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PubMed1975

Hereditary telangiectasia manifested as gastrointestinal bleeding without external visible telangiectasia.

Gastrointestinal bleeding is one of the most common problems confronting the physician. In most instances, the source of the bleeding is easily identified, e.g., peptic ulcer disease, bleeding esophageal varices or a colonic lesion. Recurrent gastrointestinal bleeding, however, represents one of the major enigmas confronting the practicing physician. The patient experiences intermittent episodes of weakness, easy fatigability and anemia with occult blood in the stool. Multiple barium radiographic examinations and often endoscopy and exploratory laparotomy are unrevealing as to the etiology of the bleeding. We have had occasion to investigate three such patients. Multiple evaluations of these individuals did not reveal the source of the bleeding until many years later--Rendu-Osler-Weber Disease (ROW). At the time of their evaluations these patients did not reveal the usual telangiectatic areas present on the skin and oral mucous membrane. The diagnosis was suggested by the presence of multiple gastric mucosal telangiectasia identified by gastroscopic examination. This report emphasizes the need for thorough endoscopic evaluation of patients with gastrointestinal bleeding and describes the gastroscopic findings that indicated hereditary telangiectasia as the probable source of bleeding from the gastrointestinal tract.

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PubMed2005

[Surgical treatment of gastrointestinal bleeding].

INTRODUCTION: The incidence of gastrointestinal bleeding is slowly decreasing in the past decades, but they represent still a major problem in the treatment of emergency cases. Bigger part of the bleedings originates from the upper gastrointestinal tract (above Treitz ligament), The most common cause of these bleeding is peptic ulcer. The most frequent cause of lower gastrointestinal bleeding is the diverticular disease of the large bowel. AIM: With the summary of the causes, the diagnostic procedures and the treatment possibilities of bleedings the authors should like to help the recovery of these patients. MATERIAL AND DISCUSSION: The most important thing is the proper diagnosis as soon as it is possible. The most acceptable method for this is the endoscopy, during which some kind of treatment procedure is often possible. This method can achieve final or transient stopping of bleeding. With additional medical treatment the urgent operation is often avoidable. In case of continuous or rebleeding operative treatment is mandatory. This kind of treatment is required mainly in case of peptic ulcer bleeding in the upper, and diverticular bleeding in the lower gastrointestinal tract. If operative treatment is chosen, the best result can be expected from an aggressive resection type solution. CONCLUSION: In case of gastrointestinal bleeding the establishment of the correct diagnosis is essential. With a careful endoscopic and medical treatment the urgent operation is often avoidable. So it would be indicated to treat patients in case of gastrointestinal bleeding in a Gastroenterology subintensive unit.

Acute Disease↗

PubMed1999

Iron-deficiency anemia due to chronic gastrointestinal bleeding.

