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PubMed1986

Bleeding due to thrombocytopenia in acute leukemias and reevaluation of the prophylactic platelet transfusion policy.

Prophylactic platelet administration is indicated at counts below 20 X 10(9)/l. The bleeding tendency and severity were compared between thrombocytopenic patients with acute-lymphocytic leukemia (ALL) and acute non-lymphocytic leukemia (ANLL) in the ranges of 10-20 X 10(9)/l platelets, while prophylactic platelet administration was given only below 10 X 10(9)/l. The bleeding tendency for ALL was quite similar at platelet counts above or below 10 X 10(9)/l. The bleeding tendency was significantly lower (p less than 0.001) when the platelets were above this level in ANLL patients. When the thrombocytopenia was caused by chemotherapy, the bleeding was significantly lower in both types of leukemia above 10 X 10(9)/l (p less than 0.05 for ALL, p less than 0.001 for ANLL) as compared with lower counts. When the thrombocytopenia was caused by leukemia, the bleeding tendency was similar in both types of leukemia and at all platelet counts (below 20 X 10(9)/l). Fever, not associated with sepsis, augmented the bleeding severity of patients with ANLL. Stable or rising counts of platelets were associated with significantly lower bleeding tendency above 10 X 10(9)/l only in ANLL patients. The decision for prophylactic platelet administration at counts below 20 X 10(9)/l should be guided by the type of the leukemia (ALL vs. ANLL), the cause of thrombocytopenia (chemotherapy vs. leukemia per se), the trend of the platelet counts, presence of fever and patient's age (below or above 18 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1997

Venous bleeding during transsphenoidal surgery: its association with pre- and intraoperative factors and with cavernous sinus and central venous pressures.

Venous bleeding during transsphenoidal surgery for resection of pituitary tumors is a common problem that interferes with the performance of the surgical procedure. In this study, data were collected prospectively from 50 patients to determine whether there were pre- or intraoperative factors (e.g., patient demographics, type and grade of pituitary tumor, intraoperative hemodynamics) associated with venous bleeding which might be used to predict its occurrence. In addition, central venous pressure (CVP), and cavernous sinus pressure (CSP) were measured in 13 patients to evaluate the relationship of these pressures to each other and to the severity of venous bleeding. During resection of the pituitary tumor, the severity of venous bleeding was graded as minimal, moderate, or severe, the latter two grades requiring therapeutic intervention. Moderate bleeding requiring intervention occurred in 15 of the 50 patients, and resolved in all cases. Moderate bleeding was not related to CSP or CVP, and no specific associated factor was observed. CSP was not correlated with CVP, and was higher than that predicted from the CVP and the position of the patient or the hydrostatic gravitational pressure gradient. These results suggest that it is not possible to predict in advance which patients will have problems with venous bleeding, but that simple therapeutic maneuvers are effective.

Adult↗
PubMed2003

Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review.

UNLABELLED: The use of nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia after tonsillectomy is controversial because NSAIDS, through platelet inhibition, may increase the risk of perioperative bleeding. We systematically searched for randomized, controlled trials that reported on the incidence of perioperative bleeding attributable to the use of NSAIDs in patients undergoing tonsillectomy. As secondary outcome measures, we analyzed the quality of pain relief and the incidence of postoperative nausea and vomiting. Twenty-five studies with data from 970 patients receiving a NSAID and 883 receiving a non-NSAID treatment or a placebo were analyzed. Data were combined using a fixed-effect model. Of four bleeding end points (intraoperative blood loss, postoperative bleeding, hospital admission, and reoperation because of bleeding), only reoperation happened significantly more often with NSAIDs: Peto-odds ratio, 2.33 (95% confidence interval [CI], 1.12-4.83) and number-needed-to-treat, 60 (95% CI, 34-277). Compared with opioids, NSAIDs were equianalgesic, and the risk of emesis was significantly decreased (relative risk, 0.73; 95% CI, 0.63-0.85; numbers-needed-to-treat, 9; 95% CI, 5-19). IMPLICATIONS: The evidence for nonsteroidal antiinflammatory drugs to increase the risk of bleeding after tonsillectomy is equivocal, and the risk-benefit ratio is not straightforward. There is some evidence for an increased likelihood of reoperation because of bleeding. The agenda must be one of further research rather than of clinical recommendations.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1984

Umbilical hernia repair in patients with cirrhosis. No evidence for increased incidence of variceal bleeding.

