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PubMed1995

Increased mortality of acute upper gastrointestinal bleeding in patients with chronic obstructive pulmonary disease. A case controlled, multiyear study of 53 consecutive patients.

The etiology, clinical presentation, and mortality of acute upper gastrointestinal bleeding in patients with chronic obstructive pulmonary disease (COPD) were analyzed in a case-controlled study of 53 consecutive patients admitted from 1985 through 1990 to a university teaching hospital. The primary controls were 40 consecutive patients with acute upper gastrointestinal bleeding and without COPD admitted from June through November 1990 to the same hospital. COPD patients had a significantly increased mortality from gastrointestinal bleeding as compared to controls with gastrointestinal bleeding and without COPD (mortality in COPD = 32%, controls = 10%, odds ratio = 4.3, confidence interval of odds ratio = 1.22-14.8, P < 0.01, Fisher's exact test) and as compared to a second control group of 53 consecutive COPD patients without gastrointestinal bleeding (mortality in second controls = 11%, odds ratio = 3.7, confidence interval of odds ratio = 1.25-11.0, P < 0.02, chi square). The study COPD patients had a significantly greater likelihood of being older, smokers, alcoholics, and taking corticosteroids than the primary controls. However, an increased mortality was still present when controlling for these differences by population stratification (eg, mortality in patients > or = 60 years old: COPD = 36%, controls = 13%, odds ratio = 4.6, P < 0.05). The two groups had similar mean values of parameters of bleeding severity, such as lowest hematocrit and units of packed erythrocytes transfused. The increased mortality was correlated with COPD severity (eg, four of five patients with prior endotracheal intubation for COPD died, 13 of 48 COPD patients without prior intubation died, odds ratio = 10, P < 0.04, Fisher's exact test).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1994

Bleeding peptic ulcer occurring in hospitalized patients: analysis of predictive and risk factors and comparison with out-of-hospital onset of hemorrhage.

We reviewed 84 consecutive cases of peptic ulcer hemorrhage, which occurred, in an area of 270,000 people, from 1986 to 1988, in patients already hospitalized for other diseases (in-bleeders). These subjects were compared with a prospective series of 386 patients who initially bled as out-patients and were then admitted (out-bleeders). Of 84 hemorrhages in hospitalized patients, 41 followed major surgery, while 43 were associated with other severe conditions. Bleeding site was duodenal in two thirds. Mean age was 67 +/- 15 years versus 59 +/- 15 among out-bleeders. Fifty percent of in-bleeders had recently received nonsteroidal antiinflammatory drugs (NSAIDs), and one third were on anticoagulants and 10% on corticosteroids; in 39 (46%) bleeding was shown to be persistent or recurrent, 5 (5.9%) underwent endoscopic and 18 (21%) surgical therapy; 29 died (34%). The corresponding figures among out-bleeders were: further bleeding 80 (20.7%), endoscopic therapy 12 (3.1%), surgery 25 (6.5%), deaths 17 (4.4%). As regards in-bleeders, only active bleeding and endoscopic stigmata emerged as statistically significant risk factors for further bleeding. The latter was shown to be significantly related to mortality. The most relevant finding was, however, that NSAIDs and anticoagulants, in association with stress and aging, are very frequently involved in peptic ulcer bleeding of hospitalized patients. The fatal outcome of one third, despite all available treatments, highlights the importance of prevention against drug- and stress-related mucosal damage in in-patients suffering from severe diseases.

Aged↗
PubMed1995

An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding.

Subjective reporting of the color of blood passed per rectum has been used to predict the location of gastrointestinal bleeding, but the validity of this clinical approach has never been evaluated systematically. In this study we determined the spectrum of patient and physician descriptors used to characterize the color of blood passed per rectum and evaluated prospectively if an objective test of stool color would correlate with or improve upon subjective descriptions in predicting bleeding locations. The objective test employed was a card containing five numbered colors that typify the spectrum of stool blood colors. One hundred twenty patients used 23 different descriptors or terms to verbalize the color of blood they passed per rectum, and in 22% of cases there was a seeming discrepancy between their verbalized color and the color they pointed to on the test card. Patients pointing to card color 4 (the black color) resulted in closer matching to an upper bleeding source than physicians using terminology such as melena or tarry stools. Likewise, patients picking card colors 1 and 2 (the brightest red colors) resulted in closer matching to a coloanorectal bleeding source than physicians using the terms hematochezia or bright red blood per rectum (P < 0.02 for each comparison). The positive predictive value of card color 4 for an upper bleeding source was very high both when patients pointed to this color or when it was determined from the available stool (0.95 and 0.98, respectively). The positive predictive value of card color 1 for lower bleeding was greater for patients selecting this color than for a direct stool comparison (1.00 vs 0.83).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Factors that influence bleeding in superficial-type colorectal tumors: study of endoscopic and histologic correlates.