AIMS: chronic gastrointestinal bleeding is the most common cause of iron deficiency anemia (IDA) in the general population. The objectives of this study were to determine the most frequent gastrointestinal lesions in IDA, the frequency and localization of potentially bleeding lesions, the value of the clinical history in diagnosis, the value of fecal occult blood testing, and the most appropriate diagnostic procedure for these patients. METHODS: we prospectively studied 80 patients older than 40 years with IDA, using upper gastrointestinal tract (GI) endoscopy and colonoscopy, beginning with the former (group A) or the latter (group B) depending on the clinical findings. Barium enema was done when colonoscopy was incomplete or unsatisfactory. If all these tests were negative, conventional barium contrast study of the small intestine and arteriography were done, if necessary. RESULTS: upper GI endoscopy found at least one lesion in 50 patients (72%), 13 in association with a colonic lesion (26%). Colonoscopy detected at least one lesion in 31 patients (45%), among whom 11 had another upper GI lesion (35.5%). Barium enema was positive in 4 out of 24 patients (17%). Barium contrast study of the small intestine detected lesions in 1 out of 7 patients (14%), and arteriography in 1 out of 4 patients (25%). The most common upper GI lesions were of peptic origin (esophagitis in 10, gastroduodenal erosions in 10, and peptic ulcer in 8). Neoplasms (17 cancers and 3 polyps) were the most common colonic lesion. Thirteen out of 38 patients (34%) with a potentially bleeding benign upper GI lesion had another lesion in the colon. The fecal occult blood test was positive in 9 out of 10 patients with colonic cancer and in 5 out of 9 with gastric cancer (74% positive predictive value). Nonsteroid antiinflammatory drug use did not correlate with the presence, location or type of lesion. The reliability of the clinically suspected origin of bleeding was 96% sensitivity, 43% specificity and 74% positive predictive value in group A, and 34%, 93% and 80% respectively in group B. CONCLUSIONS: lesions that cause chronic bleeding were more frequently located in the upper digestive tract than in the colon. There was a high prevalence of neoplasms in patients with IDA. One-third of the patients with a potentially bleeding benign lesion in the upper digestive tract had another lesion in the colon. A positive fecal occult blood test correlated highly with neoplastic lesions, and the presence of blood in the stool did not indicate whether bleeding originated in the upper or lower GI tract. Clinical history was of limited value in predicting the location of a bleeding lesion, but can be suggestive of a prior upper GI tract exploration. These patients need a complete study of both the upper and lower GI tracts. In patients in whom the aforementioned explorations are negative, the small bowel should be studied.

Adult↗

PubMed2006

The outcome of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study.

BACKGROUND AND STUDY AIM: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital. PATIENTS AND METHODS: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study. RESULTS: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % ( P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death. CONCLUSIONS: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.

Aged↗

PubMed2006

The outcome assessment of double-balloon enteroscopy for diagnosing and managing patients with obscure gastrointestinal bleeding.

Diagnosing and treating patients with obscure gastrointestinal bleeding is clinically challenging. Most lesions responsible for the origin of obscure gastrointestinal bleeding are located in the small bowel. Double-balloon enteroscopy is a novel method for exploring the small intestine and has significant therapeutic potential. This study evaluated the value of double-balloon enteroscopy in diagnosing and managing obscure gastrointestinal bleeding. From October 2003 to January 2006, a total of 20 patients (6 men, 14 women; mean age, 55.2 years old) with obscure gastrointestinal bleeding (18 obscure overt bleeding, 2 obscure occult bleeding) were investigated by double-balloon enteroscopy. A total of 29 procedures (15 via oral approach and 14 via rectal approach) were performed. The diagnostic yield, endoscopic therapeutic procedures, complications, and outcome were then assessed. Small bowel lesions potentially responsible for the bleeding were identified in 15 (75%) of 20 patients, including 9 angiodysplasias, 2 gastrointestinal stromal tumors (GISTs), 2 ulcers, 1 jejunal granulation polyp, and 1 Peutz-Jeghers polyposis. Endoscopic treatments including heater probe coagulation, polypectomy, and endoscopic mucosal resection were performed in 11 patients. Two patients with GISTs received surgical intervention. Two patients with angiodysplasias that endoscopic treatment failed underwent laparoscopic resections following tattooing. There were no complications and the procedures were tolerated well. Among the 15 patients who had a lesion identified with subsequent treatment, rebleeding occurred in 3 (20%) patients with angiodysplasias. Of the five patients in whom no definite lesion was detected, rebleeding developed in four (80%). For patients with an identified lesion that was further treated, the rebleeding rate was lower than for those with "persistent" obscure gastrointestinal bleeding (P=0.031). We conclude that double-balloon enteroscopy offers a safe and effective method for diagnosing and managing patients with obscure gastrointestinal bleeding.

Angiodysplasia↗

PubMed2005

Diagnosis of gastrointestinal bleeding in adults.