Umbilical hernias are common in patients with alcoholic cirrhosis. Often elective repair is delayed for fear of precipitating acute variceal bleeding by interruption of portal--systemic venous collaterals. In order to test this hypothesis, the incidence of variceal bleeding following repair of umbilical hernia was determined retrospectively in 22 consecutive patients from our hospital and 74 others from six reports in the literature. Overall the perioperative (less than 3 months postrepair) incidence of variceal bleeding was 11%. This incidence of bleeding was equal to the incidence of bleeding reported in the literature in a group of cirrhotics with varices who did not undergo surgery. In addition, no correlation was seen between patients with a preoperative history of varices or bleeding and those who bled after surgery. Therefore, surgical repair of umbilical hernia can be performed in these patients without additional risk of precipitating variceal bleeding.

Adult↗
PubMed1986

Impact of emergency angiography in massive lower gastrointestinal bleeding.

Fifty patients with massive lower gastrointestinal bleeding were initially managed with emergency angiography. The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units. Thirty-six patients (72%) had bleeding site located; bleeding sites were distributed throughout the colon. Etiologies of bleeding included diverticular disease (19 patients) and arteriovenous malformations (15 patients). Twenty of 22 (91%) patients receiving selective intra-arterial vasopressin stopped bleeding; however, 50% rebled on cessation of vasopressin. Thirty-five of 50 (70%) patients underwent surgery, with 57% operated on electively after vasopressin therapy. Seventeen patients had segmental colectomy, with no rebleeding. Nine of the 17 patients had diverticular disease in the remaining colon. Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency subtotal colectomy without angiography (8.6% vs. 37%) (p less than 0.02). Emergency angiography successfully locates the bleeding site, allowing for segmental colectomy. Vasopressin infusion transiently halts bleeding, permitting elective surgery in many instances.

Adult↗
PubMed2004

The use of recombinant activated factor VII for controlling life-threatening bleeding in Dengue Shock Syndrome.

To report the use of recombinant activated factor VII (rFVIIa) in controlling life-threatening bleeding episodes in patients with grades III and IV Dengue Hemorrhagic Fever (DHF), also known as Dengue Shock Syndrome. Fifteen patients (seven boys, eight girls), whose median age was 8 years, were enrolled in the study. They were divided into two groups. Group 1 included nine patients, mainly grade III, waiting for platelet concentrate, and group 2 included six patients, mainly grade IV, who had already received platelet concentrate with unresponsiveness. A single dose or repeated doses of 100 microg/kg rFVIIa was/were given at intervals of 4 h according to the bleeding symptoms. The median times from the onset of bleeding to rFVIIa initiation were 6.5 and 29.8 h in groups 1 and 2, respectively. Each patient received one to three doses. An effective response was found in eight patients (53.3%), including six patients in group 1 and two patients in group 2. They had complete cessation of bleeding without recurrence for 48 h. An ineffective response was found in seven patients (46.7%) including three patients in group 1 and four patients in group 2 for which the bleeding recurred (n = 2), temporarily slowed down (n = 3), continued (n = 1) or occurred at a new site (n = 1). These included three patients in profound shock 24-48 h before referral to comprehensive treatment centers, two patients receiving ibuprofen before hospitalization, one patient with extensive volume overloading, and one patient requiring surgical intervention to ligate the torn intercostal artery and vein. The platelet concentrate was promptly transfused to stop bleeding in patients with ineffective responses. The results revealed that the earlier initiation of rFVIIa in the mainly grade III DHF in group 1 yielded a higher effective response (66.7%) than the delayed initiation in the mainly grade IV DHF in group 2 (33.3%). Moreover, patients previously receiving ibuprofen or volume expander of low molecular weight dextran or urea-linked gelatin tended to have lower effective responses (28.6%) than patients without associated medication (75.0%). Ultimately, three of six patients with grade IV DHF died, while all nine patients with grade III DHF survived. Thus, the case-fatality rate in this study was 20%. No clinical evidence of thromboembolic complications was observed. rFVIIa seems to be effective in restoring hemostasis in a limited series of patients with Dengue Shock Syndrome exhibiting life-threatening bleeding episodes. Further study is warranted.

Adolescent↗
PubMed1999

Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group.

