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PubMed1992

Frequency of upper gastrointestinal bleeding in a pediatric intensive care unit.

OBJECTIVE: To determine the frequency of upper gastrointestinal (GI) bleeding in pediatric ICUs. DESIGN: Prospective, descriptive study. SETTING: Pediatric ICU in a university hospital. PATIENTS: All children admitted to a pediatric ICU over a 55-wk period. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Upper GI bleeding was considered to be present if there was an episode of hematemesis or if any amount of blood was seen in drainage from a nasogastric tube. Sixty-three (6.4%) upper GI bleeds were detected among 984 patients: 5.2% in 698 patients who did not receive upper GI bleeding prophylaxis, and 9.4% in 286 patients who did receive some prophylaxis. Density was defined as the number of events/1000 days.patient. The mean density was 10.8 GI bleeding episodes/1000 days.patient in a pediatric ICU. A multivariate analysis detected four independent risk factors or risk markers for upper GI bleeding: high Pediatric Risk of Mortality score, coagulopathy, pneumonia, and multitrauma. Age, sex, hepatic and respiratory failures were identified as confounding variables. An upper GI bleeding episode was defined as being clinically important if hypotension, death, or transfusion occurred within 24 hrs after the bleeding. There were four clinically important GI bleeding episodes. All were caused, at least in part, by a coagulopathy. The GI bleeding was associated with a need for transfusion in four children, and with hypotension in two. CONCLUSIONS: The frequency of upper GI bleeding is substantial, but the rate of occurrence of clinically important upper GI bleeding is low, even in a pediatric ICU where most patients do not receive any prophylaxis.

Adolescent↗
PubMed2005

Low utility of endoscopy for suspected upper gastrointestinal bleeding occurring in hospitalized patients.

OBJECTIVES: To determine the clinical utility of upper endoscopy in patients who have upper gastrointestinal bleeding after hospitalization. METHODS: Patients were studied who underwent upper endoscopy for an indication of suspected upper gastrointestinal bleeding that developed more than 48 hours after hospitalization. Demographic, clinical, and endoscopic data were extracted by chart review. Bleeding was characterized as clinically important (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion) or non-clinically important. RESULTS: Eighty-six patients met inclusion criteria. Clinically important bleeding occurred in 17%. Peptic ulcer disease and gastritis were the most common sources of bleeding in the clinically important and non-clinically important groups, respectively. The bleeding source was not found in 24% of patients. Endoscopic therapy was required in 11% (all of whom had clinically important bleeding). Upper endoscopy prompted no treatment changes in the non-clinically important bleeding group. CONCLUSIONS: Endoscopic therapy was needed only in the few patients with clinically important bleeding. Nonendoscopic treatment can be recommended for upper gastrointestinal bleeding developing in hospitalized patients who do not meet established criteria for a clinically important bleed.

Adult↗
PubMed2003

External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage.

