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PubMed1978

The double contrast barium meal in patients with acute upper gastrointestinal bleeding.

One hundred and seven patients admitted to a small general hospital with acute upper gastrointestinal bleeding have been examined by the double contrast barium meal technique. The presumed bleeding site was identified in 75 cases (70%). Twenty-eight patients showed radiological evidence of recent or active bleeding. These were all examined within 24 h of the bleed and 18 (64%) continued to bleed or had a further bleed whereas of 79 patients who did not show radiological signs of recent or active bleeding only 10(13%) continued to bleed or had a further bleed. The radiological features of recent or active bleeding seen on the double contrast barium meal are: 1, Blood clot in an ulcer or adherent to a recently bleeding lesion. 2. An artery in the base of an ulcer. 3. Active bleeding during the course of the examination seen as a dynamic alteration or disturbance in the barium as it flows over the bleeding site.

Acute Disease↗
PubMed2002

The influence of vaginal bleeding on the sexual behavior of urban, Hispanic women and men.

Irregular menstrual bleeding associated with use of hormonal contraceptives is a leading cause of contraception discontinuation. If bleeding disrupts sexual activity, this could contribute to contraceptive discontinuation. The impact of bleeding on sexual activities other than intercourse is unknown.A self-administered questionnaire in Spanish or English was used to collect information on demographics and the practice of various sexual behaviors during times of vaginal bleeding or spotting. The questionnaire was offered consecutively to 86 men and 75 women attending urban family-planning and young men's clinics. The men and women were approached individually, not as couples. Women reported a mean age of 25 years, a wide range of educational attainment, described themselves as mostly Hispanic (89%), and most chose the Spanish version of the questionnaire (67%). Men also described themselves as mostly Hispanic (80%), and reported a similar range of educational attainment, but were younger (mean age of 21, p < 0.001), and were less likely to choose the Spanish version of the questionnaire (23%, p < 0.001).Kissing, breast touching, and receiving non-genital touching did not change during bleeding or spotting. Forty-five percent of women reported usually receiving genital touching, which declined to 6% during bleeding and to 10% during spotting (p < 0.001). Similar proportions of women reported usually giving genital touching to their partner (50%) during bleeding (41%) or spotting (44%). Men also reported usually giving less genital touching to their partner, but no change in receiving genital touching during bleeding or spotting. Forty percent of women reported usually receiving oral sex, which declined to 4% during spotting or to 0% bleeding (p < 0.001). Forty-two percent of women reported usually giving oral sex, which declined to 23% during bleeding and to 35% during spotting (p = 0.06). Fifty percent of women and 68% of men reported engaging in vaginal intercourse. Among women, reported intercourse declined to 7% during bleeding and to 26% during spotting (p < 0.001). Among men, reported intercourse declined to 19% during bleeding and to 23% during spotting (p < 0.001). The presence of vaginal bleeding or spotting is associated with decreases in genital sexual behaviors among urban, Hispanic women and men. Such disruptions in sexual behavior could contribute to contraceptive discontinuation.

Adult↗
PubMed1998

White ball appearance in endoscopic ligation of bleeding esophageal varices.

BACKGROUND: Endoscopic variceal ligation is useful in the control of bleeding from esophageal varices. However, confirmation of ligation precisely at the site of bleeding is usually difficult when treating massive variceal bleeding. Characteristic endoscopic findings that appeared when ligation was performed at the site of bleeding are reported in this article. METHODS: Emergency endoscopic variceal ligation was performed in 14 patients with active bleeding from esophageal varices. Endoscopic findings after variceal ligation at the site of bleeding were compared with those at sites without bleeding. RESULTS: Active bleeding ceased just after endoscopic ligation at the site of bleeding in all patients. After ligation of the bleeding site of the varix, an unusual white-colored ball-like appearance (white ball appearance) was observed in all patients. This finding was markedly different from the purple-colored ball-like appearance that is usually observed after ligation of a varix at a site without bleeding. CONCLUSIONS: White ball appearance was a characteristic finding that appeared after ligation of a varix at the site of bleeding. This finding may be useful in the confirmation of successful ligation of a varix at its bleeding site.