The clinical evaluation of gastrointestinal bleeding depends on the hemodynamic status of the patient and the suspected source of the bleeding. Patients presenting with upper gastrointestinal or massive lower gastrointestinal bleeding, postural hypotension, or hemodynamic instability require inpatient stabilization and evaluation. The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is esophagogastroduodenoscopy; for acute lower gastrointestinal bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk. When bleeding cannot be identified and controlled, intraoperative enteroscopy or arteriography may help localize the bleeding source, facilitating segmental resection of the bowel. If no upper gastrointestinal or large bowel source of bleeding is identified, the small bowel can be investigated using a barium-contrast upper gastrointestinal series with small bowel follow-through, enteroclysis, push enteroscopy, technetium-99m-tagged red blood cell scan, arteriography, or a Meckel's scan. These tests may be used alone or in combination.

Acute Disease↗

PubMed2004

[Gastrointestinal stromal tumors: a broad clinical spectrum from incidental -discovery to acute gastrointestinal bleeding].

Three cases of gastrointestinal stromal tumors (GIST) are reported as typical examples of the broad clinical spectrum in which these rare tumors can be detected. The first case describes an 82-year-old patient with a hemorrhagic shock due to upper gastrointestinal bleeding from a GIST of the stomach. GIST most frequently present with either gastrointestinal bleeding, abdominal pain or a detectable mass on physical examination or by ultrasound imaging. Clinically asymptomatic tumor growth also occurs as demonstrated by the second case of a 44-year-old -woman with an incidental finding of GIST during surgery of the esophagus. The cases are used to discuss the consequences for therapy and prognosis resulting from the heterogeneity of this tumor entity; the relevant immunohistochemical markers used to distinguish between various tumor subtypes of gastrointestinal mesenchymal tumors (GIMT) are listed. Since gastrointestinal stromal tumors (GIST) represent the most common subgroup of GIMT, we focus on the clinicopathological prognostic factors of GIST. The third case of a 40-year-old patient with a malignant GIST recurrence after surgery and exhibiting secondary resistance after one year of successful therapy with the receptor tyrosine kinase inhibitor imatinib (Gleevec), antagonizing pathogenetically relevant constitutive c-KIT activation, illustrates the potential and limitations of the only effective drug treatment for advanced GIST.

Abdominal Pain↗

PubMedDate not supplied

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding].

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

Acute Disease↗

PubMedDate not supplied

Current management of massive lower gastrointestinal bleeding.

Massive lower gastrointestinal hemorrhage originates in the colon in 70% of cases. In half the remaining cases it originates in the small bowel, and in the other half in the duodenum. Currently available diagnostic techniques are: mesenteric angiography, barium contrast meal studies, colonoscopy, and laparotomy. Causes of massive lower gastrointestinal bleeding are: diverticulosis, angiodysplasia, ischemic colitis, inflammatory bowel disease and intestinal varices. Accurate localization of the bleeding site is essential if surgical treatment is to be successful.

Angiography↗

PubMed1992

[Hemobilia as a rare cause of gastrointestinal bleeding].

In a 67-year-old man with upper abdominal and gastrointestinal bleeding gastroscopy revealed a duodenal ulcer which was initially taken to be the source of the bleeding. But subsequent retrograde cholangiography demonstrated nearly complete occlusion of the right hepatic duct and a suspicious tumour-like structure. At laparotomy a tumour was excluded and the supplying artery to the ulcer was ligated to arrest the bleeding. Gastrointestinal bleeding recurred postoperatively so that selective angiography of the hepatic artery had to be performed. This demonstrated an aneurysm of a branch of the hepatic artery near the hilus. No further bleeding occurred after its embolization. Haemobilia is a rare cause of upper abdominal bleeding and may be difficult to diagnose, except by selective imaging techniques.

Aged↗

PubMed1975

Selective arterial embolization for control of massive upper gastrointestinal bleeding.

