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PubMed1991

A multimodality approach to endoscopic treatment of bleeding peptic ulcers.

The role of endoscopic haemostasis in the treatment of bleeding peptic ulcers is widely studied. Many trials to date have compared one or more modalities against a medical control with variable results. To date, no single modality has been shown conclusively to be superior to others. As such, in this study we have not confined the endoscopist to one modality of treatment but allowed him to customize the method of endoscopic haemostasis according to the configuration, accessibility and rate of bleeding in any particular patient. Seventy-three patients with non-variceal upper gastrointestinal (GI) bleeding were admitted to the National University Hospital in Singapore between May 1, 1988 and April 30, 1989. All were gastroscoped and 48 were found to have chronic peptic ulcer. Twenty-nine (60%) with actively bleeding peptic ulcer or stigmata of recent haemorrhage (SRH) were treated endoscopically. Initial haemostasis was achieved in 27 (93%) patients. Seven patients rebled (26%) of which four underwent repeat endoscopic treatment. Of these four patients only one rebled again and required surgery. Permanent haemostasis was achieved in 23 of 29 patients (79%). The multimodality approach for the treatment of bleeding peptic ulcers gives the endoscopist flexibility in deciding on the best way to deal with a bleeding gastric or duodenal ulcer. Each instrument has its strengths and weaknesses and the right choice of instrument is often a critical factor especially in treating a bleeding ulcer in a situation where access poses a problem.

Adult↗
PubMed1990

The effect of desmopressin on massive gastrointestinal bleeding in hereditary telangiectasia unresponsive to treatment with cryoprecipitate.

A patient with hereditary hemorrhagic telangiectasia and reduced levels of von Willebrand factor had severe recurrent gastrointestinal bleeding. Treatment with either desmopressin acetate or cryoprecipitate normalized both bleeding time and kaolin-activated partial thromboplastin time. Hematochezia (five episodes) continued, however, for a week despite daily treatment with cryoprecipitate, whereas treatment with desmopressin at the onset of three later episodes of hematochezia resulted in the prompt cessation of bleeding. After an episode of life-threatening gastrointestinal bleeding, desmopressin administration allowed a total colectomy without excessive bleeding. During the 3 years after colectomy, no further gastrointestinal bleeding occurred. In the past year, however, three episodes of severe epistaxis responded promptly to intravenous infusion of desmopressin. We conclude that desmopressin may be useful in the management of bleeding in patients with hereditary hemorrhagic telangiectasia with or without von Willebrand factor deficiency.

Adult↗
PubMed1990

17 beta-estradiol is the most active component of the conjugated estrogen mixture active on uremic bleeding by a receptor mechanism.

We have reported previously that a mixture of conjugated estrogens which is effective in shortening the prolonged bleeding time in uremic patients is also effective on bleeding time in a rat model of uremia. With the present study we took advantage from such a rat model of chronic uremia and decided to identify the component(s) of the conjugated estrogen mixture responsible for shortening the bleeding time. Moreover, we wanted to clarify whether estrogen effect on primary hemostasis is due to a receptor mechanism and can be neutralized by specific estrogen receptor antagonists such as tamoxifen or clomiphene. Both estrone sulfate and 17 beta-estradiol, but not equilin, were effective in shortening the prolonged bleeding time of uremic rats. 17 beta-Estradiol was the most active component of the mixture, reproducing the time course of bleeding time shortening of the entire mixture (effect lasting 48 hr). The effect of estrone sulfate injection lasted only 24 hr. Tamoxifen and clomiphene pretreatment prevented the shortening of bleeding time induced by conjugated estrogen mixture and its active components. These findings indicate that 17 beta-estradiol is the key compound of the conjugated estrogen mixture effective on bleeding time shortening and that the effect of estrogens on primary hemostasis is mediated by a receptor mechanism.

Animals↗
PubMed1990

[A comparative assessment of the capacity of 2 bleeding indices to represent the concentration of thromboxane B2 in the periodontal tissues].

Comparative assessment on the capability of two bleeding indexes to measure the concentration of thromboxane B2 in periodontal tissues. The aim of the study was to compare two bleeding indexes, the Gingival Bleeding Index (GBI) and the Gingival Bleeding Time Index (BTI) in evaluating the intensity of inflammation in deep periodontal tissues measured by the level of thromboxane B2 in the tissues themselves. Results showed that both bleeding indexes were closely correlated to tissue inflammation but that of the two, BTI is more significantly correlated. On the basis of these findings, the authors hope to see the application of bleeding indexes in clinical and research studies which can offer a graduated assessment of bleeding, thus increasing the specificity of this important diagnostic sign.