Emergency Treatment↗
PubMed2006

[Epidemiology of gastrointestinal bleeding in the elderly].

The epidemiological pattern of gastrointestinal bleed in western countries has been steadily changing over the last few years given the rising prevalence of an elderly population. In a one year prospective study at a referral hospital in Zurich, Switzerland, hospitalised patients were investigated with regards to the epidemiology of gastrointestinal (GI) bleeding. Of 7406 hospitalisations, a total number of 224 GI bleeds were registered (53% women, mean age 71 +/- 16, 63% with relevant co morbidities). Of 197 patients with GI bleeds, 51% had upper and 37% lower gastrointestinal bleedings. 2% had concurrent upper and lower gastrointestinal bleedings and 10% remained unexplained. The following spectrum of lesions identified as bleeding sources was: 24% ulcer bleedings, 16% diverticular bleedings, 10% colitis, 10% esophagitis and 6% Mallory-Weiss lesions. The frequency of bleeds significantly increased with patient's age. In addition, diverticular bleeding in the elderly was highly associated with intake of Aspirin. The prognosis of gastrointestinal bleeding in elderly patients in this study was excellent with a bleeding associated mortality of only 3.1%.

Age Factors↗
PubMed2002

Meta-analysis: the efficacy of intravenous H2-receptor antagonists in bleeding peptic ulcer.

BACKGROUND: Although a previous meta-analysis found that intravenous H2-receptor antagonists were only weakly beneficial in bleeding gastric ulcer and of no benefit in bleeding duodenal ulcer, patients with ulcer bleeding continue to receive such treatment. AIM: To re-evaluate the efficacy of intravenous H2-receptor antagonists in ulcer re-bleeding, surgery and mortality by updating the previous meta-analysis. METHODS: After two independent literature searches, randomized, placebo-controlled trials of intravenous H2-receptor antagonists in bleeding ulcer published between 1984 and 2000 were added to those from the initial meta-analysis. Pooled rates of re-bleeding, surgery and death were re-calculated, together with the relative risk reduction, absolute risk reduction, number needed to treat and Mantel-Haenszel odds ratio. RESULTS: Intravenous H2-receptor antagonists did not significantly reduce re-bleeding, surgery or death in bleeding duodenal ulcer. There were small but significant reductions in re-bleeding, surgery and death in bleeding gastric ulcer; the absolute risk reductions were 7.2%, 6.7% and 3.2%, respectively. CONCLUSIONS: Intravenous H2-receptor antagonists are of no value in bleeding duodenal ulcer, although they may be mildly beneficial in bleeding gastric ulcer. Because proton pump inhibitors have a greater inhibitory effect on gastric acid secretion than H2-receptor antagonists, they may be more effective in ulcer bleeding and should be further evaluated for that indication.

Histamine H2 Antagonists↗
PubMed1999

von Willebrand disease and bleeding in women.

Menorrhagia is a common health problem in women, particularly those with bleeding disorders. Little is known about the course of menorrhagia or other bleeding symptoms in women with the most common congenital bleeding disorder, von Willebrand disease (vWD). We determined the prevalence of menorrhagia, bleeding symptoms and coagulation abnormalities associated with vWD, including factor VIII activity, von Willebrand factor (vWF) antigen, ristocetin cofactor and bleeding time (BT), on a cohort of 38 females with type 1 vWD referred for diagnosis and medical care. Menorrhagia was the most common bleeding symptom in females with vWD, occurring in 93.1% of adult women. Menorrhagia was also the most common initial bleeding symptom, occurring in 53.1% of adult women in all of whom it began at menarche, median 14 years of age. There was a delay from initial bleeding symptoms, at median age 12 years, to diagnosis, at median age 16 years, P=0.0049. Although 94% undergoing surgery had previous bleeding, a vWD diagnosis was known preoperatively in only 6.2%, resulting in potentially preventable bleeding. In summary, menorrhagia is the most common bleeding symptom in females with vWD and begins at menarche. Obtaining a personal and family bleeding history promotes early diagnosis, potentially prevents postoperative bleeding, and improves the health of women with vWD.

