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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.

Aged↗

PubMed1979

A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices.

In a 25 month study of massive upper-gastrointestinal hemorrhage, 64 patients were shown to have esophageal varices on emergency endoscopy. Twenty-four patients were actively bleeding from varices and were treated with a Sengstaken tube, and in 22 this was followed by emergency injection sclerotherapy using a rigid esophagoscope and general anesthesia. These 22 patients were followed prospectively and had 51 episodes of endoscopically proven active bleeding from esophageal varices which required Sengstaken tube control of hemorrhage during 36 separate admissions. This group included our total experience of injection sclerotherapy in acute variceal bleeding. The majority (14 of 22 patients) had alcoholic cirrhosis. Definitive control of variceal bleeding during the period of hospitalization was achieved in 33 hospital admissions (92%), usually with a single injection (27 hospital admissions: 75%). The results were satisfactory in 26 hospital admissions (72%). There were nine deaths (41% overall patient mortality rate), but no patient died primarily of variceal bleeding, and exsanguinating variceal bleeding was no longer a problem. The mortality rate per injection was 18%, and the mortality rate per hospital admission was 25%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients with proven bleeding esophageal varices who do not stop bleeding on initial conservative treatment.

Acute Disease↗

PubMed1992

Terlipressin vs. somatostatin in bleeding esophageal varices: a controlled, double-blind study.

Fifty episodes of bleeding from esophageal or gastric varices in 33 patients with cirrhosis were randomized to treatment with either intravenous terlipressin (2 mg initially and 1 mg every 4 hr for 24 hr together with bolus injection and continuous infusion of placebo) or with somatostatin (250 micrograms as a bolus and continuous infusion of 250 micrograms/hr somatostatin for 24 hr and placebo injections). Standard therapy with transfusions, fluid and electrolyte correction and lactulose was administered in both groups. In the terlipressin group, 22 of 25 bleeding episodes (88%) were initially stopped by the vasoactive drugs, and in the somatostatin group 19 of 25 bleeding episodes (76%) were initially stopped by the vasoactive drugs. Two of the three bleeding episodes not arrested by terlipressin and five of the six bleeding episodes not arrested by somatostatin were controlled by balloon tamponade. In one patient in each group variceal bleeding initially could not be stopped, and the patients died. The failure rate of the vasoactive treatment alone, including rebleeding episodes within the study period, was 20% in the terlipressin group and 32% in the somatostatin group. The control rate, including balloon tamponade, was 96% in both groups. The hospital mortality rate was 16% (4 of 25) in the terlipressin group and 24% (6 of 25) in the somatostatin group. Blood transfusions, use of balloon tamponade and duration of bleeding did not differ significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed1979

Gastrointestinal bleeding in cases of ruptured cerebral aneurysms.

Among 1,000 cases of patients undergoing direct surgery on cerebral aneurysms, two, showed clear signs of preoperative, and 19 cases showed postoperative gastrointestinal bleeding. We have made a clinical analysis of various aspects of the 19 cases in which the bleeding developed postoperatively. 1. Gastrointestinal bleeding was most frequent postoperatively in cases of AComA aneurysms (4.3%) and ICA aneurysms (2.0%), and less common in MCA and ACA aneurysm cases. 2. Gastrointestinal bleeding was most frequently seen in those cases operated on between the third and seventh days after the last subarachnoid haemorrhage (8.9%) and was more common in cases with a relatively poor preoperative grade. 3. The development of such bleeding in cases with a good preoperative grade was due to problems with the surgical operation in most cases, although the influence of vasospasm must not be ignored. The development of bleeding in cases with a poor preoperative grade is thought to be due primarily to vasospasm and transitory brain damage to the hypothalamus and the orbital portion of the anterior lobe due to a haematoma caused by aneurysm rupture. 4. First, the location of gastrointestinal bleeding should be determined endoscopically and, if haemostasis is not achieved by coagulation, then the desirability of surgery should be considered early. Abdominal surgery may be performed.

Adult↗

PubMed1979

Multiple bleeds in haemophilia A.

