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PubMed1996

Laparoscopic transgastric suturing for bleeding peptic ulcers.

BACKGROUND: Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing. METHODS: After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a "lift and cut technique." Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots. RESULTS: Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm3/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement. CONCLUSIONS: It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.

Animals↗
PubMed1995

Technetium-labelled red blood cell scintigraphy: is it useful in acute lower gastrointestinal bleeding?

Radionuclide scintigraphy is commonly utilized as a screening examination before performing more invasive procedures in the work-up of patients with lower gastrointestinal (GI) bleeding. We reviewed our institutional experience with technetium-labelled red blood cell scintigraphy (TRCS) in detecting and localising acute lower GI bleeding. The study group included 72 patients who had 80 red cells scans over a five year period. Thirty-eight scans were positive (47.5%), and 42 were negative (52.5%). Sites of lower GI bleeding were confirmed by endoscopy, arteriography, surgery and/or pathology in 22 of the 38 positive scans. There were four false-negative scans (9.5%). The overall sensitivity and specificity of TRCS in detecting lower GI bleeding was 84.6% (22/26) and 70.4% (38/54), respectively. The accuracy of localization of bleeding sites in the patients with confirmed positive scans was 72.7% (16/22). Thirty mesenteric arteriograms were performed on patients in this series. Eleven arteriograms were performed after negative TRCS; one was positive. Technetium-labelled red blood cell scintigraphy appears to be a useful screening examination for patients with lower GI bleeding who are hemodynamically stable. This may avoid the potential morbidity of arteriography in patients who are not actively bleeding.

Acute Disease↗
PubMed1986

Upper gastrointestinal bleeding caused by gastroduodenal vascular malformations. Incidence, diagnosis, and treatment.

Within a two-year period, 12 patients with upper gastrointestinal bleeding due to gastroduodenal vascular malformations were admitted to a specialized intensive care unit. They represented 2.1% of all admissions for upper gastrointestinal bleeding, and 3.7% of those with severe hemorrhage (greater than or equal to 2 units of blood transfused). Early endoscopy was nondiagnostic during the first bleeding episode in all nine patients with nonhereditary vascular malformations; the diagnosis was eventually made after relapsing hemorrhage by repeat endoscopy in five patients, angiography in two, and histology in another two. These nine patients accounted for 23.6% of all cases of upper gastrointestinal bleeding considered to be of unknown origin after initial work-up. The remaining three patients had Rendu-Osler-Weber disease, and the first endoscopy was diagnostic in all of them. Emergency treatment was required for 11 patients; surgery was undertaken in seven, and transendoscopic therapy (electrocoagulation or endoscopic clipping) in four. There was a 25% mortality rate. No further bleeding has occurred in eight patients after a mean follow-up period of two years. Gastroduodenal vascular malformations are a more frequent cause of upper gastrointestinal bleeding than heretofore recognized, especially in patients whose hemorrhage is deemed to be of unknown origin after an initial work-up. Endoscopy, which may need to be repeated, is the most rewarding diagnostic procedure. Awareness of their possible existence facilitates endoscopic recognition. When available, transendoscopic therapy is a good choice to stop active bleeding from such lesions.

Adolescent↗
PubMed1993

Bleeding duodenal ulcer. Role of gastric acid hypersecretion.

Basal gastric acid output was analyzed prospectively in 110 patients with endoscopically documented duodenal ulcer disease to determine the frequency of gastric acid hypersecretion in patients with bleeding versus nonbleeding ulcers. Thirty-eight patients with stigmata of an actively or recently bleeding duodenal ulcer had a mean basal output of 12.6 +/- 8.9 meq/hr. In comparison, 72 patients with nonbleeding duodenal ulcers (and no history of prior bleeding) had a significantly lower mean basal acid output of 8.7 +/- 7.5 meq/hr (P < 0.05). Twenty-four of the 38 patients (63%) with bleeding and 28 of the 72 (39%) with nonbleeding duodenal ulcers had gastric acid hypersecretion, defined as a basal acid output of greater than 10.0 meq/hr. There was a statistically significant association between bleeding duodenal ulcer and acid hypersecretion (P = 0.01). All 110 patients were treated with standard doses of H2-receptor antagonists for eight weeks. In that time, 87 patients healed and 23 patients (14 with prior bleeding and nine with nonbleeding duodenal ulcers) remained unhealed. Significantly more patients who had bled had nonhealing duodenal ulcers (P = 0.004). Irrespective of bleeding history, all 23 patients with nonhealing duodenal ulcers at eight weeks had basal acid outputs of greater than 10.0 meq/hr (range 10.1-49.1 meq/hr). These 23 patients with nonhealing duodenal ulcers were treated with increased doses of ranitidine (mean 690 mg/day, range 600-1200 mg/day) for up to eight additional weeks. All were observed to have complete endoscopic healing documented within that period.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1983