Adolescent↗
PubMed1999

Causes and outcome of upper and lower gastrointestinal bleeding: the Grady Hospital experience.

BACKGROUND: Gastrointestinal (GI) bleeding remains a common medical condition, with a mortality rate believed to have remained unchanged over the past five decades. METHODS: Over a 50-month period, the gastroenterology consultative service at a large inner-city hospital prospectively evaluated acute upper GI (UGI) bleeding or lower GI (LGI) bleeding in consecutive patients. A number of clinical variables were recorded at admission on a standardized data collection form. The cause of bleeding was determined in most patients by endoscopic examination. RESULTS: Of the 796 patients assessed for UGI bleeding, 727 (91%) had upper endoscopy. The most common causes of UGI bleeding were gastric ulcer (32%), duodenal ulcer (28%), esophageal varices (9%), and Mallory-Weiss tear (6%). The rebleeding rate was 14% and 20% of patients had endoscopic therapy. Surgical therapy for bleeding was required in 7% of patients. Of the 165 patients assessed for LGI bleeding, 150 (91%) had colonoscopy. Colonic diverticulosis was considered etiologic in 56% of patients, followed by colonic ulcers in 10%, carcinoma in 7%, and vascular ectasias in 5%. The rebleeding rate in these patients was 20%, and surgical therapy for bleeding was required in 10%. The overall mortality for patients with UGI bleeding was 9% and was independently associated with portal hypertension and rebleeding. In contrast, the mortality rate for LGI bleeding was 4%, and there was little power to determine significant factors associated with death. CONCLUSIONS: The causes of gastrointestinal bleeding remain little changed over the past several decades, though in our large series the need for surgical therapy and the mortality from both upper and lower GI bleeding were low.

Aged↗
PubMed2005

Postoperative bleeding after diathermy and dissection tonsillectomy.

OBJECTIVE: To analyze the incidence and pattern of bleeding after tonsillectomy performed by either cold dissection or diathermy. DESIGN: A prospective, nonrandomized cohort study of postoperative hemorrhage after tonsillectomy. METHODS: Monthly reporting of the number of tonsillectomies and postoperative bleeds from otolaryngologists working in rural areas of Victoria, Australia over a 2.5 year period. Criteria for bleeding were either 1) repeat anesthesia and surgery because of hemorrhage (including return to theater from the recovery room), or 2) readmission to hospital because of bleeding, or 3) blood transfusion to replace blood loss. Main outcome measures were the incidence, volume, and time course of postoperative hemorrhage. RESULTS: The number of bilateral tonsillectomies with removal by cold-blunt dissection was 3,087. In this group, there were 57 (1.85%) bleeds. The number of bilateral tonsillectomies with removal by diathermy dissection was 1,557. In this group, there were 37 (2.38%) bleeds. If cold dissection is taken as the "control" and diathermy tonsillectomy as the "treatment" group, the relative risk of bleeding after diathermy tonsillectomy is 1.30 (95% confidence interval 0.88-1.93). The pattern of bleeding after each technique differs significantly over time, with more reactionary bleeds in the dissection group and more bleeds between 4 to 7 postoperative days after diathermy. When bleeding occurred, it was in excess of 500 mL in 16% of dissection cases and 43% of diathermy tonsillectomies. CONCLUSIONS: The difference in the risk of bleeding after each technique did not reach statistical significance, but the temporal pattern of hemorrhage differed, and more bleeds exceeding 500 mL were seen in the diathermy group.

Adolescent↗
PubMed2006

Hemorheology in patients with liver cirrhosis: special emphasis on its relation to severity of esophageal variceal bleeding.