OBJECTIVE: To evaluate the incidence and risk factors for clinically important upper gastrointestinal bleeding in critically ill patients requiring mechanical ventilation. DESIGN: In duplicate, blinded adjudicators determined the presence of clinically important gastrointestinal bleeding using a priori criteria, evaluating relevant clinical, laboratory, and diagnostic data. Cox proportional hazards regression analyses were used to examine baseline and time-dependent risk factors for bleeding. SETTING: Sixteen university-affiliated intensive care units (ICUs) in Canada. PATIENTS: A total of 1,077 critically ill ICU patients ventilated for at least 48 hrs. INTERVENTIONS: Patients were randomized to stress ulcer prophylaxis with intravenous ranitidine or nasogastric sucralfate; otherwise, management was at the discretion of the ICU team. MEASUREMENTS AND MAIN RESULTS: Demographic data included patient characteristics, Acute Physiology and Chronic Health Evaluation II score, and multiple organ dysfunction (MOD) score. Each day in the ICU, physiologic measurements including MOD score, feeding, and other treatment variables were recorded. The significant risk factors for upper gastrointestinal bleeding in the univariable analyses were low platelet count, maximum serum creatinine, maximum MOD score, maximum pulmonary component of the MOD score, maximum hepatic component of the MOD score, maximum renal component of the MOD score, enteral nutrition, and stress ulcer prophylaxis with ranitidine. The only independent predictors of bleeding in the multivariable analysis were maximum serum creatinine (relative risk = 1.16 [95% confidence interval = 1.02-1.32]), enteral nutrition (relative risk = 0.30 [95% confidence interval = 0.13-0.67]), and ranitidine administration (relative risk = 0.39 [95% confidence interval = 0.17-0.83]). CONCLUSIONS: In critically ill ventilated patients, renal failure was independently associated with an increased risk of clinically important gastrointestinal bleeding, whereas enteral nutrition and stress ulcer prophylaxis with ranitidine conferred significantly lower bleeding rates.

APACHE↗
PubMed2002

Acute upper gastrointestinal bleeding in critically ill patients: causes and treatment modalities.

Upper gastrointestinal bleeding from peptic ulcers or other nonvariceal causes generally stops spontaneously; if it fails to do so, aggressive management is required. Such measures also are necessary for patients at high risk for rebleeding. Endoscopic therapy achieves hemostasis in >90% of bleeding patients and reduces mortality. After successful hemostasis of the initial bleeding episode, the primary concern becomes the prevention of rebleeding, which occurs in up to 20% of patients. Acid suppression with histamine-2-receptor antagonists has been widely used for many years to prevent recurrent bleeding. However, in acutely bleeding patients, these agents have not been shown to reduce the number of episodes of further bleeding or rebleeding or to reduce the need for transfusions or surgery. Omeprazole, an intravenous proton pump inhibitor, significantly reduced the rate of rebleeding in a recent placebo-controlled trial in which only patients with endoscopic confirmation of successful hemostasis were enrolled. Although this drug does not seem to reduce the need for surgical intervention or to decrease mortality, the trial does indicate the promise of intravenous proton pump inhibitors in reducing upper gastrointestinal bleeding. Evidence from additional well-controlled trials is needed to confirm this finding. The use of proton pump inhibitors in this setting also may have a positive economic impact, and a decrease in the percentage of patients who experience rebleeding will eliminate the cost of further management strategies in those cases.

Acute Disease↗
PubMed1987

Source of upper gastrointestinal bleeding in patients with esophageal varices seen at endoscopy.

Many claim that upper gastrointestinal hemorrhage in patients with varices is frequently not of variceal origin. Such teaching is contrary to our experience. We therefore reviewed the records of 127 consecutive patients with 165 episodes of acute upper gastrointestinal bleeding who were found to have esophageal varices by endoscopy. Varices were the only potential site of the index bleed in 101 of the 127 patients (79.5%). In addition to varices, other potential sites of bleeding were gastric ulcer in 9 (7%), Mallory-Weiss tear in 4 (3.1%), duodenal ulcer in 3 (2.3%), and multiple gastroduodenal erosions in 10 (7.8%). We used the characteristics of the clinical presentation (e.g., varix seen bleeding) and the known natural course of the variceal bleeding to attempt to define the site of bleeding in the group with more than one potential site. In 15 we could make a judgment as to the likely source: In 9 it was variceal and in 6 nonvariceal. When varices are seen at endoscopy in a patient with a major hemorrhage, they are responsible for the bleeding in greater than 80% of cases.

Esophageal and Gastric Varices↗
PubMed1990

A comparison between emergency and delayed endoscopic injection sclerotherapy of bleeding esophageal varices in nonalcoholic portal hypertension.

To study whether or not emergency sclerotherapy was more effective than a program of stabilization and elective sclerosis, we studied 84 patients with bleeding esophageal varices. They underwent 332 sessions of endoscopic injection sclerotherapy, 134 of which were performed for acute variceal bleeding. Most patients (90.5%) had nonalcoholic portal hypertension. Emergency sclerotherapy (1-6 h after presentation) was performed in 65 bleeding episodes in 43 patients, and delayed sclerotherapy (more than 24 h from presentation) was performed in 69 episodes in 41 patients. The selection of patients was randomized. Emergency sclerotherapy arrested active variceal bleeding in all patients and resulted in an earlier eradication of varices and for a longer period than delayed sclerotherapy. Larger volumes of sclerosant (a mean of 26 ml compared to 13 ml) were more effective in arrest of bleeding and in an early eradication of varices. We conclude that emergency sclerotherapy, mainly with a large sclerosant volume, is highly effective in arresting active variceal bleeding. Such earlier arrest of bleeding was associated with reduced morbidity and mortality.

