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Other than gastrointestinal bleeding, there are few clinical emergencies the successful management of which is so dependent on the setting of priorities. Sequential attention to resuscitation, localization, specific diagnosis, and definitive therapy at a pace proportional to the rate of blood loss results in a satisfactory outcome in most patients who present with lower gastrointestinal bleeding.
Gastrointestinal bleeding has been proposed to be a contributing factor in the development of 'runner's anaemia'. To study the incidence of gastrointestinal bleeding, 2-3 prerace and 2-3 postrace faecal samples from 63 marathon runners were tested for the presence of blood. Five of the participants had faecal blood before but not after the race. A reasonable explanation for the bleeding was found for four. Eight runners (13%) had positive tests for faecal blood after the competition. Clinical investigation disclosed no gastrointestinal disease. Postrace haematuria was discovered in another 13% of the runners. None of the runners observed overt gastrointestinal bleeding or haematuria, nor did anyone develop anaemia. Gastrointestinal disturbances related to running were reported by 54%. It is concluded that gastrointestinal complaints and gastrointestinal bleeding are prevalent among marathon runners.
BACKGROUND/AIMS: Acute upper gastrointestinal bleeding is a common and potentially life-threatening medical emergency. Various factors modulating morbidity and mortality on upper gastrointestinal bleeding have been reported. However, there are no reports on the prognosis of bleeding ulcers on the anterior wall of corpus (on fundus-corpus junction, 10-15 mm from the lesser curvature) bleeding ulcers on the anterior wall of the corpus. Thus, in this trial we tried to investigate the role of bleeding ulcers on the anterior wall of the corpus on acute upper gastrointestinal bleeding mortality and morbidity. METHODS: One hundred seventy-seven (63 women and 114 men, mean age 52 years) patients with a clinical diagnosis of upper gastrointestinal bleeding were endoscoped between August 1999 and December 2002. All patients were treated endoscopically, medically or with surgery. The site of the bleeding was noted and compared regarding rebleeding and mortality rates. RESULTS: 50% (3/6) of the patients with bleeding ulcers on the anterior wall of the corpus required further surgical procedure or were associated with mortality, but only 7% (12/171) of the patients with bleeding sites other than bleeding ulcers on the anterior wall of the corpus had mortality or required further surgical intervention (p<0.05). Recurrent bleeding occurred in 50% (3/6) of our patients with bleeding ulcers on the anterior wall of the corpus during their hospitalization compared to 7.60% (13/171) (p<0.05) of patients with bleeding sites other than bleeding ulcers on the anterior wall of the corpus. CONCLUSIONS: Bleeding ulcers on the anterior wall of the corpus is indicative of recurrence or persistence of the hemorrhage and of greater mortality. Bleeding from this site needs more aggressive and diligent care.
Obscure gastrointestinal (GI) bleeding is a common but frustrating disease for clinicians because of its elusive nature despite extensive work-up. We evaluate the role of helical computed tomography (CT) imaging using rapid infusion of intravenous contrast and water as oral contrast in the work-up of patients who are actively bleeding. Helical CT may be a useful noninvasive, alternative study to consider when routine work-up fails to determine the cause of active GI bleeding. Our preliminary study shows that helical CT was able to identify a wide variety of causes of obscure GI bleeding.
Obscure gastrointestinal (GI) bleeding is relatively common but difficult to manage. By definition, diagnosis of a specific etiology is particularly challenging. We report the diagnostic use of provocative angiography in a patient with recurrent obscure GI bleeding. Although provocative angiography led to localization of bleeding and allowed specific treatment (placement of a 2-mm long, 0.010-inch diameter platinum coil, resulting in cessation of bleeding for 2 months), ultimately, the use of provocative angiography delayed specific diagnosis in our patient. We conclude that provocative angiography is a potentially powerful adjunct in the management of obscure GI bleeding, but that caution is required when using it. Provocative angiography should be reserved for patients who have had adequate imaging studies with negative results.
Occult gastrointestinal (GI) bleeding from small-bowel tumors is relatively uncommon, and bleeding from neural tumors is rare. A case of chronic bleeding from a ganglioneuroma that led to ileal ulceration is presented. This case documents the important role of exploratory celiotomy and thorough exploration of the abdomen in carefully selected patients with occult GI blood loss. In this case, a complete preoperative evaluation was negative, but a nondirected celiotomy resulted in diagnosis and successful treatment.