BACKGROUND: Patients with decreased blood viscosity are supposed to have a higher risk of bleeding and increased severity of bleeding (severity of bleeding proportional to transmural pressure x area of variceal tear/blood viscosity). However, the hemorheological factors have never been assessed in patients with esophageal variceal bleeding. Therefore, the purpose of the present study was to examine the hemorheological factors in liver cirrhotic patients with special emphasis on the outcome of variceal bleeding. METHODS: Forty-two liver cirrhosis patients with variceal bleeding and another 44 matched patients without bleeding were enrolled. The hemorheological and hemostatic factors of their peripheral blood were examined. The clinical course was under careful surveillance. RESULTS: Patients with poor hepatic reserve (Child B + C vs A) had lower whole blood viscosity (4.34 +/- 0.56 mPa.s vs 5.06 +/- 1.35 mPa.s, P < 0.05), lower hematocrit levels (32.86 +/- 5.97% vs 36.62 +/- 5.44%, P < 0.05), lower platelet counts (79.7 +/- 47.6 x 10(3)/mL vs 108.0 +/- 71.2 x 10(3)/mL, P < 0.05) and prolonged prothrombin time (2.88 +/- 2.33 s vs 1.27 +/- 1.37 s, P < 0.05). Patients with bleeding (vs non-bleeding group) had lower hematocrit levels (31.44 +/- 5.75% vs 36.57 +/- 5.19%, P < 0.01) and lower fibrinogen levels (226.7 +/- 92.7 mg/dL vs 286.4 +/- 111.8 mg/dL, P < 0.05). Patients with bleeding with shock had worse liver cirrhosis (Child A/B/C = 0/5/4 vs 11/18/4, P < 0.05), lower whole blood viscosity (4.01 +/- 0.17 mPa.s vs 4.57 +/- 0.76 mPa.s, P < 0.05), reduced erythrocyte aggregability (2.94 +/- 0.41 vs 3.54 +/- 0.61, P < 0.001), and lower platelet counts (56.22 +/- 17.05 x 10(3)/mL vs 88.87 +/- 38.12 x 10(3)/mL, P < 0.001). The Child-Pugh grade and erythrocyte aggregability were two independent factors associated with bleeding shock. CONCLUSIONS: Whole blood viscosity, hematocrit levels and platelet counts were lower in patients with advanced liver cirrhosis. Advanced liver cirrhosis and reduced erythrocyte aggregability were independent factors for hypovolemic shock in cirrhotic patients with esophageal variceal bleeding. However, the causal relationship between hemorheology and bleeding needs to be clarified in further studies.

Aged↗
PubMed2004

Bleeding after transrectal ultrasonography-guided prostate biopsy: a study of 7-day morbidity after a six-, eight- and 12-core biopsy protocol.

OBJECTIVE: To compare, in a prospective study, bleeding (in three categories, i.e. haematuria, haematospermia and rectal) and consultations with the general practitioner (GP), after a six-, eight- or 12-core prostate biopsy, as data on whether taking more prostate core biopsies increases bleeding complications are not conclusive. PATIENTS AND METHODS: Over a 5-year period, patients undergoing outpatient transrectal ultrasonography (TRUS)-guided prostate biopsy (six, eight or 12-core biopsy) completed a self-administered questionnaire. The prevalence and duration of the three bleeding complications and GP or hospital visits for a biopsy-related complication were assessed and compared for the 7 days after biopsy. The contribution of local anaesthetic (LA) injection to bleeding rates was also assessed. RESULTS: Of 1384 patients biopsied, 1000 were given questionnaires and 884 (88%) forms were returned. Of these, 760 were suitable for analysis (307 after six-core, 325 eight-core and 128 12-core biopsies); 351 patients were given LA before biopsy. The prevalence of bleeding complications (six-, eight- and 12-core, respectively) was: haematuria 44%, 41% and 39%; haematospermia 13%, 16% and 12%; and rectal bleeding 17%, 26% and 27%. Rectal bleeding was significantly more prevalent in the eight- and 12-core groups (P = 0.0037 and 0.019). The duration of bleeding was not significantly greater in any biopsy group. Subgroup analysis showed no significant difference in the prevalence and duration of rectal bleeding after LA. About 5% of patients in each group consulted their GP because of a complication and 2.4% consulted because of bleeding. Three men with major complications required hospitalization, of which only one was caused by bleeding. CONCLUSIONS: Only rectal bleeding was more prevalent after taking more than six cores, but the duration was no greater. Giving LA did not affect the rectal bleeding rate. With all strategies the major complication and hospitalization rate was very low.