BACKGROUND: Bleeding pelvic fractures (BPF) carry mortality as high as 60%, yet controversy remains over optimal initial management. Some base initial intervention on fracture pattern, with immediate external fixation (EX FIX) in amenable fractures aimed at controlling venous bleeding. Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim was to evaluate markers of arterial bleeding in patients with BPF, thus identifying patients requiring early ANGIO regardless of fracture pattern. METHODS: Patients with pelvis fracture were identified from a Level I trauma center registry over a 7-year period and records reviewed. From this group, two subsets were analyzed: those with initial hypotension related to pelvic fracture, and those without hypotension who underwent pelvic ANGIO. Data included hemodynamics, response to resuscitation, presence of contrast blush on CT, fracture treatment and outcome. Adequate response to initial resuscitation (R) was defined as a sustained (>2 hours) improvement of systolic blood pressure to >90 mm Hg systolic after the administration of < or = 2 units packed red blood cells. Those with repeated episodes of hypotension despite resuscitation were classified as non-responders (NR) RESULTS: From 1/94-1/01, 1171 patients were admitted with pelvic ring fracture. Thirty-five (0.3%) had hypotension attributable to pelvis fracture. 28 fell into the NR group, and 26 of these underwent ANGIO. Nineteen (73%) showed arterial bleeding while 3 resuscitation response patients underwent ANGIO with none demonstrating bleeding (p = 0.03). Sensitivity and specificity of inadequate response to initial resuscitation for predicting the presence of arterial bleeding on ANGIO were 100% and 30% respectively while negative and positive predictive value were 100% and 73%. In patients with fractures amenable to external fixation (n = 16), 44% had arterial bleeding on ANGIO, and all were in the NR group. An additional 17 patients without hypotension also underwent ANGIO. Contrast blush on admission CT was seen in 4, 3 of which had arterial bleeding seen on ANGIO (75%). Sensitivity and specificity for contrast blush in predicting bleeding on ANGIO were 60% and 92% with positive and negative predictive value being 75% and 85%. CONCLUSIONS: In patients with hypotension and pelvic fracture, therapy selection based on initial response to resuscitation in BPF yields a 73% positive ANGIO rate in NR patients. Delay in ANGIO for EX FIX in patients with amenable fractures would have delayed embolization in the face of ongoing arterial bleeding in 44% of patients. In stable patients with pelvic fracture, contrast blush also indicates a high likelihood of arterial injury and ANGIO is indicated. Optimal therapy in the face of BPF requires early determination of the presence of arterial bleeding so that ANGIO can be rapidly obtained, and response to initial resuscitation as well as the presence of contrast blush aid in this decision.

Adult↗
PubMed2005

Review article: the management of lower gastrointestinal bleeding.

Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.

Acute Disease↗
PubMed1995

Rectal bleeding: prevalence and consultation behaviour.

OBJECTIVES: To determine prevalence of rectal bleeding in the community and to examine factors that lead some patients to consult their general practitioner about rectal bleeding while others do not. DESIGN: Questionnaire survey followed by semistructured interviews of sample of respondents with rectal bleeding. SETTING: Two general practices on Tyneside. SUBJECTS: 2000 adult patients registered with the general practices were sent a validated questionnaire. Respondents with rectal bleeding were divided into consulters and non-consulters, and 30 patients from each group (matched for age, sex, and characteristics of bleeding) were interviewed. MAIN OUTCOME MEASURES: Prevalence of rectal bleeding, proportion of subjects with rectal bleeding who sought medical advice, and reasons for consulting or not consulting a doctor about rectal bleeding. RESULTS: 287 of the 1200 respondents to the questionnaire had noticed rectal bleeding at some time in their lives, and 231 had noticed it within previous 12 months. Only 118 (41%) of all respondents with rectal bleeding had ever sought medical advice for the problem. Those aged over 60 were most likely to have consulted, as were those who reported blood mixed with their stools. Main difference between those who had sought medical advice and those who had not was that consulters were more likely than non-consulters to perceive their symptoms as serious. CONCLUSIONS: Although rectal bleeding is common, only minority of patients seek medical of symptoms seems to be most important factor in deciding whether to consult a doctor for rectal bleeding.

Adult↗
PubMed2001

Inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective cohort study.

OBJECTIVES: To determine the association between inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding. DESIGN: Retrospective cohort study from population based databases. SETTING: Ontario, Canada. PARTICIPANTS: 317 824 elderly people observed for more than 130 000 person years. The patients started taking an antidepressant between 1992 and 1998 and were grouped by how much the drug inhibited serotonin reuptake. Patients were observed until they stopped the drug, had an upper gastrointestinal bleed, or died or the study ended. MAIN OUTCOME MEASURE: Admission to hospital for acute upper gastrointestinal bleeding. RESULTS: Overall, 974 bleeds were observed, with an overall bleeding rate of 7.3 per 1000 person years. After controlling for age or previous gastrointestinal bleeding, the risk of bleeding significantly increased by 10.7% and 9.8%, respectively, with increasing inhibition of serotonin reuptake. Absolute differences in bleeding between antidepressant groups were greatest for octogenarians (low inhibition of serotonin reuptake, 10.6 bleeds/1000 person years v high inhibition of serotonin reuptake, 14.7 bleeds/1000 person years; number needed to harm 244) and those with previous upper gastrointestinal bleeding (low, 28.6 bleeds/1000 person years v high, 40.3 bleeds/1000 person years; number needed to harm 85). CONCLUSIONS: After age or previous upper gastrointestinal bleeding were controlled for, antidepressants with high inhibition of serotonin reuptake increased the risk of upper gastrointestinal bleeding. These increases are clinically important for elderly patients and those with previous gastrointestinal bleeding.