Adult↗
PubMed1990

Self-assessment of gingival bleeding.

The benefit obtained from the use of a manual for self-assessment of gingival bleeding was evaluated among a group of Finnish army conscripts. After the baseline examination, performed by a dentist, three test groups self-assessed bleeding from their gums during toothbrushing and when cleaning between their teeth with a toothpick. The dentist re-examined the first test group 1 month, the second group 3 months and the third group 6 months after the self-assessment. Gingival bleeding among the test group subjects was compared with that of control group subjects who had been matched for number of bleeding sites at baseline. The self-assessed gingival bleeding was found to correlate with the clinical findings of bleeding. One and 3 months after the self-assessment the test groups had better gingival health than their respective control groups. Six months after the self-assessment, no difference in gingival health was found between the test and control groups. Observed gingival bleeding during the original self-assessment was found to be a positive predictive factor for the subsequent improvement in gingival health.

Dental Devices, Home Care↗
PubMed1990

[Transcatheter arterial embolization for massive abdominal bleeding in post-pancreatoduodenectomy--first report].

Transcatheter arteria embolization (TAE) was carried out for 10 cases (14 times) with massive intra-abdominal bleeding after pancreatoduodenectomy (PD). The results obtained were as follows: 1. The ten patients (carcinoma of the pancreas head 4, carcinoma of the papilla Vater: 3, carcinoma of the bile duct: 2. leiomyosarcoma of the duodenum: 1) included eight men and two women aged 45 to 75, with an average age of 63.7. The time span before TAE was instituted averaged 20.8 days. 2. Infection due to leakage noted in all cases. 3. A good course was noted when manifestation of symptoms related to poor sutures or the onset of intra-abdominal bleeding after PD was delayed and the time from the onset of intra-abdominal bleeding to TAE was short. 4. Bleeding sites could be determined in all cases. Pseudoaneurysm accounted for five and extravasation accounted for nine of the total of 14 bleeding sites. The prognosis was apparently good in cases of pseudoaneurysm as compared with that in cases of extravasation. 5. Bleeding was controlled in all cases. 6. No complication due to TAE occurred. These results indicate the TAE is a safe and effective procedure for the control of massive intra-abdominal bleeding after PD.

Abdomen↗
PubMed1989

Treatment of upper gastro-intestinal bleeding with the H2-receptor antagonist famotidine.

Gastro-intestinal bleeding from peptic and stress ulcers is serious and life-threatening. Critically ill patients in intensive care units have many of the risk factors associated with bleeding from peptic and stress ulcers, including trauma, burns, sepsis, shock and multiple organ failure. This study investigated the results of treatment with famotidine, administered intravenously twice daily, to those in a control group that received treatment before the introduction of H2-receptor antagonists. The study was designed to determine whether famotidine reduced the need for emergency surgery in patients with bleeding ulcers and whether a reduction in mortality was associated with its use. The overall efficacy rate of famotidine was greater than 88%. The percentage of patients with a bleeding ulcer undergoing surgery was 24.5% compared with 50.3% in the historical control group. Twice daily intravenous administration of famotidine effectively stopped bleeding in patients with moderate to severe peptic ulcer and stress ulcer. Drug therapy for the treatment of upper gastro-intestinal bleeding, however, has limitations. Criteria for the use of famotidine include reduced mortality, rate of recurrent bleeding and rate of emergency surgery.

Anti-Ulcer Agents↗
PubMed1989

[Gastrointestinal bleeding in children].

The site and nature of lesions producing gastrointestinal bleeding was evaluated in pediatric patients admitted to Tokai University Hospital. The differential diagnosis was possible based upon the character of the bleeding and the age of the patient. Upper endoscopy is the diagnostic maneuver of choice in evaluating the upper gastrointestinal bleeders. Sigmoidoscopy, colonoscopy, technetium scans, tagged red cell scans and intraoperative angiography were helpful in locating bleeding sites of lower bleeders. Common causes of bleeding were as follows: Hemorrhagic disease, necrotizing enterocolitis, and midgut volvulus in neonates; intussusception and internal hernia in infants; juvenile polyp and infectious diarrhea in children; duodenal ulcer and ulcerative colitis in adolescents. Gastro-duodenal ulcers were found in all age groups. One neonate died of indomethacin induced bleeding, however, bleeding from acute ulcer was usually controlled by conservative treatments. Increasing frequency of variceal bleeding due to portal hypertension after successful Kasai procedure for congenital biliary atresia was emphasized.