Adult↗
PubMed2005

Validation of a clinical prediction rule for severe acute lower intestinal bleeding.

OBJECTIVES: Acute lower intestinal bleeding is a heterogeneous disorder and identification of high-risk patients is challenging. We previously retrospectively identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to prospectively validate a clinical prediction rule for severe acute lower intestinal bleeding. METHODS: This was a prospective, observational cohort study of consecutive patients admitted to an academic, tertiary care or a community-based teaching hospital for management of acute lower intestinal bleeding. Data were collected on seven previously identified predictors of severe bleeding: heart rate > or = 100/min, systolic blood pressure < or = 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 h of evaluation, aspirin use, and >2 comorbid conditions. Severe bleeding was defined as transfusion of > or =2 units of red blood cells, and/or a decrease in hematocrit of > or =20% in the first 24 h, and/or recurrent rectal bleeding after 24 h of stability (accompanied by a further decrease in hematocrit of > or =20%, and/or additional blood transfusions, and/or readmission for acute lower intestinal bleeding within 1 wk of discharge). Patients were stratified into 3 risk groups according to the previously developed prediction rule: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). RESULTS: A total of 275 patients with acute lower intestinal bleeding were identified. The risk of severe bleeding in each risk category was similar in the validation and derivation cohorts (p values >0.05): low risk 6%versus 9%, moderate risk 43%versus 43%, and high risk 79%versus 84%. The area under the receiver operating characteristic curve was 0.754 for the validation cohort and 0.761 for the derivation cohort. The magnitude of the risk score was significantly correlated with major clinical outcomes including surgery, death, blood transfusions, and length of stay. CONCLUSION: We have developed and prospectively validated a clinical prediction rule for acute severe lower intestinal bleeding. This prediction rule could improve the triage of patients to appropriate levels of care and interventions, and guide a more standardized approach to acute lower intestinal bleeding.

Acute Disease↗
PubMed2004

The risk of bleeding complications in patients with cytochrome P450 CYP2C9*2 or CYP2C9*3 alleles on acenocoumarol or phenprocoumon.

The principal enzyme involved in coumarin metabolism is CYP2C9. Allelic variants of CYP2C9, CYP2C9*2 and CYP2C9*3, code for enzymes with reduced activity. Despite increasing evidence that patients with these genetic variants require lower maintenance doses of anticoagulant therapy, there is lack of agreement among studies on the risk of bleeding and CYP2C9 polymorphisms. It was, therefore, our objective to study the effect of the CYP2C9 polymorphisms on bleeding complications during initiation and maintenance phases of coumarin anticoagulant therapy. The design of the study was a population-based cohort in a sample of the Rotterdam Study, a study in 7,983 subjects. All patients who started treatment with acenocoumarol or phenprocoumon in the study period from January 1, 1991 through December 31, 1998 and for whom INR data were available were included. Patients were followed until a bleeding complication, the end of their treatment, death or end of the study period. Proportional hazards regression analysis was used to estimate the risk of a bleeding complication in relation to CYP2C9 genotype after adjustment for several potentially confounding factors such as age, gender, target INR level, INR, time between INR measurements, and aspirin use. The effect of variant genotype on bleeding risk was separately examined during the initiation phase of 90 days after starting therapy with coumarins. The 996 patients with analysable data had a mean follow-up time of 481 days (1.3 years); 311 (31.2%) had at least 1 variant CYP2C9 allele and 685 (68.8%) had the wild type genotype. For patients with the wild type genotype, the rate of minor bleeding, major bleeding and fatal bleeding was 15.9, 3.4 and 0.2 per 100 treatment-years, respectively. For patients with a variant genotype, the rate of minor, major and fatal bleeding was 14.6, 5.4 and 0.5 per 100 treatment-years. Patients with a variant genotype on acenocoumarol had a significantly increased risk for a major bleeding event (HR 1.83, 95% CI: 1.01-3.32). During the initiation phase of therapy we found no effect of variant genotype on bleeding risk. In this study among outpatients of an anticoagulation clinic using acenocoumarol or phenprocoumon, having a variant allele of CYP2C9 was associated with an increased risk of major bleeding events in patients on acenocoumarol, but not in patients on phenprocoumon. Although one might consider the assessment of the CYP2C9 genotype of a patient for dose adjustment before starting treatment with acenocoumarol, a prospective randomised trial should demonstrate whether this reduces the increased risk of major bleeding events.