Massive upper gastrointestinal bleeding was controlled in 11 of 15 patients by the use of selective injected arterial emboli. Embolization is most successful in the treatment of patients with demonstrated arterial bleeding sites at angiography. This group of patients generally has ulcers and it is this group in whom vasopressin infusion has the lowest success rate. At the same time we were successful in controlling only 1 of 4 patients who were bleeding from diffuse hemorrhagic gastritis, those patients in whom vasopressin infusion is very successfu, We, therefore, now embolize only patients in whom arterial bleeding sites are demonstrated at angiography or in whom vasopressin infusion has failed to control the bleeding from hemorrhagic gastritis. Our experience also indicates that short acting occlusive agents, such as autogenous blood clot mixed with aminocaproic acid, are as successful in controlling bleeding as the more permanent types of embolic material.

Adult↗

PubMed2003

[Clinical features of obscure-overt gastrointestinal bleeding].

BACKGROUND/AIMS: Obscure gastrointestinal bleeding (OGIB) is defined as recurrent acute or chronic bleeding for which no sources have been identified by routine endoscopic and contrast studies. The patients with OGIB are frequently difficult to manage and often undergo extensive investigation and even laparatomy without diagnosis. The aim of this study was to review our overall experiences of the investigation and treatment of OGIB. METHODS: We reviewed, retrospectively, medical records of 41 cases with OGIB from June 1996 to July 2002. RESULTS: Of the 41 patients with OGIB, there were 21 men and 20 women and their mean age was 47.8 years (range, 18 to 81 years). Diagnosis was possible in 13 patients (31.7%) and no specific causes were identified in the remaining 28 patients (68.3%). The principal etiologies were gastrointestinal stromal tumor of the small bowel in 3 cases, duodenal diverticulum in 2 cases. Other causes are as follows: adenocarcinoma of the duodenal 3rd portion, duodenal varix at the 4th portion, splenic artery pseudoaneurysm, Crohn's disease, jejunal ulcer, ileal ulcer, ileal angiodysplasia, and anastomosis site bleeding after hemicolectomy. CONCLUSIONS: We conclude that further and logical diagnostic investigations such as small bowel enteroscopy and wireless capsule endoscopy will promise better results.

Adult↗

PubMed2001

Non-variceal upper gastrointestinal bleeding.

Severe upper gastrointestinal bleeding remains a common medical emergency. In the last two decades endoscopy has become the cornerstone of diagnosis, risk stratification and treatment of peptic ulcer bleeding. Clinical assessment and endoscopic recognition of the stigmata of recent haemorrhage can allow the identification of patients with a high risk of rebleeding. Patients with active bleeding at the time of endoscopy and with non-bleeding visible vessels should receive endoscopic treatment. Studies comparing different treatment modalities are mostly single centre studies with relatively small groups of patients and therefore lack statistical power. Furthermore most of those trials were heterogeneous because of differences in the end points, differences in the risk factors for rebleeding and differences in the levels of experience of the endoscopists in both recognition and treatment of bleeding ulcers. Recently different treatment modalities have been studied. The injection of clot-inducing factors, a combination of injection and thermal therapies, repeat endoscopies and the use of mechanical devices such as clips and ligatures are promising new techniques. However, there are, at present, no convincing data to suggest that any one of these treatment modalities is superior when looking at the overall group of patients with bleeding peptic ulcer. Larger randomized controlled trials must focus on tailoring therapies and using the optimal therapy for different subgroups of patients.

Acute Disease↗

PubMed2002

Management of Gastrointestinal Bleeding in Children.

