discharge Registry and the Civil Registration System, we identified incident cases with upper gastrointestinal bleeding (n = 780) and randomly selected controls (n = 2906), respectively. All cases and controls had previous gastrointestinal diseases. Data on drug exposure were obtained from the countywide Prescription Database. RESULTS: Thirty-five cases (4.5%) filled prescriptions for cyclo-oxygenase-2 inhibitors within 30 days of the date of upper gastrointestinal bleeding, compared with 79 controls (2.7%). Adjusted odds ratios for upper gastrointestinal bleeding according to prescription for celecoxib, rofecoxib and non-steroidal anti-inflammatory drugs were 1.3 [95% confidence interval (CI), 0.7-2.8], 2.1 (95% CI, 1.2-3.5) and 3.3 (95% CI, 2.4-4.4), respectively. CONCLUSIONS: In patients with increased susceptibility to gastrointestinal adverse events, a lower risk of upper gastrointestinal bleeding was observed in users of cyclo-oxygenase-2 inhibitors compared with users of other non-aspirin, non-steroidal anti-inflammatory drugs.
Gastrointestinal (GI) bleeding is a common and important problem for all clinicians. Patients may present with signs of bleeding, such as hematemesis, melena, or hematochezia. The patient must first be hemodynamically stabilized. Initial assessment of patients with GI bleeding includes thorough history taking and physical examination. Patients with acute bleeding or an unstable condition must be resuscitated immediately and the source of bleeding must be localized to the upper or lower GI tract. Panendoscopy is often the initial diagnostic test and is useful to stop GI bleeding, at the same time.
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.