To clarify the mechanisms responsible for superficial-type colorectal tumor (STT) bleeding, 74 STTs were studied to determine whether their size, shape, surface area features, colorectal site, and level of invasion were correlated with bleeding. The bleeding rate, the proportion of specimens from patients with positive fecal occult blood test (FOBT) results relative to the total number of specimens in each morphological group and probability of an STT being an invasive submucosal carcinoma were positively correlated with tumor size, and bleeding was more common in submucosal than in intramucosal lesions. Logistic regression analysis indicated that the level of submucosal invasion had a significant influence on bleeding. It was also found that the length of erosion on the surface of STTs was significantly greater in bleeding tumors, and that the potential for invasion into the submucosa increased with the area of erosion.

Colon↗
PubMed1989

Rectal bleeding. Do other symptoms aid in diagnosis?

It has been shown previously that it is difficult for a general practitioner to predict anal vs. colorectal sources of bleeding in patients presenting with rectal bleeding. The aim of the present study was to determine whether there are any aspects of such a patient's history or clinical features that strongly indicate bleeding from a colorectal cancer or polyp. One hundred forty-five consecutive patients, aged 40 years and older, who had complained of rectal bleeding to a general practitioner, were referred to a specialist for full colonic investigation. Among 15 symptoms and clinical features examined, few had any statistically significant association with the source of bleeding. There was an elevated probability of colorectal cancer (21 percent) in patients who had seen blood mixed with feces. Most bowel symptoms and clinical features are not helpful in deciding whether to proceed with full colorectal assessment in patients aged 40 and older who have rectal bleeding of recent onset.

Adult↗
PubMedDate not supplied

Colonoscopy in the diagnosis of unexplained rectal bleeding.

Colonoscopy, done to elucidate the cause of obscure rectal bleeding not diagnosable on the basis of previous proctoscopic and barium-enema examinations, resulted in a 17 per cent diagnostic yield in this series. Eighteen of 105 patients were found to have lesions: three had carcinomas, six had polyps, eight had colitis, and one had proctitis. When bleeding had been demonstrated by the physician, there was a higher diagnostic yield (22.5 per cent) than when bleeding was reported only by the patient (5.9 per cent). Descriptions of the bleeding by the patients were found to be somewhat unreliable. Sixteen of the 18 lesions revealed by the colonoscope were in the left colon. It is suggested that the basic work-up for undiagnosed rectal bleeding should include history, physical examination, sigmoidoscopy, and barium-enema study. When no diagnosis is found, subsequent work-up must be individualized. When bleeding has been demonstrated to originate from the colon, colonoscopic examination should be performed.

Adolescent↗
PubMed2004

Predictors of spontaneous bleeding in Dengue.

OBJECTIVE: To identify the predictive factors for spontaneous bleeding manifestations in Dengue illness in infants and children. METHODS: 60 cases of Dengue viral infection with spontaneous skin and or mucosal bleed were compared with 72 cases without spontaneous bleed. The protean bleeding manifestations in dengue infection were recorded. Various clinical and laboratory parameters were analyzed using univariate and logistic regression analysis. RESULTS AND CONCLUSION: Prothombin time was abnormal only in cases with spontancous bleed. A combination of (a) biphasic pattern of fever, (b) hemoconcentration, (c) platelet count less than 50,000/mm3 and (d) elevated ALT had a sensitivity of 79.2%, specificity of 64.7% with a positive predictive value of 70% and a negative predictive value of 75% in predicting spontaneous bleeding in dengue.

Age Distribution↗
PubMed1985

Endoscopic bipolar electrocoagulation in massive upper gastrointestinal bleeding.