Gastrointestinal bleeding in infants and children is a potentially life-threatening problem that is encountered by virtually all practicing pediatric gastroenterologists. Youngsters with a normal hematocrit, hemodynamic stability, and a history consistent with an acute, self-limited illness most frequently need only close observation; others require more in-depth assessment and intervention. Meticulous attention to the patient's cardiopulmonary status and knowledge of appropriate pediatric resuscitation schemes form the cornerstones on which more specific therapeutic interventions are based. Many treatment techniques and approaches have been extrapolated for pediatric use from adult studies; the regimen implemented for a child should be individualized and based on factors such as patient size, underlying condition, and operator expertise. Although the physician treating pediatric gastrointestinal hemorrhage requires more than a modicum of patience and determination, this must be tempered with a ready willingness to seek consultation from surgical colleagues to ensure optimal outcomes. Knowledge of acid-suppressive and vasoactive medications is essential, as is familiarity with at least one injection technique and one thermocoagulation technique for hemostasis. Endoscopic sclerotherapy and variceal band ligation are equally efficacious in achieving control of acute variceal bleeding, but band ligation is emerging as the technique best suited for prophylaxis. Beta blockade appears to have a smaller and less well-defined role in pediatric variceal prophylaxis compared with that in adults, but random controlled trials are necessary to confirm this impression.

Journal Article↗

PubMed1994

[Therapeutic possibilities in the management of gastrointestinal bleeding in thrombocytopenic patients].

Gastrointestinal bleeding is often fatal in elderly. The danger could be multiplied by thrombocytopenia or by other disorder of the coagulation system. In a thrombocytopenic patient with myelodysplastic syndrome life threatening gastrointestinal bleeding occurred which could not be controlled by conventional methods (cimetidine, antacids, aminocaproic acid, platelet transfusions, blood transfusion 400-1200 ml/day). Continuous i.v. infusion of somatostatin [250 micrograms/hour Stilamin (Serono)] and per os omeprazole [2 x 1 capsule Losec (Astra)] resulted in the cessation of bleeding in 24 hours. Adverse effect was not observed.

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PubMed1982

Gastrointestinal bleeding and amyloidosis.

Although gastrointestinal bleeding is well known in patients with amyloidosis, when it occurs as the initial or sole overt manifestation of the disease it is much rarer and frequently causes diagnostic difficulty. This subject is reviewed in the context of a patient who underwent multiple invasive and noninvasive examinations to achieve this diagnosis. Both upper and lower gastrointestinal bleeding of all degrees has been shown to occur with amyloidosis. It appears that diffuse involvement of the gastrointestinal tract is much more common than a specific lesion. Our patient was ultimately found to have multiple waxy amyloid plaques and extremely friable jejunal mucosa at endoscopy. Radiographically, amyloidosis may cause diffuse thickening of the mucosal folds, a finding that carries a broad differential diagnosis. Arteriography, although not used frequently as a diagnostic modality in amyloidosis, may reveal luminal irregularities, truncation, and diffuse attenuation of the vasculature. The treatment of amyloidosis thus far has been unrewarding and difficult. Several new therapeutic measures which appear promising are discussed.

Aged↗

PubMed1986

The appearance of a large mesenteric varix on a technetium-99m red blood cell gastrointestinal bleeding study.

Detection of gastrointestinal bleeding using Tc-99m labeled RBCs has proven to be clinically useful although false-positive images associated with abnormal vascularity remain problematic. The scintigraphic appearance of a large mesenteric varix is presented, and its potential confusion with gastrointestinal bleeding is discussed. Correlative CT and angiographic images are presented.

Angiography↗

PubMed2006

A rare cause of acute upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding (AUGB) remains a common indication for admissions and is associated with significant morbidity and mortality. Peptic ulcer diseases and varices are the commonest lesions identified during endoscopy. However, endoscopists need to be aware of the rare causes of AUGB, as missing such lesions can potentially be fatal. Rare causes can be missed if they are not looked for systematically during endoscopy. We report a case of AUGB secondary to bullous pemphigoid involving the esophagus in an elderly gentleman presenting with significant blood loss from hematemesis. A review of the English literatures on bullous pemphigoid involvements of the esophagus was carried out and the underlying pathogenesis and management are discussed.

Acute Disease↗