Acute Disease↗
PubMed2006

Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT.

PURPOSE: To prospectively evaluate accuracy of arterial phase multi-detector row helical computed tomography (CT) for detection and localization of acute massive gastrointestinal (GI) bleeding, with angiography as reference standard. MATERIALS AND METHODS: Institutional review board approved this study; written informed consent was obtained from each patient or patient's family after procedures, including radiation dose, were explained. Twenty-six consecutive patients (17 men, nine women; age range, 18-89 years) had acute massive GI bleeding (defined as requirement of transfusion of at least 4 units of blood during 24 hours in the hospital or as hypotension with systolic blood pressure <90 mm Hg) and underwent arterial phase multi-detector row CT before angiography. Scans were obtained during arterial phase to identify extravasation of contrast material with attenuation greater than 90 HU within bowel lumen; this finding was considered diagnostic for active GI bleeding. Presence of contrast medium extravasation in each anatomic location was recorded. Sensitivity, specificity, positive and negative predictive values, and accuracy of multi-detector row CT for detection of acute GI bleeding were assessed. Accuracy for localization of acute GI bleeding was assessed by comparing locations of active bleeding at both multi-detector row CT and angiography in each patient who had active bleeding. RESULTS: Arterial phase multi-detector row CT depicted extravasation of contrast material in 21 of 26 patients. Overall location-based sensitivity, specificity, accuracy, and positive and negative predictive values of multi-detector row CT for detection of GI bleeding were 90.9% (20 of 22), 99% (107 of 108), 97.6% (127 of 130), 95% (20 of 21), and 98% (107 of 109), respectively. Overall patient-based accuracy of multi-detector row CT for detection of acute GI bleeding was 88.5% (23 of 26). The location of contrast material extravasation on multi-detector row CT scans corresponded exactly to that of active bleeding on angiograms in all patients with contrast medium extravasation at both multi-detector row CT and angiography. CONCLUSION: Arterial phase multi-detector row CT is accurate for detection and localization of bleeding sites in patients with acute massive GI bleeding.

Acute Disease↗
PubMed2005

Gastrointestinal bleeding rates among managed care patients newly started on cox-2 inhibitors or nonselective NSAIDs.

OBJECTIVE: While cyclooxygenase-2 (COX-2) inhibitors were introduced to the U.S. market with the promise of less gastrointestinal (GI) toxicity than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), additional research is needed to examine this outcome in the naturalistic setting. The objective of this study was to examine whether use of COX-2 inhibitors is associated with reduced risk of GI bleed in a managed care population. METHODS: Adult patients in a multistate managed care organization that were initiated on a nonselective NSAID between January 1999 and August 2002 were identified and matched using propensity scoring with patients in the same managed care organization that were initiated on a COX-2 inhibitor. Matching variables included age, gender, geographical state, comorbidity index, corticosteroid use, warfarin use, arthritis indication, and history of recent GI bleed. Patients were followed until they switched or discontinued their NSAID or COX-2 inhibitor, disenrolled from the health plan, developed a GI bleed, or reached the end of the 1-year follow-up period. A GI bleed was defined as an inpatient hospitalization for GI bleed or at least 2 medical claims with a primary diagnosis for GI bleed. The relative risk (RR) of GI bleed was calculated using proportional hazards regression. RESULTS: Overall, 35,007 pairs of COX-2 inhibitor and nonselective NSAID users were evaluated. Mean age was 63 years, and 65% were female. There were 375 cases of GI bleed among 19,201 follow-up years for COX-2 users (19.5 cases per 1,000 person-years) versus 228 cases of GI bleed among 12,680 follow-up years for NSAID users (18.0 cases per 1,000 person-years). The risk of GI bleed was not significantly different for COX-2 users compared with nonselective NSAID users (RR 1.07; 95% confidence interval [CI], 0.90-1.26). Even among high-risk patients, there was no reduction in the risk of a GI bleed among users of COX-2 inhibitors (RR 0.995; 95% CI, 0.84 -1.19). CONCLUSION: Overall, within this managed care population, COX-2 inhibitor users did not have a reduced risk of a GI bleed compared with patients with similar baseline characteristics using nonselective NSAIDs.