One hundred and eighty-one bleeding episodes involving two sites simultaneously were noted during a survey of 4935 bleeding episodes, an incidence of 3.7%. Elbows, knees and ankles were the commonest sites involved in double bleeds, while the thigh, upper arm and elbow were the commonest sites involved in the double bleeds needing most transfusions. The overall transfusion requirements were less than for single bleeds. The frequency of multiple bleeds correlated significantly with the overall bleeding frequency, but not with the number of days under observation.

Ankle↗

PubMed1976

Emergency arteriography in acute gastrointestinal bleeding.

Emergency arteriography was carried out on 35 patients with acute gastrointestinal bleeding, in 31 of them within two hours of active bleeding (a haematemisis; a diagnostic change in central venous pressure, pulse rate, or blood pressure; or gastric aspiration of fresh blood). A definite site of bleeding was identified in 27 patients (77%)-this being a small-intestinal vascular abnormality in three--and a probable site in three. Confirmation of the bleeding site was obtained in 20 out of 23 patients treated surgically. An intra-arterial vasoconstrictor infusion was given as a temporary measure before surgery in seven patients, only one of whom showed active bleeding at operation. An intra-arterial vasoconstrictor infusion was tried as definitive treatment in an additional 10 patients, but in four out of seven with a chronic ulcer bleeding recurred after 5-68 hours and was therefore treated surgically. We recommend the diagnostic use of arteriography in patients with reliable evidence of active bleeding if its site cannot be determined by endoscopy. We do not recommend its therapeutic use in those with a chronic ulcer, except to facilitate resuscitation before surgery; further studies are needed to define its role in those with an acute lesion.

Aged↗

PubMed1979

Patterns of bleeding in adolescents with severe haemophilia A.

Eighty-two boys with severe haemophilia A who spent some time at Lord Mayor Treloar College during 1973-7 were studied. All episodes of bleeding that occurred during term time were recorded, along with the number of transfusions. The bleeding frequency among these boys, most of them aged 10-17 years, increased steadily from 8,31 episodes/100 days in 1973 to 12,63 episodes/100 days in 1977. At the same time there was a steady fall in bleeding frequency with age. Altogether 24% of bleeding episodes were into the elbow joint, 22% into the knee, and 15% into the ankle. As the boys grew older the proportion of bleeding episodes in the legs declined and that in the arms increased. The overall results reflect the fact that special schools now see only the severest cases of haemophilia. The pattern of bleeding during adolescence suggests that concepts of management of arm bleeding need modifying.

Adolescent↗

PubMed1976

Abnormal uterine bleeding.

The management of patients with abnormal uterine bleeding requires a logical, rational approach, and an awareness of etiologic factors. A careful history and examination should attempt to answer these questions: (1) Is the bleeding truly from the uterus? (2) Is the bleeding superimposed upon ovulatory cycles or (3) is the bleeding anovulatory? The endometrial biopsy obtained during the bleeding episode, and the basal temperature chart are diagnostically useful. Massive uterine bleeding not due to a complication of pregnancy, neoplasis, or blood dyscrasia, usually responds immediately to curettage, done in operating room or office; follow-up hormonal therapy with progesterone and a progestational agent should control the episode. More chronic forms of abnormal uterine bleeding are approached by identifying and treating the etiologic cause. If the cause is not correctable (e.g., obesity), most patients will respond satisfactorily to the cyclic administration of a progestational agent, or, if indicated, to induction of ovulation.

Dilatation and Curettage↗

PubMed1979

In vivo platelet retention in human bleeding-time wounds. II. Effect of aspirin ingestion.

PRB was studied in normal human subjects before and after aspirin ingestion. Aspirin ingestion resulted in a prolongation of individual bleeding times greater than 2.4 min (greater than 2 S.D. beyond the group mean before aspirin) in 62.5% of 48 paired studies. The relationship of platelets retained vs. time was linear during the first 3 min of bleeding before and after aspirin. The mean PRB decreased from 22.1 +/- 9.2 to 9.6 +/- 8.6 (p less than 0.001) after aspirin ingestion. Subjects whose bleeding time was prolonged greater than 2.4 min had a significantly higher mean PRB before aspirin and a significantly greater mean decrease in PRB after aspirin than those whose bleeding time was prolonged less than or equal to 2.4 min. Aspirin ingestion reduced the number of EDTA-irreversible clumped platelets present in wound blood approximately 50% during the second and third minute of bleeding, but large numbers of EDTA-reversible platelet clumps were observed in wound blood before and after aspirin. Although platelet retention was significantly decreased during the first 3 min of bleeding after aspirin, the percent of venous blood platelets present in wound blood just prior to the arrest of hemorrhage was equal before and after aspirin. These observations indicate that aspirin prolongs the bleeding time by decreasing platelet clumping and slowing the rate of platelet thrombus formation in severed blood vessels. The presence of platelet clumps in wound blood after aspirin ingestion indicates that alternative mechanisms of platelet aggregation, independent of the arachidonate pathway of prostaglandin synthesis, proceed in vivo unaltered by aspirin.