We have reviewed 50 cases of upper gastrointestinal bleeding treated by endoscopic bipolar electrocoagulation (BPEC) and assessed its value in the management of massive bleeding. Initial hemostasis was achieved in 94% of cases with an overall rebleeding rate of 19.1%. The rebleeding rate was high among patients requiring blood transfusions more than 2,000 ml (47.3%) and those with acute gastric mucosal lesion (AGML) (35.3%). In AGML one or two primary sites of bleeding can be effectively controlled initially, but rebleeding tends to occur from other sites. Mortality from the direct effects of bleeding was also high in massive bleeders (33.3%) and those with AGML (22.2%); the overall mortality, including deaths from ongoing underlying diseases, was 38%. Although BPEC failed to alter the fatal outcome of patients with massive acute mucosal bleeding, permanent or temporary hemostasis contributed to reducing the amount of blood transfusions, avoiding emergency operation, preventing rapid deterioration and prolonging the survival time. Endoscopic BPEC has proven to be an effective emergency hemostatic method in massive bleeding of the upper gastrointestinal tract as an alternative to surgical intervention.

Adolescent↗
PubMed2000

[Ileal conduit bleeding in portal hypertension. A rare complication].

The ileal conduit is a simple and safe supravesical urinary diversion with few postoperative complications. In patients with liver disease with portal hypertension, however, the risk of recurrent, peracute conduit bleeding is increased. While the diagnosis is simple, several therapeutic options are available. In most cases the bleeding comes from stomal varices, that can be controlled with local sclerotherapy with 3% Ethoxyscerol or ligation of the bleeding vessel. The resection of the part of the conduit carrying the varices is an option if bleeding is life threatening or the source cannot be localised. If bleeding recurs excision of the conduit should be considered. Malignant disease must be excluded as a bleeding source.

Aged↗
PubMedDate not supplied

Enhanced CT for initial localization of active lower gastrointestinal bleeding.

BACKGROUND: Active lower gastrointestinal (GI) bleeding is a potentially dangerous situation because patients with this condition may fall into shock. Colonoscopy, angiography, and scintigraphy have been used widely to localize the source of bleeding, but time is needed to perform these examinations. The purpose of this study was to illustrate how vividly enhanced computed tomography (CT) may show active lower GI bleeding in a short time. METHODS: Five of 10 patients with active lower GI bleeding underwent dynamic enhanced CT. Scans were obtained 0.5 and 5 min after intravenous contrast. RESULTS: Pooling of contrast medium was found in four of five patients. Among the five patients, three had diverticular disease of the colon, one had a rectal ulcer, and one had a small intestinal ulcer. The localization procedure completed within 15 min in all patients. Extravasations of medium were confirmed by two surgeons. CONCLUSION: Enhanced helical CT was useful for the detection of an active lower GI bleeding source. The procedure was brief, less invasive, and less demanding. Enhanced CT may be the first step for diagnosing lower GI tract bleeding.

Adult↗
PubMedDate not supplied

Endoscopic injection treatment of gastrointestinal bleeding in hemophiliacs.

The aims of this prospective study were to determine the patterns of gastrointestinal (GI) bleeding in hemophiliacs and to assess the hemostatic effect of injection therapy with alcohol. During a 5-year period (1990-1994) 89 hemophiliacs were admitted to our department with acute GI bleeding. Among these patients duodenal ulcer was found endoscopically to be the most common (42.7%) cause of hemorrhage; gastric ulcer was the source of the bleeding in only three patients (3.4%). A group of 46 patients met the criteria of active or recent bleeding and underwent injection therapy with alcohol. The injected bleeding lesions were duodenal ulcer in 32 patients, duodenal erosion in 2, gastric ulcer in 3, and other gastric lesions (Mallory-Weiss tear, Dieulafoy lesion, stomal ulcer, erosions) in 9 patients. Initial hemostasis was achieved in 100% and permanent hemostasis in 82.6%. Rebleeding was observed in eight patients (17.4%), with five of them successfully treated by reinjections. Three patients (6.5%) required emergency surgery. The mortality rate in the group of injected patients was 2.2%. One patient died of stroke on day 10 after partial gastrectomy. All injected patients were given replacement therapy with factor VIII or IX for 2 days (29 patients) or 7 to 14 days (17 patients). Analysis of the hemostatic effect achieved in these two subgroups indicate that short-term replacement therapy (2 days) may be sufficient to ensure adequate hemostasis in hemophiliacs. The results of the present study indicate that injection therapy with alcohol is an effective, safe, proved method to control GI bleeding in hemophiliacs.

Duodenal Ulcer↗
PubMed2006

Nonvariceal upper gastrointestinal bleeding.