Acenocoumarol↗
PubMed2004

Successful treatment of severe bleeding in hemophilic target joints by selective angiographic embolization.

Bleeding into the joints is common in patients with hemophilia. After total knee or elbow replacement, profuse intraarticular bleeding unresponsive to high-dose clotting factor replacement sometimes occurs. In some patients who have severely damaged elbow or knee joints the same profuse bleeding pattern can be seen. To control bleeding in these patients, selective catheterization with a microcatheter and therapeutic embolization with microcoils was performed whenever a severe blush or microaneurysm was observed on angiography. Over 12 years, in 23 cases of massive joint bleeding in 18 patients with hemophilia selective catheterization was performed. In 15 cases the bleeding was postoperative and in 8 spontaneous. Results of angiographic imaging revealed vascular blush, false aneurysm, true aneurysm, and arteriovenous shunt in combination with an aneurysm as cause of bleeding. In 2 patients, the cause of bleeding was not found. In 21 cases an embolization procedure was performed, in which the bleeding was completely controlled by a single procedure in 14 cases. Recurrence of the bleeding occurred in 7 cases and required a second embolization procedure; in one patient even a third embolization was required to stop the bleeding completely. No difference in the outcome, that is, clinical end of bleeding and joint range of motion, was observed, when comparing postoperative and spontaneous bleeding.

Adolescent↗
PubMed2005

Percutaneous coronary intervention-related bleeding risk factors in current practice.

BACKGROUND: Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Little is known about the risk factors for bleeding complications. OBJECTIVE: To report our PCI-related observations from a single institution and use the information to establish risk factors for short-term bleeding complications, with special focus on examining the importance of renal function. METHODS: A retrospective record review was conducted of the admission of 300 patients grouped according to antithrombotic regimen: unfractionated heparin alone (n = 187), bivalirudin (n = 26), and glycoprotein IIb/IIIa antagonist plus heparin (n = 103). Bleeding and ischemic outcomes were tracked. A model was constructed to predict independent bleeding risk factors. RESULTS: Treatment groups differed significantly regarding any bleeding (p = 0.001), minor bleeding (p < 0.001), and length of stay (p = 0.01). Multivariate predictors of any bleeding included antithrombotic regimen, creatinine clearance (Cl(cr)) <30 mL/min, and hypertension. Any bleeding was associated with prolonged length of stay. Major bleeding was predicted by Cl(cr) <30 mL/min and was associated with prolonged length of stay and death. Minor bleeding was predicted only by choice of antithrombotic regimen. CONCLUSIONS: The major influences on bleeding risk appeared to be Cl(cr) <30 mL/min and choice of antithrombotic regimen. It is important to note that other markers of renal function, including serum creatinine value and serum creatinine at a cutoff level of 1.5 mg/dL, did not predict bleeding events.

Aged↗
PubMed1995

Thromboelastography for the prediction of bleeding after transplant renal biopsy.