Nonvariceal upper gastrointestinal bleeding (NVUGIB) remains an important cause of morbidity and mortality. The etiological role and the relative risk of nonsteroidal anti-inflammatory drugs (NSAIDs) in association with other clinical factors are the focus of several papers published in the last year. Data from studies that evaluate the interaction of NSAIDs with Helicobacter pylori suggest that there is a clear role for eradication in aspirin-related bleeding. Although the benefit of H. pylori eradication in nonaspirin NSAID-related bleeding is being debated, they should both be eliminated given their relative contribution to the causation of peptic ulcer hemorrhage. The search for reliable and accurate tools to predict outcomes after NVUGIB continues. Recent important contributions in this area of research are the use of a clinical prediction guide to identify patients who are likely to require endoscopic intervention, and the use of Doppler ultrasound examination of the ulcer base to predict rebleeding. The role of antisecretory therapy in the setting of acute NVUGIB has been revisited in two meta-analyses and one randomized, placebo-controlled trial of omeprazole as an adjunct to endoscopic intervention. Until more definitive data are available, it appears that the effect of acid-decreasing medications is more important when endoscopic therapy is not provided than when effective endoscopic intervention is instituted. With regard to therapeutic endoscopy for upper gastrointestinal bleeding, the few randomized trials that have been published in full form in the last year focus on the use of mechanical methods of hemostasis for peptic ulcer bleeding and other etiologies such as Mallory-Weiss tears and Dieulafoy lesions.
Gastrointestinal bleeding remains one of the most challenging areas in medicine today, especially in the patient with cancer. New techniques and technology have added much to the diagnosis and management of gastrointestinal bleeding. Although gastroenterologists remain at the center of the evaluation of these patients, the incorporation of new techniques has meant that interventional radiologists and nuclear medicine specialists often have important roles in assessing and treating these patients as well. Because patients with cancer are members of a unique group, gastrointestinal bleeding may also require intervention by surgical oncologists, medical oncologists, and radiation oncologists. This review will address the multidisciplinary approach required for the proper diagnosis and management of gastrointestinal bleeding in patients with cancer.
BACKGROUND & AIMS: Unlike in upper tract bleeding, prognostic factors for ongoing or recurrent bleeding from the lower gastrointestinal tract have not been well-defined. The aim of this study was to identify risk factors for severe lower gastrointestinal bleeding and for significant adverse outcomes. METHODS: All patients seeking attention at a university emergency department for gastrointestinal bleeding were prospectively identified during a 3-year period. Ninety-four of 448 (21%) admitted patients had lower gastrointestinal bleeding. Clinical predictors available in the first hour of evaluation were recorded. The primary outcome, severe lower gastrointestinal bleeding, was defined as gross blood per rectum after leaving the emergency department associated with either abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) or more than a 2-unit blood transfusion during the hospitalization. Significant adverse outcomes, including death, were tabulated. RESULTS: Thirty-seven patients (39%) had severe lower gastrointestinal bleeding. Independent risk factors for severe lower gastrointestinal bleeding were initial hematocrit </=35% (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.2-16.7); presence of abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) 1 hour after initial medical evaluation (OR, 4.3; 95% CI, 1.4-12.5); and gross blood on initial rectal examination (OR, 3.9; 95% CI, 1.2-13.2). Nineteen patients (20%) experienced a significant adverse outcome, including 3 deaths. The main independent predictor of adverse outcomes was severe lower gastrointestinal bleeding (OR, 5.3; 95% CI, 1.7-16.5). CONCLUSIONS: Risk factors are available in the first hour of evaluation in the emergency department to identify patients at risk for severe lower gastrointestinal bleeding. Severe lower gastrointestinal bleeding is a significant risk factor for global adverse outcomes.
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Gastrointestinal bleeding in elderly individuals is a frequent cause of consultation with a physician and of hospital admissions. Co-morbidity and greater medication use in this steadily growing patient group influence the clinical course and adversely affect outcome. Clinical presentation is often predictable and guides subsequent patient management. Due to a surprising lack of prospective controlled data in the area of gastrointestinal bleeding, the selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithmic approach. Advances in endoscopic, medical, radiological and surgical treatment modalities offer promising new diagnostic and therapeutic tools, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. This chapter will address clinical presentation, aetiology, diagnosis and treatment of both upper and lower gastrointestinal bleeding in the elderly.