Adolescent↗
PubMed1989

Exacerbation of bleeding with renal insufficiency.

An elderly patient with upper gastrointestinal bleeding of peptic ulcer disease and renal insufficiency was presented. Her bleeding was complicated by an underlying hemostatic defect related to her renal disease and secondary bleeding prolongation. Cryoprecipitate reversed the defect and stopped the clinical bleeding. In the elderly adult population where renal insufficiency and elevated creatinines are more common, it is important to consider the hemostatic defect that may be associated with renal disease and bleeding. Infusion of cryoprecipitate may result in both a delayed correction of the abnormal bleeding time and reversal of clinical bleeding.

Aged↗
PubMed1988

Risk indicators of variceal bleeding.

Variceal bleeding is a catastrophic event in the history of liver cirrhotics. However, in more than half of the patients it never occurs. Thus, measures to prevent bleeding should be undertaken only in patients at the highest risk of bleeding. Risk indicators should help to select those patients. Hemodynamic and endoscopic parameters as well as liver function and coagulation status and the patient's history have been studied in relation to the bleeding incidence. The following parameters are correlated with an increased bleeding risk: The first year after diagnosis of varices, a positive history of variceal bleeding, presence of varices with large diameters, high blood pressures or a red colour sign, concomitant gastric varices or development of a liver cell carcinoma. Other parameters may be of less importance for the occurrence of variceal bleeding.

Endoscopy↗
PubMed1987

Early experience with the use of anti-inhibitor coagulant complex to treat bleeding in hemophiliacs with inhibitors to factor VIII.

Early clinical experience with anti-inhibitor coagulant complex in the treatment of bleeding in patients with factor VIII inhibitors is described. Sixty patients with a total of 120 bleeding episodes were studied. Satisfactory responses were obtained in 86.6% of bleeding episodes. Efficacy was slightly better in open bleeding than in closed bleeding. Higher doses were significantly better than lower doses in treating open bleeding. The incidence of adverse reactions was low. The results reported support the safety and efficacy of anti-inhibitor coagulant complex in the treatment of bleeding in patients with factor VIII inhibitors.

Adolescent↗
PubMed1987

Evaluation of risk factors in intraoperative bleeding tendency.

The effects of preoperative administration of non-steroidal anti-inflammatory drugs, intraoperative infusion of plasma expanders, type of anaesthesia, blood group and certain coagulation parameters on the bleeding tendency of 354 patients undergoing abdominal and urological surgery were analyzed. The bleeding tendency was estimated by the surgeon at the end of the operation. The preoperative use of non-steroidal anti-inflammatory drugs was associated with an increased bleeding tendency (p less than 0.05). Excessive bleeding was more common in patients who had received dextran intraoperatively, but did not reach statistical significance. Other potential risk factors were not associated with increased bleeding tendency. Two months after the operation, factors VIII:C and vWF:Ag of 32 patients were analyzed. Increased bleeding tendency was not more common in patients with low F VIII activity associated with blood group O, than in others. We conclude that the disorder of primary haemostasis caused by non-steroidal anti-inflammatory drugs is common and causes increased bleeding tendency in surgical patients. If the patient has additional risks of haemostasis, or if accurate surgical haemostasis is of particular importance, it seems justified to withdraw non-steroidal anti-inflammatory drug medication before operation.

Adult↗
PubMed1979

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

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

Adult↗
PubMed1979

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

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

Adult↗
PubMed1988

Gastrointestinal bleeding after aortic surgery. The role of laparotomy to rule out aortoenteric fistula.