Arterio-venous epidural shunting in epidural bleeding radiological and physiological characteristics. An experimental study in dogs.

In order to test the possibility suggested in previous studies that the long bleeding time and the large bleeding volume observed in experimental epidural bleeding can be explained by the development of an arterio-venous shunt, water soluble X-ray contrast was injected into the epidural space in dogs during an epidural bleeding in progress. It was found that the contrast medium left the epidural space through diploic veins in the cranial bone to the neck veins. By draining off epidural blood the arterio-venous shunt counteracts the intracranial pressure tamponade developing in intradural bleeds and thus prolongs bleeding. Perfusion experiments showed the absorption capacity for saline to be about 20 times as large in the epidural space as in the CSF space. While there was no apparent absorption limit for blood in the epidural space the absorption capacity for blood of the subarachnoid space became progressively saturated, leading to a continuously increasing CSF outflow resistance and CSF steady-state pressure. A theory for the formation of epidural haematoma is proposed which in essence implies that the epidural shunt is a major determinant of the clinical outcome of an epidural bleeding.

Animals↗
PubMed1994

Evaluation of anemia caused by hemorrhoidal bleeding.

PURPOSE: Hemorrhoidal bleeding and anemia are two common entities. The purpose of this article is to review the incidence of hemorrhoidal bleeding that causes anemia in a stable population, to describe patients who have hemorrhoidal bleeding that caused anemia, and to define observations regarding the recovery of their anemia. METHOD: This was a retrospective chart review of patients seen at the Mayo Clinic and Olmsted Community Hospital in Rochester, Minnesota, from 1976 through 1990. RESULTS: Incidence of hemorrhoidal bleeding that caused anemia was found to be 0.5 patients per 100,000 population per year in Olmsted County from 1976 to 1990. The mean age of 43 patients studied was 50 (range, 25-72) years. Twenty-seven patients were male, and 16 were female. Ninety-three percent of these patients had grade 2 or 3 internal hemorrhoidal disease. Six had impaired coagulation. The mean hemoglobin concentration before treatment was 9.4 g/dl (+/- 0.97 SD). Of note was the description of hemorrhoidal bleeding that included blood squirting or clots passing in 84 percent of patients for whom a description was available. It was found that recovery from anemia after definitive treatment with hemorrhoidectomy was rapid, with a mean hemoglobin concentration of 12.3 g/dl after two months, and by six months, the mean hemoglobin concentration was 14.1 g/dl. CONCLUSION: It is imperative to evaluate other causes of anemia when presented with hemorrhoidal bleeding with anemia. If no other sources are identified, treatment of the hemorrhoid should be undertaken, and a rapid return of hemoglobin concentration can be expected within two months, and all patients should have a normal hemoglobin by six months. Failure to recover hemoglobin concentration should prompt further or repeated evaluation for other causes of bleeding.

Adult↗
PubMed1997

Lower gastrointestinal bleeding.

BACKGROUND: Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy. PURPOSE: This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome. METHODS: Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed. RESULTS: The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding. CONCLUSION: Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.

Angiography↗
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↗
PubMed1991

Variceal bleeding after endoscopic injection sclerotherapy: an analysis of 108 subjects undergoing endoscopic injection sclerotherapy.