Adult↗

PubMed1992

Localization of obscure gastrointestinal bleeding by technetium 99m-labeled red blood cell scintigraphy.

When a bleeding source from the gastrointestinal (GI) tract cannot be identified with conventional diagnostic studies, it is known as GI bleeding of an obscure origin. In the past three years, in vivo Technetium 99m-labeled red blood cell scintigraphy (RBC scan) has been added to our armamentarium for the diagnosis of obscure GI bleeding. Out of a total of 26 cases, the bleeders could be detected in 12 or 46.2% by RBC scan. The time required ranged from 15 minutes to 24 hours (median, one hour). In 14 patients with active bleeding during the scan period, 11 had positive scans (sensitivity, 78.6%). In 12 patients with inactive bleeding, 11 had negative scans (specificity, 91.7%). Angiography was conducted in nine cases, with all showing negative findings; however, six of them had a positive focus by RBC scan. Laparotomy was performed in seven scan-positive patients, and in three scan-negative patients because of a positive Meckel's scan (two cases) or recurrent bleeding (one case). Of the 12 scan-positive patients, incorrect localization was noted in two patients due to rapid transit of the labeled RBC in the small bowel. False localization could be prevented by shortening the sequential imaging interval. It is concluded that an RBC scan is a very sensitive and safe tool for detection of GI bleeding of an intermittent nature, because the bleeder can be monitored for 24 hours after a single injection. It can be used as a preangiographic screening test and to guide the surgeon in surgical planning or decision-making.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1979

[Gastrointestinal bleeding in cases of ruptured cerebral aneurysms (author's transl)].

Among the 1,000 cases of direct surgery on cerebral aneurysms, two cases showed clear signs of preoperative and 19 cases showed postoperative gastrointestinal bleeding. Here we have made a clinical analysis of various aspects of the 19 cases in which the bleeding developed postoperatively. (1) Gastrointestinal bleeding was most frequent postoperatively in cases of VBA aneurysms (4.3%) and AcomA aneurysms (2.9%) and less common in MCA and ACA aneurysm cases. (2) Gastrointestinal bleeding was most frequently seen in those cases operated on between the third and seventh days from the last hemorrhage attack (9.0%) and was more common in those cases with a relatively poor preoperative grade. (3) The development of such bleeding in cases with a good preoperative grade was due to problems with the surgical operation in most cases, although the influence of vasospasm must not be ignored. The development of bleeding in cases with a poor preoperative grade is thought to be due primarily to vasospasm and transitory brain damage to the hypothalamus and the orbital portion of the anterior lobe due to hematoma caused by aneurysm rupture. (4) First the location of gastrointestinal bleeding should be determined endoscopically and, if hemostasis is not possible even after attempted coagulation, then the desirability of surgery should be determined in an early period and abdominal surgery performed.

Adult↗

PubMed1979

Evaluation of gastrointestinal bleeding by red blood cells labeled in vivo with technetium-99m.

To determine the effectiveness of abdominal imaging with RBCs labeled in vivo with Tc-99m, for the detection of gastrointestinal (GI) bleeding, 28 control subjects and ten patients with suspected bleeding underwent scintigraphy at 0-24 hr after tracer injection. Colonic activity was noted in one of the controls within 3 hr of injection, and in five of ten controls at 24 hr, all of whom had initial gastric activity. Of the ten patients with suspected GI bleeding, eight had documented active bleeding; seven of these had positive scintigrams. Nasogastric (NG) suction markedly decreased the presence of initial gastric activity in the patients with active bleeding. With this blood-pool radiopharmaceutical, frequent imaging of the abdomen over 24 hr can be done to test active bleeding. Continuous NG suction is recommended to reduce accumulation of gastric activity. These results suggest that red blood cells labeled in vivo with Tc-99m provide a sensitive method of detecting active GI bleeding.