The frequency and causes of gastrointestinal (GI) bleeding occurring after aortic surgery were evaluated retrospectively to determine the incidence of aortoenteric fistula (AEF) in relation to other causes and to place in perspective the role of laparotomy for the diagnosis of AEF. Two hundred fifty-three patients in whom aortic prostheses have been inserted were observed for a mean of 46 months. Seventy-four bleeding episodes occurred in 21% of patients between 1 and 108 months after surgery (mean 29 months). Only one AEF appeared that was associated with GI bleeding, for an incidence of 1.4% of bleeding episodes and 0.4% of grafts inserted. No diagnostic workup for GI bleeding was performed for 20 of the 74 episodes and no AEFs were noted in this group during a mean follow-up of 28 months. Diagnostic evaluation was done for the remaining 54 episodes. No cause for bleeding was identified in 16 patients and no AEF developed in this group during a mean follow-up of 26 months. A potential bleeding site was identified in 38 patients, of whom 30 had intrinsic GI lesions and no subsequent evidence of AEF during a mean follow-up of 28 months. Laparotomy for a suspected AEF was recommended for the remaining eight episodes in eight patients and was performed in six patients. An AEF was seen in one patient with abnormality found on preoperative CT scanning; an intrinsic GI lesion was identified in three patients; and no pathologic condition was found in the remaining two (negative laparotomy rate, 33%).(ABSTRACT TRUNCATED AT 250 WORDS)

Aorta, Abdominal↗
PubMed1988

A case study: nonsteroidal antiinflammatory drugs and gastrointestinal bleeding.

This paper describes a postmarketing drug surveillance study which examined the association of upper gastrointestinal (GI) bleeding and exposure to nonsteroidal antiinflammatory drugs (NSAID). The rate of upper GI bleeding was compared in 47,136 patients exposed to a NSAID and 44,634 unexposed patients. The risk of bleeding was 1.5 times higher in patients exposed to a NSAID (95% confidence interval, 1.2-2.0). Dose (p less than 0.01) and duration (p less than 0.001) response relationships were identified. The rate of upper GI bleeding was then compared among 88,044 patients exposed to only one NSAID. Sulindac was associated with the highest rate of upper GI bleeding. Control for multiple potential confounding variables did not change the results. These results suggest that NSAID are associated with upper GI bleeding, and that sulindac may lead to upper GI bleeding more frequently than other NSAID.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1988

Unsuspected perforation in bleeding duodenal ulcers.

A combination of bleeding and perforation rarely occurs simultaneously in peptic ulcer disease. The charts of 127 patients undergoing surgery for either complication were reviewed (bleeding, 91; perforation, 36). Nine of 91 (9.9%) patients in the bleeding group were found at operation to have a unsuspected perforated duodenal ulcer. The operative mortality in the patients with the combined complications (44%, 4/9) was significantly higher than that in patients with bleeding alone (8/82, 9.8, P less than 0.001) or those with perforation alone (4/36, 11.00, P less than 0.025). The mean age of nonsurvivors was significantly higher than that of the survivors (74 +/- 8.01 vs 50.4 +/- 5.65 years, P less than 0.005). The duration of symptoms until operation was longer in patients who died (63 +/- 12.7 hours) than in survivors (40.2 +/- 6.02 hours, P = NS). All patients who died, and three of five survivors, had preoperative fever (greater than 99.0 F), leukocytosis (greater than 12,000/mm3), and persistent tachycardia despite adequate hydration and blood replacement. Perforation in bleeding peptic ulcers is not an uncommon finding, and was present in 9.9 per cent of patients. The presenting symptom of bleeding may obscure signs of perforation, delay surgery, and contribute to the higher mortality rate. The presence of fever, leukocytosis, and tachycardia despite adequate fluid and blood replacement warrants a suspicion of perforation in patients with bleeding peptic ulcer.

Adult↗
PubMed1987

Bleeding esophagogastric varices: an endoscopic study.

Among 857 patients admitted from October 1977 to December 1984 with acute upper gastrointestinal hemorrhage, 165 (19.5%) had endoscopically proved esophageal or gastric varices. Among this group, varices were considered as the actual bleeding lesion in only 83 (9.7%). Stigmata of variceal bleeding were observed in 76 (92%) including 35 venous spurts, 12 venous oozes, 20 adherent clots, and 14 "platelet aggregates." In only seven cases, variceal rupture could only be presumed, because no other lesion was present. In the other 82 patients, a lesion other than varices was the bleeding source, mostly peptic ulcers (32 = 38%) and erosive gastritis (30 = 36%). One-third of the patients with bleeding varices required more than one endoscopy to provide evidence of variceal bleeding. The most frequent bleeding point was the cardia and a good correlation between variceal size and bleeding was observed. There was no relationship with evidence of gastroesophageal reflux.

Acute Disease↗