Among 108 cases of endoscopic injection sclerotherapy (EIS) performed from January 1984 through September 1989, post-EIS variceal bleeding occurred in 38 case (35%). Death was significantly more frequent among the post-EIS bleeders than non-bleeders (55% v. 27%). Background factors were analyzed for failure to prevent bleeding. The curve of the cumulative non-bleeding rate following emergency EIS (21 cases) was significantly lower (P less than 0.01) than that following elective EIS (22 cases), and there was more frequent rebleeding (13/21 v. 7/22) within a shorter mean period of time (4.9 months v. 14.1 months) in the former; association of hepatocellular carcinoma was also more frequent (13/21 v. 3/22). Continuation of drinking showed no difference between post-EIS bleeders (5/38) and non-bleeders (9/70). After complete variceal eradication the curve of the cumulative non-bleeding rate was significantly higher than after incomplete eradication (P less than 0.001). Following prophylactic EIS (65 cases) there was significantly less frequent bleeding (P less than 0.01) than following EIS performed after variceal rupture (43 cases). The risk of variceal bleeding after EIS can be minimized by complete eradication of varices at the initial EIS. Prophylactic EIS was suggested to contribute to reducing the frequency of post-EIS bleeding.

Emergencies↗
PubMed2004

Experimental study on the expression of HIF-1alpha and its relationship to apoptosis in tissues around cerebral bleeding loci.

The expression of hypoxia inducible factor-1 alpha (HIF-1alpha) and its relationship to apoptosis in tissues around cerebral bleeding loci was studied. The expression of HIF-1alpha and apoptosis in 37 samples of tissues around cerebral bleeding loci and 9 samples of normal cerebral tissues was assessed by immunohistochemical straining and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling methods. In 37 tissue samples around cerebral bleeding loci, the positive rate of the HIF-1alpha expression was 40.6%. Especially in the patients with amount of bleeding >60 ml, the positive rate (88.9%) of the HIF-1alpha expression was significantly higher than those with the amount of bleeding ranging from 30-45 ml or 45-60 ml (P<0.05). The expression of HIF-1alpha was increased as the amount of bleeding and operative time increased (P<0.05). There existed a positive correlation between HIF-1alpha labeling index and apoptosis index (n=12, r=0.56, P<0.01). These results suggested that the expression of HIF-1alpha was closely related with the time of hemorrhage and the amount of bleeding, and could induce the apoptosis of neurons.

Adult↗
PubMed2003

Uterine doughnut in early proliferating phase: potential pitfall in gastrointestinal bleeding studies.

A 41-year-old woman with rectal bleeding was referred to our department for gastrointestinal (GI) bleeding study. She was in early post-menstrual period and had stable vital signs. A GI bleeding study with Tc-99m SC revealed uterine blush in the pelvis. The shape of activity and quick fading excluded a GI bleeding. To rule out an intermittent bleeding, patient underwent a second bleeding study with Tc-99m RBC. Serial images showed uterine "doughnut" in the pelvis. The activity neither changed in shape nor showed distal movement with time excluding a GI hemorrhage. Uterus in early proliferating phase could be a potential pitfall in GI bleeding studies.

Diagnosis, Differential↗
PubMed1998

Readmission for bleeding after outpatient surgery.

PURPOSE: To examine the frequency of readmission due to surgical bleeding after ambulatory surgery. METHODS: A retrospective review of hospital records for patients readmitted to the same hospital after surgery in our Daycare centre was conducted for January 1984 to December 1992. The charts of all patients readmitted to hospital within 48 hr of surgery were examined. Readmissions for bleeding were studied with respect to demographics, time when bleeding occurred after arrival in PACU(latent interval) and treatment. Matched controls were identified and a case-control analysis performed to identify factors associated with an increased risk of readmission from bleeding. RESULTS: There were 172,710 outpatient procedures and 64 readmission for bleeding (0.04%). Gynaecological and urological surgery accounted for the highest number of bleeders (86%). Most patients who bled excessively in the OR continued to bleed in PACU. Those who bled in the PACU alone had a latent interval of 54 +/- 77 min. Those who bled both in the OR and PACU had a latent interval of 20 +/- 7 min. Those who bled mainly at home had a latent interval of 104 +/- 68 min. A majority of bleeders could have been identified if they had been observed for 30-45 min. Logistic regression of case-control matches did not identify any risk factor likely to increase the risk of readmission in bleeders. CONCLUSIONS: Bleeding after outpatient surgery is uncommon and discharge criteria need to be re-examined in order to take this into account and permit appropriate fast tracking of outpatients.