Adult↗

PubMed1976

Studies on the prolonged bleeding time in von Willebrand's disease.

Three experimental models have been employed to investigate the mechanism of the prolonged bleeding time in patients with von Willebrand's disease (vWd). 1-deamino-8-D-arginine vasopressin (DDAVP), a synthetic analogue of the antidiuretic hormone, was administered to normal volunteers and patients with vWd in order to induce a short-term, endogenous increase of factor VIII procoagulant activity (VIIIAHF), factor VIII-related antigen (VIIIAGN), and Willebrand factor (VIIIVWF); and to investigate the relationship between bleeding time and plasma variations of factor VIII-associated properties. In normal subjects DDAVP administration was followed by a marked increase of VIIIAHF, VIIIAGN, and VIIIVWF; yet the bleeding time remained unchanged. The same parameters were also raised in two groups of patients with vWd. In a third group of patients with severe recessive vWd, factor VIII-associated properties, which were not measurable before the infusion, were unmodified. The bleeding time remained unchanged in all vWd patients. To investigate the effect of the exogenous increase of factor VIII-associated properties, cryoprecipitate was given to ten vWd patients before dental surgery. Despite the marked increase of VIIAHF, VIIAGN, and VIIVWF observed after the infusion, bleeding time was not shortened. Finally, in order to evaluate the hypothesis that factor VIII may exert its effect on primary hemostasis locally in the vessel wall, VIIIAGN and its relationship with the bleeding time were studied by direct immunofluorescence in gum-biopsy specimens obtained in vWd patients before cryoprecipitate infusion. No reaction could be elicited in five patients with severe, recessive vWd, whereas venules and arterioles stained positively in five patients with a moderate form of the disease. Immunofluorescence microscopy was also carried out in specimens obtained after cryoprecipitate at a time when the plasma defects were corrected but the long bleeding time was not modified; no reaction was detectable on the vessel wall of the three patients who were negative before the infusion.

Adult↗

PubMed1979

Shortening of the bleeding time in thrombocytopenic rabbits after exposure of jugular vein to high aspirin concentration.

Aspirin, in doses which inhibit platelet thromboxane A2 production, prolongs the bleeding time but this effect on the bleeding time is lost when doses of aspirin which also inhibit vessel wall prostaglandin I2 (PGI2) production are used. PGI2 is both a potent inhibitor of platelet aggregation and a powerful vasodilator. We have investigated the contribution of the vascular effect of PGI2 on hemostasis by studying the effect of high concentrations of aspirin on the jugular vein bleeding time in severely thrombocytopenic rabbits and on the loss of non-platelet-containing fluid from standard puncture wounds in aspirin-treated veins perfused under constant pressure. After aspirin treatment, the bleeding time was significantly shortened in both normal and thrombocytopenic rabbits. This effect was associated with a decreased production of PGI2-like material by the vessel wall and a reduction in the volume of fluid lost from the standard puncture wound in the jugular vein. The effect of aspirin on the bleeding time and on PGI2 production was relatively short-lived and the bleeding time returned to normal within 2-3 hours. These observations indicate that PGI2 can influence hemostasis by mechanisms independent of platelet aggregation.

Animals↗

PubMed2025

Exome-wide association study of bleeding events in patients receiving direct oral anticoagulants.