Adult↗
PubMed1981

Endoscopic YAG-laser treatment in massive upper gastrointestinal bleeding. Report of a controlled randomized study.

In patients with massive upper gastrointestinal bleeding the results of endoscopic control by coagulation with YAG-laser have been compared with the results of an active surgical approach with early operation in a controlled randomized study. The laser coagulation was done at admission in patients in whom an actively bleeding lesion was diagnosed at endoscopy. Of the 66 patients belonging to the laser group, 23 were bleeding at admission and endoscopy, and in 15 of these coagulation was attempted and initial haemostasis was achieved in 14. Seven of the latter rebled and five of them were then operated upon with on postoperative death. Two patients died from bleeding oesophageal varices and hepatic failure. In the patient in whom haemostasis was not achieved, an operation was done for a duodenal ulcer. She died postoperatively. Of the 43 patients belonging to the laser group and not bleeding at endoscopy, nine patients rebled and three of them were operated upon, the with on postoperative death. An additional four patients died in this group, three of bleeding oesophageal varices in combination with hepatic failure and one of bleeding from an unknown source. Sixty-nine patients belonged to the control group and in 19 of these patients bleeding lesions were diagnosed at endoscopy. Five of these were operated upon, with two postoperative deaths. An additional three patients died of bleeding oesophageal varices and hepatic failure. Of the 50 patients belonging to the control group and not bleeding at endoscopy, eight later showed signs of recurrent bleeding. Four of them had oesophageal varices and two died. The other four with recurrent bleeding were operated upon with no postoperative mortality. Thus nine patients (five with oesophageal varices) died in the laser group and seven (five with oesophageal varices) in the control group. There was no statistically significant difference between the two groups regarding mortality, need of blood transfusion or time of treatment in the hospital. However, the material is too small to make any definite conclusions, and further studies are necessary in which laser treatment is compared with an aggressive surgical policy with early operations.

Aged↗
PubMed2000

[Gastrointestinal bleeding in children--etiology and diagnosis. Survey of patients in a Tel Aviv medical center, in the years 1990 to 1997].

During 1990-1997 we investigated 201 children with gastrointestinal bleeding. Average age was 3.9 +/- 6 years; 57.2% were males. There were 129 (64.2%) cases of lower and 72 (35.8%) of upper GI bleeding. Complications of upper GI bleeding were more severe than those of the lower: 6 of 8 (75%) patients who deteriorated into hypovolemic shock had upper GI bleeding; 40 of 50 (80%) who required i.v. fluids (crystaloids and/or blood) had also bled from the upper GI tract; but anemia was more frequent (27.7% vs 17%) in lower GI bleeding. The main etiology for upper GI bleeding was peptic ulcer, and for lower GI bleeding anal fissure. Mean hospital stay for upper GI bleeding was 3.87 +/- 2.61 days vs 3.40 +/- 3.51 for lower (not significant). In 34% the etiology of bleeding was undetermined. Although current literature refers to intussusception as a common cause of GI bleeding in infancy, we had no such cases. This difference might have resulted from our diagnoses being made earlier, before mucosal damage could have caused bleeding. We found polyps the second most frequent cause for lower GI bleeding in children. Endoscopy was of more benefit than any other diagnostic method, while barium enema and ultrasound had no diagnostic value. Stool culture did not contribute to diagnosis: only 3 of 36 were positive, so it is only necessary when there is bloody diarrhea.

Adolescent↗
PubMedDate not supplied

Diagnosis and treatment of bleeding colonic diverticula.