The ability of prebiopsy coagulation assays to predict mild postbiopsy bleeding was evaluated in renal transplant patients undergoing renal allograft biopsy (N = 120). The coagulation assays studied included the bleeding time, prothrombin time, partial thromboplastin time, platelet count, and thromboelastograph (TEG). Coagulation results were defined as abnormal if they fell outside the established normal reference range. Bleeding was defined as a drop in the hematocrit equal to or more than 4 points 6 h after the procedure or ultrasound evidence of a new perirenal hematoma. Overall, 21% of patients showed evidence of mild bleeding. Of those who bled, 78% had normal results on all coagulation tests, indicating that most mild bleeding was not associated with coagulation abnormalities. Of the assays tested, only abnormal TEG:angle (P < 0.01) and TEG:k (P < 0.04) values were associated with an increased risk of bleeding. Bleeding times were not predictive of an increased risk of postbiopsy bleeding; five patients had abnormal bleeding times ranging from 10 to 20 min of whom only one bled. All prothrombin time, partial thromboplastin time, and platelet count abnormalities were mild (e.g., no prothrombin times longer than 15 s, no platelet counts below 129,000/microL); none of these assays predicted postbiopsy bleeding. Other clinical characteristics, including patient age, sex, serum creatinine, blood pressure (if less than 160/90 mm Hg), number of biopsy passes, or renal pathology, did not appear to influence bleeding after biopsy. It was concluded that most bleeding after transplant renal biopsy was not associated with coagulation abnormalities and that the TEG was the best assay for detecting mild coagulation abnormalities associated with an increased risk of bleeding.

Biopsy↗
PubMed2004

[Surgical therapy options for bleeding gastroduodenal peptic lesions].

INTRODUCTION: Mortality rate of bleeding into the upper GIT has remained relatively unchanged during the past 30 years, i.e. about 30%, even though the development of new technologies brought along substantial changes in diagnostic and therapeutic procedures. METHODOLOGY: This work deals with the surgical solution of bleeding into the upper GIT of peptic etiology. It covers a 5-year period (from January 1, 1999 until October 1, 2003) during which time the Regional Hospital in Pardubice admitted 1,310 patients with bleeding into the upper GIT of peptic etiology. 190 of them were hospitalized at the Surgical Clinic due to the developing hemorrhagic shock; the others were hospitalized at the Clinic of Internal Medicine. If it failed urgent endoscopy to stop the bleeding, the patient was referred to undergo an urgent surgery. If the bleeding was stopped by endoscopy yet it recurred after certain time, a second endoscopic homeostasis was attempted. If it failed, an urgent surgery was indicated. RESULTS: A total number of 24 patients underwent an acute surgery. A frequently used procedure was stomach resection, type BII, which was applied to a total number of 12 patients. However, this type of urgent surgery was accompanied with a relatively high number of complications. Reoperation had to be performed 4 times (33.3%). In one case (8.3%) for recurrent bleeding. In 12 patients one of the other procedures was performed: an injection and a trunkal vagotomy (3x), an injection and the ligation of the gastroduodenal artery (2x), proximal jejunum resection (1x), an injection accompanied with fundoplication according to Nissen-Rosseti (1x). Two of the patients who received this other group of procedures had to be reoperated for recurrent bleeding (16.7%). DISCUSSION: The decision about a suitable surgical procedure applicable to bleeding into the upper GIT after the failure of endoscopic homeostasis poses a substantial problem. It is necessary to choose from more radical procedures--resection--that stop bleeding reliably, yet their execution in an acute condition (often coinciding with the patient's hemorrhagic shock) results in a relatively large number of complications; and from less radical procedures that feature a smaller number of post-surgical complications yet that can be burdened with a larger percentile number of recurrent bleeding. Nearly the same number of serious recurrent bleeding in this study indicates that the appropriate choice of a procedure (according to the patient's current condition, ulcer localization, and associated diseases) makes both approaches (resection vs. a less radical procedure) similar as to the number of necessary reoperations after bleeding. CONCLUSION: The development of endoscopic methods introduced significant changes in the diagnostic-therapeutic algorithm of bleeding into the upper GIT. Nevertheless, the choice of an appropriate surgical procedure continues to present a relevant surgical issue.

Acute Disease↗
PubMed2001

Acute gastrointestinal bleeding: Part I.