BACKGROUND: In chronic gastrointestinal bleeding, success rates in the range of 48% to 76% have been reported for diagnosing clear bleeding sources using capsule endoscopy. The influence of patient selection on the numbers of positive findings yielded by capsule endoscopy is as yet unclear. METHODS: From April 2001 to June 2003, capsule endoscopy was carried out in 74 of a total of 127 patients (58%) who presented for capsule endoscopy with a high suspicion of gastrointestinal bleeding in the small-bowel region. Seventy of the 74 patients were included in the analysis. This group of patients was divided into a study group (32 patients) and a post-study group (38 patients), and the two groups were compared. RESULTS: Stricter patient selection was carried out in the study group than in the post-study group: 49% of those in the study group underwent capsule endoscopy, compared with 65% of those in the post-study group. The overall success rate for detecting relevant bleeding sources was 54%; in the study group, the rate was 66%; whereas in the post-study group, it was only 45%. Significant differences observed between the two groups of patients included the lowest hemoglobin value (5.9+/-1.4 g/dL in the study group, compared with 7.7+/-2.1 g/dL in the post-study group) and transfusion requirements (a median of 10 units in the study group, vs. 2 units in the post-study group). None of the patients who had a minimum hemoglobin value >or=10 g/dL had a positive capsule result. CONCLUSIONS: Patient selection has a considerable influence on the success rate of capsule endoscopy. In patients with chronic gastrointestinal bleeding, the minimum hemoglobin value and transfusion requirements appear to be the decisive parameters.
HISTORY: An 80-years-old man was admitted to our clinic because of upper gastrointestinal bleeding with tarry stool for 3 days after taking non steroidal antiinflammatory drugs (NSAID) for back pain. The history was otherwise unremarkable. INVESTIGATIONS: Laboratory results showed anaemia. Initial endoscopy revealed acute bleeding from an elevated ulcer in the pars inferior of the duodenum. The bleeding was successfully treated by epinephrine and fibrin injection. Biopsies showed inflammatory changes without presence of malignant cells. In the CT scan of the abdomen there was a mass near the ligament of Treitz of 6.3 cm in diameter adjacent to the duodenum. CLINICAL COURSE: The abdominal tumor was not suitable for ultrasound-guided biopsy. Therefore, laparotomy and surgical resection of the tumor were performed. Histology showed a gastrointestinal stromal tumor (GIST) with infiltration of the muscle layer of the duodenal wall with one small local metastasis. No lymph node metastases were present. The tumor was surgically completely removed and the regular follow-up examinations have fo far shown no evidence for tumor recurrence or metastases. CONCLUSIONS: In upper gastrointestinal bleeding from unusual sites, GIST has to be considered as an underlying disease even if endoscopic biopsies are negative for neoplastic changes.
Gastrointestinal bleeding is a common and potentially life-threatening problem. The incidence of upper gastrointestinal bleeding (UGIB) is 40 to 150 episodes per 100,000 population per year. Mortality in large series is 6% to 10% for UGIB and has remained unchanged over the past 30 to 60 years. The incidence of hospitalization for acute lower gastrointestinal bleeding is about 20 to 27 episodes per 100,000 population per year, with a 200-fold increase with advancing age from the third to ninth decades. The mortality rate is 4% to 10% or higher. The evaluation of overt or acute gastrointestinal bleeding in the ED is reviewed here from the perspective of evidence-based medicine.
OBJECTIVE: The diagnostic yield of enteroclysis was retrospectively evaluated for patients with obscure bleeding from the gastrointestinal tract. MATERIALS AND METHODS: A total of 128 patients with obscure gastrointestinal bleeding were referred to our department for enteroclysis between 1988 and 1993. The original radiologic reports were reviewed to determine the radiographic findings in these patients. The radiographic findings then were correlated with medical, surgical, and pathologic findings. RESULTS: Thirty-two patients had lesions found at enteroclysis. Nineteen of those patients had confirmation of the radiographic diagnosis, primarily by pathologic examination of the surgical specimen. Five other patients were found at surgery to have had false-positive diagnoses at enteroclysis. Eight patients ceased to bleed without pathologic corroboration, but their clinical presentation and course supported the radiographic diagnosis. Thus, 27 (21%) of the 128 patients had confirmed or highly probable lesions seen at enteroclysis as the cause of obscure gastrointestinal bleeding. Seventeen patients (13%) had tumors involving the small bowel, and three (2%) had arteriovenous malformations in the jejunum. CONCLUSION: This study corroborates earlier reports that enteroclysis is a useful diagnostic test for examining the small intestine in patients with obscure gastrointestinal bleeding.