BACKGROUND/AIMS: Colonic diverticula are the most frequent cause of major lower intestinal bleeding and pose a diagnostic and therapeutic challenge to the attending physician. Emergency surgical resection is associated with a high mortality and morbidity and patients who will stop bleeding spontaneously cannot be distinguished from those who will continue to bleed. Our aim was to evaluate the efficacy of barium enema as a sole less invasive treatment option for severe diverticular bleeding. METHODOLOGY: We evaluated 102 patients admitted with colonic diverticular bleeding, from 1993 to 1997, who needed transfusion of 2 or more units of blood. We compared the clinical efficacy of surgical resection, conservative treatment, and therapeutic barium enema with regard to the cessation of bleeding, morbidity, mortality, and rebleeding rate. The therapeutic strategies used after further episodes of bleeding were also registered. RESULTS: Transfusion requirements were highest in patients who underwent surgical treatment, while the least amount of blood was required by the barium enema group (6.9 +/- 3.1 vs. 3.6 +/- 1.5 units of blood). However, the quantity of transfused blood did not correlate with the initial hemoglobin level, which was highest in the conservative treatment group and lowest in the operative group (9.0 +/- 1.2 vs. 8.1 +/- 1.3 g/dL). These data support the fact that the most severe bleeding would necessitate surgical resection and that therapeutic barium enema may be considered more effective than conservative treatments. With regard to the outcome of treatment, conservative treatment led to a rebleeding rate of 43.3%, which differed significantly from a 15.9% rebleeding rate after therapeutic barium enema (P = 0.009). No rebleeding was registered in surgically treated patients. Sixty percent of patients in whom therapeutic barium enema failed were treated by colonic resection without mortality, while 77% of patients who had rebleeding after conservative treatment were successfully treated with barium enema. Overall, barium enema was the most frequently applied second-line treatment (56.5%). The mortality after surgery was significantly higher than that after other treatment modalities (33% vs. 1%; P = 0.0001). CONCLUSIONS: If diverticular bleeding is clinically suspected as the cause of major lower intestinal hemorrhage, barium enema is a more promising alternative than conservative treatment because of diagnostic and therapeutic importance in the long-term. In the event of urgent secondary surgery following the failure of barium enema to stop bleeding, we recommend a sigmoidoscopy and, optionally, an angiography before surgery in order to first localize the bleeding. We conclude that therapeutic barium enema is the treatment of choice for the first bleeding episode, while surgical resection should be performed if rebleeding occurs.

Aged↗
PubMed2002

The assessment of bleeding patterns in postmenopausal women during continuous combined hormone replacement therapy: a review of methodology and recommendations for reporting of the data.

OBJECTIVES: To systematically review methods used to report data on bleeding patterns among postmenopausal women enrolled in clinical trials of continuous combined hormone replacement therapy (HRT); and to propose the use of standardized terms, definitions, and methods for collecting and reporting bleeding data in such trials. METHODS: A MEDLINE search identified 18 published reports of bleeding patterns among postmenopausal women enrolled in prospective clinical trials that included a continuous combined HRT treatment arm. Only two of these trials were not randomized. Methods for collecting and analyzing bleeding pattern data were collated from these published reports and examined for consistency. RESULTS: Comparisons across studies revealed little consistency in definitions and indices utilized to report bleeding patterns among postmenopausal women administered continuous combined HRT regimens in clinical trials. While a majority of the trials incorporated definitions established by the World Health Organization for the evaluation of bleeding with hormonal contraception, a number of the studies expanded on these definitions to reflect additional dimensions of bleeding such as volume. Indices calculated from daily bleeding data to describe bleeding patterns in treatment groups were highly variable among studies. CONCLUSION: Inconsistencies among clinical trials in bleeding pattern definitions and indices limit understanding and comparison of typical bleeding patterns with continuous combined HRT regimens. Standardized definitions, data collection procedures, and indices are proposed to enhance understanding of bleeding patterns with hormone therapy and enrich the quality of patient counselling on HRT.

Clinical Trials as Topic↗
PubMedDate not supplied

[Endoscopic treatment combined with adrenaline injection and coagulation with argon plasma in gastroduodenal peptic ulcer bleeding].