OBJECTIVE: To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation. DATA SOURCES: Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding. SUMMARY OF REVIEW: Gastrointestinal bleeding is a relatively frequent problem in the critically ill patient. Common causes include acute stress ulceration (ASU), peptic ulceration and bleeding oesophageal varices. Non-variceal upper gastrointestinal bleeding requires resuscitation and correction of coagulation disturbances before endoscopy is performed. If a bleeding ulcer is detected it is often managed by an adrenaline injection or electrocautery into the base of the lesion and a proton pump inhibitor (e.g. omeprazole 80 mg i.v. followed by 8 mg/hr for 72 hr then 20 mg orally for 8 weeks). Surgery is considered for all patients in whom bleeding persists despite endoscopic or medical therapy. While H(2) receptor antagonists have been used for the management of ASU, proton pump inhibitors are currently prescribed due to their greater gastric acid suppressant effect (e.g. omeprazole 40 mg i.v. daily for ASU prophylaxis, 40 mg daily or 12-hourly for ASU with mild blood loss and 80 mg i.v. followed by 8 mg/hr for 72 hrs for ASU with severe haemorrhage). With severe haemorrhage, fibrinolytic inhibitors (e.g. tranexamic acid 3-6 g i.v. daily) may also be of benefit. For lower gastrointestinal bleeding or if there is no obvious upper gastrointestinal lesion during endoscopy, then selective mesenteric angiography with embolisation of the bleeding point (if the bleeding is brisk, e.g. > 0.5-2.0 mL/min) or colonoscopy with electrocautery or adrenaline injection (for diverticular haemorrhage) may be considered as an alternative to surgery. CONCLUSIONS: Acute upper gastrointestinal bleeding is often managed by intravenous proton pump inhibitors and endoscopy with electrocautery or adrenaline injection when a bleeding at the base of an ulcer is found. For lower gastrointestinal haemorrhage, selective mesenteric angiography with embolisation of the bleeding point is an alternative to surgery in critically ill patients. Fibrinolytic inhibitors may have added benefit.

Journal Article↗
PubMed1989

Hypotension and bleeding with various anatomic patterns of blunt splenic injury in adults.

A retrospective study of 112 consecutive adult patients with blunt splenic lacerations was performed. All of the patients had operative grading of the splenic injuries according to a prospective protocol. Data on preoperative hypotension (systolic blood pressure of less than 100) and intraoperative splenic bleeding were collected from hospital records. Patients with subcapsular hematomas were excluded. Over-all, 55.4 per cent of the patients with splenic lacerations were hypotensive preoperatively and 76.6 per cent were noted to be bleeding from the spleen at operation. For injuries not involving the hilum, seven of 22 of the patients with Grade I injuries were hypotensive preoperatively versus 19 of 29 of the patients with Grade IV injuries (p = 0.025). Fourteen of 21 patients with Grade I injuries were noted to be bleeding at operation. Seventeen of 23 with Grade IV injuries were noted to be bleeding. This difference was not significant. Of the patients with injuries involving the hilum, 25 of 38 were hypotensive preoperatively and 25 of 29 were noted to be bleeding at operation. No difference in the incidence of hypotension or bleeding was found between superficial and deep hilar injuries. No significant difference was found between the active bleeding with hilar and nonhilar injuries (p = 0.19). For isolated splenic injuries (N = 36), the incidence of hypotension was 39 per cent. However, 79 per cent of the patients with isolated splenic injuries were noted to be bleeding at operation. Of 49 patients with nonisolated splenic injuries who had been hypotensive preoperatively, 72.9 per cent were found to be bleeding at operation. Of the 27 patients never hypotensive preoperatively, 78 per cent were noted to be bleeding at operation (NS). For isolated splenic injury also, no relationship was found between preoperative hypotension and the presence of operative bleeding. No significant correlation was found between preoperative hypotension or the anatomic grade of splenic injury and the incidence of bleeding found at operation. Even if computed tomographic scans can reliably grade splenic injuries, anatomic grade may not be a predictor of clinical behavior. Hypotension also failed to predict the occurrence of continued splenic bleeding.

Adolescent↗