Adolescent↗
PubMed2006

[A surgical approach to acute intestinal bleeding].

The estimated incidence of lower gastrointestinal bleeding (LGIB) is 20/100,000 patients per year. Of these cases, 70-80% are minor or stop spontaneously and do not present as emergency hospital admissions. Colonoscopy and angiography detect 80-90% of major LGIB, and subsequent endoscopic intervention or embolisation can control approximately 70%. Emergency surgical intervention is required in haemodynamically unstable patients with persistent bleeding. The surgical treatment of choice is directed to resecting the bleeding bowel segment. Subtotal colectomy is performed in patients with colonic bleeding that can not exactly be localized. Segmental colon resection is often associated with rebleeding and not recommended in this situation. Primary anastomosis can usually be performed; elderly patients in reduced condition, however, are candidates for stoma. In case of persistent or recurrent bleeding and differentiation between intestinal and colonic bleeding fails, loop ileostomy may be performed. If the bleeding appears to originate from somewhere in the small bowel, an additional loop jejunostomy may be performed for specification. The mortality from acute LIGB is approximately 5% but increases with emergency surgery. Risk factors are age, comorbidity, and shock on admission.

Acute Disease↗
PubMed2005

Main comedications associated with major bleeding during anticoagulant therapy with coumarins.

OBJECTIVE: To study the main comedications associated with major bleeding during anticoagulant therapy with coumarins in a non-selected population under everyday circumstances. METHODS: The study population for this retrospective cohort study included all new users of phenprocoumon or acenocoumarol aged 40-80 years, during the period 1992-2000 in the PHARMO Record Linkage System. All patients were followed until the last dispensing of phenprocoumon or acenocoumarol, the first bleeding complication requiring hospitalization, death, or the end of the study period. The number of days on coumarins alone and the number of days on coumarins in combination with several potentially interactive drugs during follow-up were determined for each patient. RESULTS: The inclusion criteria of this study were met by 19,935 new users of phenprocoumon or acenocoumarol. During follow-up, 552 patients were hospitalized for bleeding. Of all potentially interactive drugs started during anticoagulant therapy by at least 50 patients and with at least five bleedings, antibacterial drugs were associated with a four to seven times increased risk of bleeding. Among non-steroidal anti-inflammatory drugs, naproxen had the highest relative risk. Antithrombotic salicylates and tramadol were associated with a three times increased risk of bleeding. CONCLUSION: Antibacterial drugs, non-steroidal anti-inflammatory drugs, antithrombotic salicylates and tramadol were the main potentially interactive drugs associated with major bleeding during anticoagulant therapy with coumarins under everyday circumstances.

Acenocoumarol↗
PubMed2006

Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality.

BACKGROUND: Many factors can cause morbidity and mortality in patients with severe acute lower gastrointestinal bleeding (LGIB). The objectives of this study are to analyze three aspects related to severe acute LGIB: (1) indications and prognostic factors for urgent surgery, (2) risk factors for morbidity and mortality, and (3) relapse rates. PATIENTS AND METHODS: A retrospective cohort was collected between 1985 and 2002 in a tertiary referral center. One hundred seventy-one patients with severe acute LGIB were reviewed (LGIB is defined as frank rectal bleeding either with a hematocrit decrease >/=10 points or when a transfusion of at least three units of concentrated red blood cells is needed). The main outcome measures are: (1) indications for urgent surgery and results, (2) morbidity and mortality, and (3) relapse. RESULTS: There were 158 (92%) stable patients, and in 61% of these, the bleeding was identified via colonoscopy. Bleeding was identified using urgent colonoscopy in a higher percentage of patients compared to delayed colonoscopy (68% versus 14%; p < 0.001). Urgent surgery was indicated in 24 (14%) patients, and the approach was peri-anal in 5 (21%) patients and abdominal in the rest. Local intestinal resection was performed on the 15 patients in which bleeding was identified, whereas a subtotal colectomy was performed on the remaining 4 patients. The presence of hypotension (p = 0.001; 35 versus 10%) and etiology of LGIB (p < 0.001) are prognostic factors of urgent surgery. Morbidity was 6.4%, and mortality was 4.7%. The only morbidity or mortality risk factors detected were the presence of associated comorbidities (p = 0.008) and the need for urgent surgery (p = 0.002). The most frequent etiology was diverticulosis (25%). After a mean follow-up of 132 +/- 75 months, bleeding relapsed in 30% of patients. CONCLUSIONS: It is difficult to predict which patients are going to need urgent surgery in severe acute LGIB; only the presence of hypotension on arrival at the emergency ward would lead us to suspect a negative outcome for the hemorrhage. In severe acute LGIB, morbidity and mortality is high, and this is mainly due to the high level of associated comorbidity and the need for urgent surgery. It is necessary for strict hemodynamic monitoring of the patients at risk if we want to improve outcomes. The bleeding relapse rate is high in LGIB, although generally, it is not severe.