Although endoscopic injection therapy is an effective method for bleeding peptic ulcers, it is associated with significant re-bleeding rate; whether the addition of thermal method improves the outcome is still unclear. Our previous experience showed that Argon Plasma Coagulation (APC) alone is not sufficient in stopping spurting haemorrhage, and potentially dangerous for large non bleeding visible vessels (NBVV). Our hypothesis was that combination of adrenaline injection (AI) and thermal therapy could be more efficient than thermal therapy alone for permanent haemostasis of active bleeding peptic ulcers, and particularly appropriate for NBVV treatment. From October 1998 to February 2000 we examined two hundred patients with upper gastrointestinal bleeding. Fifty-three patients with major peptic ulcer haemorrhages received combined injection therapy with adrenaline 1:10.000 and Argon plasma coagulation; there were 34 male and 19 female with a mean age of 63.2 +/- 1.2 years (range 22-93). The bleeding site was duodenal in 30 patients, gastric in 17 patients, anastomotic in 5 patients and esophageal in 1 patient. Endoscopic findings were the following: active bleeding in 23 patients (6 spurting, 17 oozing), non bleeding visible vessels in 12 patients and fresh adherent clots in 18 patients. Initial haemostasis was achieved in 52/53 patients (98.1%). Re-bleeding was observed in 5/52 cases (9.6%). Surgery was necessary in 3/53 patients (5.6%). Mortality was 7.5% (4 cases). No major complications resulted from this treatment. Primary adrenaline injection provided initial bleeding arrest, facilitating the following application of APC, because of a more precise definition of the active bleeding site. Rates of initial hemostasis were significantly higher with combined therapy (injection + APC) compared to APC treatment alone. We believe that Adrenaline and APC combined therapy is an effective and safe method for treatment of non-variceal gastrointestinal bleeding.

Adult↗
PubMedDate not supplied

[GASTROINTESTINAL BLEEDING IN PATIENTS ADMITTED TO THECAYETADNO HEREDIA PUBLIC HOSPITAL]

A prospective study was performed to evaluate the epidemiological characteristics, clinical outcome and to determine the cause of bleeding in patients admitted to the Cayetano Heredia National Hospital with the diagnosis of gastrointestinal bleeding. Between August 1994 and May 1995, 100 patients were admitted, 86 patients with upper gastrointestinal bleeding and 14 with lower gastrointestinal bleeding. The mean age for the former was 45,25 years and the male/female ratio was 3.5/1. The main complaints were tarry stools and haematemesis in 56,9% and 26,7% only with melena. A history of non steroidal antiinflamatory drugs intake within 48 hours before the bleeding episode was obtained in 19,7% and alcohol ingestion was observed in 19,7%. In 36% of the patients a history of a previous episode of bleeding was obtained. The major causes of bleeding were duodenal ulcer in 38,3%, acute lesions of the gastric mucosa in 20,9%, gastric ulcer in 11,6% and esophageal varices in 5,8%, Mallory Weiss syndrome in 4,6%, gastric carcinoma in 2,3%, prolapse gastropaty 2,3%, esophagitis in 2,3%, esophageal ulcer 1,1 %, duodenitis 1,1%, arteriovenus malformations in 1,1%. The etiology of the hemorrhage could not be established in 8% of cases. The diagnostic rate of endoscopy was 91,7%.In 66% of the patients the endoscopy was carried out within the 24 hours of admission 20,9% of the patients had other potential bleeding lesions 9,1% of the patients had a new episode of bleeding during hospitalization and surgery was needed in 11,6%. Injectotheraphy was done in 7 (8,13%) patients (4 for variceal 2 for duodenal and 1 for gastric bleeding ) The overall mortality was 3,4% Fourteen patients with lower gastrointestinal bleeding were evaluated. The mean age was 53,14 years and the male/female ratio was 1.6/1. The main complaint was hematochezia. The major causes of bleeding were hemorrhoidal disease in 64,2% and rectal cancer in 14,28%.

Journal Article↗
PubMed2004

Capsule endoscopy and push enteroscopy in the diagnosis of obscure gastrointestinal bleeding.