Adolescent↗
PubMed1990

Can the blood urea nitrogen/creatinine ratio distinguish upper from lower gastrointestinal bleeding?

We wanted to know if the blood urea nitrogen to creatinine (BUN/Cr) ratio could help distinguish upper from lower gastrointestinal bleeding. We analyzed retrospectively patients admitted to our hospital for gastrointestinal bleeding over the past 5 years. A total of 126 patients represented 74 upper bleeds and 52 lower bleeds. The mean BUN/Cr ratio was significantly higher in upper than lower bleeders, 34.8 and 17.8 respectively (p less than 0.001). No lower bleeder had a ratio of greater than or equal to 36, whereas 38% of upper bleeders had a ratio of greater than or equal to 36. The BUN/Cr ratio may be an easy, cheap method of distinguishing upper from lower gastrointestinal bleeding in some cases. A BUN/Cr ratio of greater than or equal to 36 suggests upper gastrointestinal bleeding, whereas a ratio of less than 36 is not helpful in locating the source of bleeding.

Adult↗
PubMed2001

Refractory gastrointestinal bleeding treated with thyroid hormone replacement.

Although bleeding diathesis has been associated with hypothyroidism, refractory gastrointestinal bleeding has not been previously described in association with hypothyroidism. We report a patient who presented with refractory gastrointestinal bleeding over an 8-week period. Extensive work-up demonstrated small intestinal vascular malformations as the source of bleeding. Despite endoscopic therapy and hormonal therapy, bleeding continued and required transfusion of 54 units of packed red blood cells. Surgical therapy was offered to the patient but was declined. Ultimately, correction of the patient's underlying hypothyroidism resulted in cessation of gastrointestinal bleeding, and no further blood transfusion was necessary. To date, the patient has remained euthyroid without further gastrointestinal bleeding for 30 months.

Aged↗
PubMed2002

Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate.

BACKGROUND: bleeding from gastric varices is a life-threatening complication of portal hypertension. Fundal and isolated gastric varices are at high risk for variceal bleeding. In this study, we report our experience with n-butyl-2-cyanoacrylate (BC) in patients with large gastric varices. STUDY: twenty-nine patients (15 male, 14 female) with large fundal varices (active bleed, 5; passive bleed after eradication of esophageal varices, 13; unbled fundal varices with red color sign, 11) underwent endoscopic sclerotherapy with BC. Cirrhosis was present in 13 patients; extrahepatic portal venous obstruction, in 13; and noncirrhotic portal fibrosis, in 3. N-Butyl-2-cyanoacrylate after mixing with lipiodol (1:1) was given to the initial 10 patients and was given in undiluted form to the remaining patients, followed by injection of 0.7 mL of distilled water to rinse the injection catheter. One to three injections (0.5-1 mL) were given until all gastric varices became hard. All patients were on long-term endoscopic sclerotherapy or variceal ligation programs for eradication of esophageal varices. RESULTS: acute variceal bleeding was controlled in all five patients with BC injections. Eradication of gastric varices was achieved in 27 (93.1%) patients (20 patients in 1 session, 4 patients in 2, and 3 patients in 3-6). Rebleeding occurred in three (10.3%) patients who responded to repeat BC injections. Complications related to the procedure occurred in two (6.9%) patients. In one patient, the needle became impacted into the tissue adhesive. This patient died 5 days later because of massive upper gastrointestinal bleeding. In the other patient, there was distal embolization. CONCLUSIONS: sclerotherapy of gastric varices with BC is a safe and an effective treatment for control of bleeding and eradication. The needle should be withdrawn immediately after the BC injection to prevent its impaction into the tissue adhesive.

Adolescent↗
PubMedDate not supplied

A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding.