Acute Disease↗
PubMed2001

Incidence and pathophysiology of peptic ulcer bleeding.

Peptic ulcer accounts for about 50% of all cases of upper gastrointestinal bleeding. Acute mortality may be as high as 14%. Infection with Helicobacter plyori (Hp) and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the predominant risk factors. While the prevalence of Hp in ulcer bleeding is still debated, there is strong evidence that eradication of bacteria reduce the risk of re-bleeding significantly. The use of NSAIDs increases the frequency of ulcer bleeding about four- to sixfold on average. Additional factors such as advanced age, concomitant use of corticosteroids or anticoagulants, prior ulcer complications and co-morbid diseases may further increase the risk of bleeding. Whether or not Hp infection also represents an additive risk factor in NSAID-related bleeding remains to be clarified. The pathophysiologic action of both Hp and NSAIDs is quite complex. Hp promotes the aggressive factor acid and damages several mucosal defence mechanisms by liberating lipopolysaccharide, urease and vacuolating cytotoxin. In NSAID toxicity the cyclo-oxygenase enzymes (COX) have been studied intensively. With the advent of COX-2-selective NSAIDs, the clinical problem of NSAID-induced ulcer bleeding may be markedly reduced or abolished completely.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

Jejunal leiomyosarcoma, a rare cause of obscure gastrointestinal bleeding diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a relatively frequent disorder and may account for as many as 5% of all cases of gastrointestinal bleeding. The etiology of these hemorrhages may be attributed to lesions in the small intestine, which may not show up in radiologic studies, located in areas inaccessible to conventional endoscopy. The case of a 50-year-old patient admitted to the hospital on two occasions for gastrointestinal bleeding requiring blood transfusions is reported. On the first occasion, the bleeding was thought to be caused by a duodenal ulcer because no other lesions prone to bleeding were found. At the next admission for recurrent bleeding, the ulcer was found to have healed and thus was ruled out as the cause. Wireless capsule endoscopy detected an ulcerated tumor invading the submucosa of the jejunum. The pathologic diagnosis was low-grade leiomyosarcoma. Wireless capsule endoscopy has proved to be far superior to other radiologic and endoscopic techniques for the diagnosis of obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Blood Transfusion↗
PubMed2001

Endoscopic ligation for patients with active bleeding Mallory-Weiss tears.

BACKGROUND: Only a few patients with active nonesophageal variceal upper gastrointestinal bleeding have been treated with endoscopic ligation. To further address this issue, four patients with active bleeding Mallory-Weiss tears who underwent endoscopic band ligation are presented. PATIENTS AND METHODS: Endoscopic ligation was performed in four patients with a median age of 52 years (range, 40-93 years) after a diagnosis of active bleeding Mallory-Weiss tears (MWTs). A 45-year-old man with massive persistent upper gastrointestinal bleeding as a cause of a MWT underwent therapeutical endoscopic band ligation after an unsuccessful endoscopic injection trial. On the contrary, injection therapy should have been performed on a 93-year-old woman with multiple myeloma because of an actively bleeding MWT caused by the fibrotic tissue after an unsuccessful endoscopic ligation trial, although her other actively bleeding MWT lesion had been ligated successfully. RESULTS: After endoscopic ligation, all patients achieved complete hemostasis, and rebleeding did not occur. They were discharged without complications after a control endoscopy. CONCLUSIONS: Endoscopic ligation can be performed easily and without any complications such as perforation or delayed hemorrhage in patients with actively bleeding nonfibrotic MWTs.

Adult↗