BACKGROUND: In obscure gastrointestinal (GI) bleeding, it is often difficult to detect the bleeding sites located in the small bowel with conventional radiological, scintigraphic or angiographic techniques. Push enteroscopy and capsule endoscopy are currently considered to be the most effective diagnostic procedures. The aim of this study was to compare the detection rates between capsule endoscopy and push enteroscopy. METHODS: From May 2002 through January 2003, we prospectively examined by capsule endoscopy 39 patients with suspected small bowel diseases, in particular GI bleeding of unknown origin in Renji Hospital. Among them, 32 complained of obscure recurrent GI bleeding. Between January 1993 and October 1996, we used push enteroscopy on 36 patients who suffered from unexplained GI bleeding. All patients had prior normal results on gastroscopy, colonoscopy, small bowel barium radiography, scintigraphy and/or angiography. RESULTS: M2A capsule endoscopy disclosed abnormal small bowel findings in 26 (82%) out of 32 patients. Twenty-one of them had significant pathological findings explaining their clinical disorders. Diagnostic yield was therefore 66% (21 of 32 patients). Definite bleeding sites diagnosed by capsule endoscopy in 21 patients included angiodysplasia (8), inflammatory small-bowel (5), small-bowel polyps (4), gastrointestinal stromal tumour (2), carcinoid tumour and lipoma (1), and hemorrhagic gastritis (1). Push enteroscopy detected the definite sources of bleeding in 9 (25%) of the 36 patients. Patients with definite bleeding sources included angiodysplasias (2), leiomyosarcoma (2), leiomyoma (1), lymphoma (1), Crohn's disease (1), small-bowel polyps (1) and adenocarcinoma of ampulla (1). Suspected bleeding sources were shown by push enteroscopy in two additional patients (6%), and in other five patients (16%) by capsule endoscopy. CONCLUSIONS: The present study of patients with obscure GI bleeding showed that capsule endoscopy significantly superior to push enteroscopy in detecting GI bleeding (P < 0.001). Capsule endoscopy is safe and painless, and should become the initial diagnostic choice for patients with obscure GI bleeding.

Adolescent↗
PubMed2005

[Severe gastrointestinal bleeding after allogeneic hematopoietic stem cell transplantation--15 case analysis].

OBJECTIVE: To analyze the features, causes, treatments and outcomes of severe gastrointestinal (GI) bleeding after allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS: Fifteen patients suffered from massive GI bleeding (blood loss leading to hemorrhagic shock) or subacute GI bleeding (at least 1 or more units of red blood cell transfusion on each of two consecutive days) were observed and analyzed after allo-HSCT. RESULTS: Seventeen severe GI bleeding episodes occurred in 15 patients. The severe bleeding occurred in three periods of time: within 1 week, 1 to 2 months and 4 to 7 months after transplantation. The main manifestation was hematemesis and hematochezia in the first period, and hematochezia alone in the second and third periods. Platelet counts at the onset of severe bleeding were < or = 50 x 10(9)/L in the majority of patients. Causes of bleeding were conditioning regimen-related toxicity in 2 patients/episodes, graft versus host disease (GVHD) or/and intestinal cytomegalovirus (CMV) or fungal infections in 11 patients/12 episodes, intestinal CMV infections in 1 patient/episode, acid-peptic ulcer in 2 patients/episodes, and cause unknown in 1 patient/episode. Supportive care such as transfusions of platelet, red blood cell and fresh frozen plasma, H2 receptor blockers and omeprazole were given to all patients, immunosuppressive drugs to patients developed GVHD and antiviral drugs to patients with complicated CMV infection. Eight patients/9 episodes of bleeding were controlled. Eight patients continued severe GI bleeding and died of acute GVHD or related serious complications. CONCLUSIONS: Severe GI bleeding after allo-HSCT are mainly caused by regimen-related toxicity, GVHD or/and intestinal CMV infection. Bleeding caused by conditioning regimen-related toxicity is self-limited and has a better prognosis. However, treatment failure and mortality are high if the patient's bleeding resulted from GVHD and intestinal CMV infection.