GOALS: We hypothesized that large volume gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding would improve the quality of endoscopic examination. BACKGROUND: Blood retained in the stomach can impair visualization during esophagogastroduodenoscopy. Patients with acute upper gastrointestinal bleeding and a retained gastric fundic pool during endoscopy may have worse outcomes than patients without a retained fundic pool. No trials to date have evaluated if large volume gastric lavage prior to endoscopy improves visualization during acute upper gastrointestinal bleeding. STUDY METHODS: Patients with acute upper gastrointestinal bleeding were randomized to esophagogastroduodenoscopy alone or large volume tap water gastric lavage prior to esophagogastroduodenoscopy. The quality of endoscopic visualization was assessed using a 5-point scale. Clinical outcomes were compared for lavaged and nonlavaged patients. RESULTS: A total of 39 patients were randomized. In 1 patient, lavage was unsuccessful. The quality of visualization was not significantly different between groups for the esophagus, gastric antrum, or duodenum but was significantly better for the gastric fundus for patients randomized to lavage (P = 0.02). There was no significant difference between groups for ability to define a bleeding source, achieve hemostasis, recurrent bleeding, need for repeat endoscopy, and length of stay or death. There were no complications. CONCLUSIONS: Large volume gastric lavage prior to esophagogastroduodenoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus.

Acute Disease↗
PubMed1992

BUN/Cr ratio as an index of gastrointestinal bleeding mass in children.

Determining the site and severity of blood loss is important in the management of children with gastrointestinal (GI) bleeding. Blood urea nitrogen (BUN) and serum creatinine (Cr) were measured on the day of hospitalization and the ratio of BUN/Cr was calculated in 11 children with 16 episodes of upper GI bleeding and 49 with lower GI bleeding. There was a significant difference between the two GI bleeding groups with regard to BUN/Cr ratio (p less than 0.001). When the ratio was 30 or above, the specificity of upper GI bleeding was 98% with a sensitivity of 68.8%. A linear relationship was found between the BUN/Cr ratio and delta Hb (delta Hb = 0.08 x BUN/Cr +/- 0.8 g/dl) for bleeding originating from the upper GI tract. This study confirms that measurement of the BUN/Cr ratio is useful for localizing the source of bleeding to the upper GI tract and also demonstrates its usefulness as an estimation of the severity of blood loss from the upper GI tract.

Adolescent↗
PubMed1996

In vitro measurement of silicone bleed from breast implants.

A method to measure gel bleed from intact silicone gel-filled breast implants was developed. This nondestructive technique permits accurate and reproducible serial measurements of silicone bleed from smooth wall breast implants (n=10) under simulated physiologic conditions in vitro. Gel bleed rates from new low bleed gel-filled implants and intact explants (unbarriered, low bleed, double lumen) were determined. These results demonstrate the reliability of this method to quantify silicone gel bleed and may permit a meaningful comparison of bleed rates from implants in the future.

Breast Implants↗
PubMed2000

Relationships between a sign of rectal bleeding and the results of an immunochemical occult blood test, and colorectal cancer.

A cross-sectional study based on medical check-up was carried out to investigate the association between signs of rectal bleeding and colorectal cancer, and the results of an immunochemical faecal occult blood test. The 9625 patients received both an immunochemical faecal occult blood test using a two-consecutive-day method and colonoscopy. They were then divided into two groups, according to the results of a self-completed questionnaire on the signs of rectal bleeding. The positivity rate of the immunochemical faecal occult blood test as well as the positive predictive value for colorectal cancer were determined in these two groups. The faecal occult blood test was positive in 9.3% of patients with rectal bleeding and in 4.4% of patients without rectal bleeding, and the positive predictive value for colorectal cancer was 0.79 and 0.27 in patients with and without rectal bleeding, respectively. This indicates a significant difference in the positivity rate (P < 0.001) as well as the positive predictive value (P < 0.05) between these two groups. The results suggest that there are positive associations between the signs of rectal bleeding and the results of immunochemical faecal occult blood test, and between the patients presenting with rectal bleeding and colorectal cancer.

Adult↗
PubMed1996

Mesenteric arteriovenous fistula causing portal hypertension and bleeding duodenal varices.

We report a case of portal hypertension associated with a non-traumatic arteriovenous fistula, presenting with bleeding duodenal varices. The patient was admitted for melaena. Emergency endoscopy showed oesophageal varices with no signs of recent bleeding and with no blood in the upper gastrointestinal tract. Arteriography of the coeliac axis and superior mesenteric artery failed to detect any bleeding source. Endoscopy was repeated because of persistent bleeding and revealed active bleeding from varices in the distal duodenum. The patient underwent surgery and a large paraduodenal varicose vein associated with an arteriovenous fistula was found. Resection of the paramural varix and surgical occlusion of the arteriovenous fistula were effective in the control of bleeding. Liver biopsy revealed mild portal fibrosis without cirrhosis. Three years after surgery the patient still has oesophageal varices but has not had recurrent bleeding. There was regression of intraduodenal varices.

Aged↗