BackgroundDirect oral anticoagulants (DOACs) are first-line medications for stroke prevention in non-valvular atrial fibrillation (AF). However, variability in drug response poses risks of hemorrhagic or thromboembolic events.ObjectivesAlthough genetic influences on DOACs safety are increasingly recognized, robust evidence directly linking specific polymorphisms to bleeding risk remains limited.DesignMulti-center observational case-control study including exome-wide association analysis of 196 non-valvular AF patients treated with rivaroxaban or apixaban, comprising 97 with bleeding complications and 99 without.MethodsDOAC plasma concentrations, urinary 6-β-hydroxycortisol and cortisol levels were measured for CYP3A4 phenotyping. Sequencing was performed on the DNBSEQ G-400 platform. Single-nucleotide variant (SNV) associations with bleeding risk were assessed using logistic regression with additive, dominant, and recessive genetic models. Polygenic risk scores (PRSs) were calculated to evaluate cumulative genetic effects.ResultsNo SNVs reached Bonferroni-corrected significance under any model. PRSs showed weak predictive ability for bleeding with apixaban. For rivaroxaban, regression indicated that ln Css min/D + 1 index increased with PRS, age, and 6-β-hydroxycortisol/cortisol ratio, but decreased with higher 6-β-hydroxycortisol and coronary heart disease presence. No statistically significant differences were found for the PharmGKB Level 3 variants rs1045642 (rivaroxaban) and rs2231142 (apixaban). Trends toward statistical significance were observed for the rs2472304-G variant in rivaroxaban users, rs6977165-C in apixaban users, and for the CYP3A4*1/*36 diplotype.ConclusionResidual equilibrium concentration of DOACs, including dose-adjusted, did not independently predict bleeding risk in non-valvular AF patients. Variants rs2472304 and rs6977165 may warrant further investigation as potential contributors to bleeding risk.

Humans↗

PubMedDate not supplied

Reference period analysis of vaginal bleeding with triphasic oral contraceptive agents containing norethindrone or levonorgestrel: a comparison study.

The World Health Organization recommends the use of fixed reference periods for quantification of the incidence and severity of vaginal bleeding when patients use various forms of contraception. Ninety- and 110-day reference periods were used in the analysis of data from daily menstrual diaries kept by 72 healthy women in a one-year study of oral contraceptive agents containing ethinyl estradiol and either norethindrone or levonorgestrel. Analysis of bleeding patterns reported during both 90-day and 110-day periods revealed fewer days of bleeding and/or spotting overall with norethindrone than with levonorgestrel (e.g., a mean of 16.06 vs. 19.55 days, respectively, over the first 90-day period; P = .013) and significantly shorter bleeding and/or spotting episodes with the norethindrone preparation. This trend persisted when data were adjusted for a day-1 pill start. Using either method of analysis, duration of bleeding episodes was shorter among subjects taking norethindrone than levonorgestrel. Pills were missed in both study groups, but more women in the LNG/EE group missed from 1 to 3 pills in at least one cycle (31 vs. 21 in the NET/EE group). The between-group difference in bleeding events may be due to intrinsic hormonal differences in regimens or to the greater number of pills missed among levonorgestrel users.

Adult↗

PubMed1975

Electrocoagulation of bleeding in the upper part of the gastrointestinal tract: a preliminary experimental clinical report.

Electrocoagulation of gastric or esophageal bleeding sites was evaluated in dogs using a flexible suction coagulator electrode passed through the endoscope using an electrocautery unit (Cameron-Miller model 80-7910). Acute and chronic coagulation studies in 25 dogs showed that electrocoagulation of both the esophageal and gastric mucosa was safe at an electrocautery unit setting of 5 for three to five seconds. This level of coagulation was successful in stopping bleeding created from actively bleeding esophageal and gastric mucosal defects by taking multiple large biopsy specimens. Based on these data, six patients with active bleeding gastric lesions have undergone mucosal coagulation. This successfully stopped the bleeding initially in all six patients; two patients rebled and required operative intervention within 48 hours. Further clinical evaluation is being implemented to determine its clinical role in the treatment of bleeding in the upper part of the gastrointestinal tract.

Adult↗

PubMed1978

Transcatheter therapy of gastrointestinal arterial bleeding.

Transcatheter therapy for arteriocapillary gastrointestinal bleeding is often an effective form of treatment. The choice of transcatheter therapy (ie, vasoconstrictor or occlusive) often is dependent on the etiology and location of bleeding. Vasopressin is a generally safe form of treatment which is often successful in treating bleeding secondary to gastritis, Mallory-Weiss mucosal tears, and diverticular disease. It is less effective in treating bleeding peptic ulcers, neoplastic bleeding, or bleeding when clotting abnormalities exist. Occlusive therapy is an effective alternate form of therapy in selected circumstances. Ischemic complications from vasoconstrictor and embolic therapy may occur and require appropriate caution and discretion with their use.

Aged↗