Gastrointestinal Hemorrhage↗
PubMed2005

Predictive factors of recurrent bleeding in Mallory-Weiss syndrome.

BACKGROUND/AIMS: Although the majority of patients with Mallory-Weiss syndrome (MWS) have a benign course, MWS patients with recurrent bleeding have an unfavorable outcome and require intensive care. Therefore, this study was carried out to identify the risk factors for recurrent bleeding in MWS patients. METHODS: The medical records of patients with MWS between January 1999 and December 2003, were reviewed retrospectively. Demographics, initial clinical and laboratory parameters, and endoscopic findings of the patients with and without recurrent bleeding were compared and the potential risk factors predicting recurrent bleeding in MWS were evaluated. RESULTS: A total of one hundred and fifty-nine patients (22 women, 137 men, mean age 48.1 years old) were enrolled in the study. Recurrent bleeding was observed in 17 patients (10.7%). Those patients with recurrent bleeding showed higher frequency for the presence of shock at initial manifestation, combined liver cirrhosis and endoscopic findings of active bleeding, lower hemoglobin level and platelet count, higher amount of transfusions and epinephrine-mixed fluid injections, and longer hospital stay than those patients without recurrent bleeding. Significant risk factors predicting the recurrent bleeding in MWS were the presence of shock at initial manifestation (OR 3.71, 95% CI 1.07-14.90) and the evidence of active bleeding on endoscopic examination (OR 9.89, 95% CI 1.88-51.98) on multivariate analysis. CONCLUSIONS: Intensive care with close monitoring is required for the patients with shock on initial manifestation or with evidence of active bleeding on endoscopic examinations since these are independent risk factors predicting the recurrent bleeding in MWS patients.

Female↗
PubMed2005

[High risk factors of upper gastrointestinal bleeding after neurosurgical procedures].

OBJECTIVE: To analyze high risk factors of postoperative upper gastrointestinal (GI) bleeding after neurosurgery so as to give guidance for prevention of GI bleeding. METHODS: A questionnaire was developed to investigate the medical records of 1500 patients who were hospitalized and underwent neurosurgical operations in 1997. Logistic regression analysis was made. RESULTS: 1430 valid questionnaires were obtained. Postoperative upper GI bleeding occurred in 75 patients (5.24%). The incidence of upper GI bleeding were 6.64% (54/813) in the male patients and 3.40% (21/617) in the female persons (P = 0.007); 9.88% (41/415) in those aged > 50 and 3.35% in those aged < or = 50 (P = 0.001). Glasgow Coma Score less than 10 pre- and post-operation, the incidence of upper GI bleeding was more than 17.5% (14/80, pre-operation GCS 7-10) and 20.9% (14/67, pre-operation GCS 3-6), and 20.25% (16/79, first day of post-operation GCS 7-10) and 23.75% (19/80, first day of post-operation GCS 3-6). The incidence of upper GI bleeding of the patients with intracerebral hematoma, intraventricular hemorrhage, subdural hematoma, and extradural hematoma were 15.7%, 10.0%, 6.00%, and 2.94% respectively (P = 0.02). The incidence of upper GI bleeding of the patients with tumors of fourth ventricle of cerebrum, brainstem, cerebral hemisphere, and sellar hypothalamus were 15.79% (3/19), 7.89%, 5.71%, and 3.74% respectively. In the emergent cases, the incidence of upper GI bleeding was higher in those with hypertension. The incidence of upper GI bleeding was 5.46% in the patients undergoing adrenocortical hormone treatment, significantly higher than that in those who did not receive such treatment (2.13%). CONCLUSION: Patients who are at high risk of developing postoperative upper GI bleeding including that: age greater than 50 years; male; Glasgow Coma Score less than 10 pre and post operation; The lesion was located in brain stem and forth ventricle; Hypertensive cerebral hemorrhage; Intracerebral and intraventricular hemorrhagic brain trauma; Postoperative pneumonia, brain edema, encephalic high pressure, pyogenic infection of the central nervous system and other postoperative complications. The mortality of patients with postoperative upper GI bleeding was evidently higher than that of the patients without postoperative upper GI bleeding.

Age Distribution↗