Nonvariceal upper gastrointestinal bleeding (NUGB) remains a major medical problem even after advances in medical therapy with gastric acid suppression and cyclooxygenase (COX-2) inhibitors. Although the incidence of upper gastrointestinal bleeding presenting to the emergency room has slightly decreased, similar decreases in overall mortality and rebleeding rate have not been experienced over the last few decades. Many causes of upper gastrointestinal bleeding have been identified and will be reviewed. Endoscopic, radiographic and angiographic modalities continue to form the basis of the diagnosis of upper gastrointestinal bleeding with new research in the field of CT angiography to diagnose gastrointestinal bleeding. Endoscopic and angiographic treatment modalities will be highlighted, emphasizing a multi-modality treatment plan for upper gastrointestinal bleeding.

Angiography↗
PubMed2005

Bleeding remains a major complication during laparoscopic surgery: analysis of the SALTS database.

BACKGROUND AND AIMS: The aim of this study was to determine the incidence of bleeding complications from various laparoscopic procedures in a nationwide prospective multicentre study in Switzerland from 1995 to 2001 following an initial learning curve. PATIENTS AND METHODS: Since 1989, the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) has prospectively collected data from patients undergoing laparoscopic or thoracoscopic surgery at 114 surgical institutions (university, county and district hospitals, private practice). More than 130 items of data, including indication for surgery, intraoperative course, local as well as general postoperative complications, mortality and follow-up were recorded on a computerised data sheet. RESULTS: Some 43,028 procedures were assessed and analysed. Local morbidity (e.g. wound infections) occurred in 0.05% of the whole patient group, whereas 3.3% developed general postoperative complications. The overall mortality rate was 0.2%. In 1.7% of the cases, the intraoperative course was complicated by internal bleeding or haematoma of the abdominal wall. In the postoperative course, 1.5% of the patients presented with internal bleeding or bleeding of the abdominal wall. Major vascular injury occurred in 0.09%. This patient group with bleeding complications was analysed in the context of the operator's experience, instrumental lesions (Veress needle or trocar) and conversion incidence. Furthermore, a trend analysis of the complication rate from 1995 to 2001 was performed. CONCLUSION: Although the initial learning curve of laparoscopic procedures is probably finished, the rate of bleeding complications is still substantial. These results demonstrate that the collection of data in the form of multicentre studies is essential for quality control. It permits recognition and understanding of the current problems in laparoscopic surgery in order to improve the quality of daily surgical practice. The fact that the operator's experience seems to play an important role shows that improvement in learning and teaching programmes is still necessary and should be coordinated on a national basis.

Adolescent↗
PubMed2003

Colonoscopically placed hemoclips as treatment for massive appendiceal stump bleeding.

Massive bleeding from an appendiceal stump is a rare but occasionally seen severe complication. The bleeding may drain into the abdominal cavity, the retroperitoneum, or the digestive tract. Gastrointestinal hemorrhage may occur early or even years after appendectomy. The typical management includes ligation of the bleeding vessel or cecal resection done by either emergency laparotomy or laparoscopy. An alternative treatment option would be an angiographic embolization of the bleeding vessel. We report on a 33-year-old woman with severe lower gastrointestinal hemorrhage 1 day after an apparently uncomplicated appendectomy for acute phlegmonous appendicitis with ligation and invagination of the appendiceal stump. Hemoglobin level dropped to 6.3 g/dl and made blood transfusion necessary. The cause of bleeding was a small intramural branch of the appendiceal artery at the appendiceal stump, which was diagnosed by emergency colonoscopy. The hemorrhage could be controlled endoscopically by placing hemoclips on the distinct vessel in combination with a biological tissue adhesive. The patient recovered thereafter without further intervention. Endoscopic clipping for the treatment of appendiceal stump bleeding is a novel, effective, and safe procedure. Thereby, conventional emergency laparotomy or laparoscopy or angiographic embolization can be avoided.

Adult↗
PubMed2005

Serious intestinal bleeding from vascular ectasia secondary to portal thrombosis after living-related liver transplantation in a child.

Serious intestinal bleeding from vascular ectasia secondary to extrahepatic portal thrombosis is much less frequent than variceal bleeding, and its treatment is not clearly defined. We describe a 4-year-old girl with repeated intestinal bleeding from vascular ectasia, without any varix, with late extrahepatic portal vein thrombosis (PVT) and late hepatic artery thrombosis (HAT) after living-related liver transplantation. The bleeding stopped after simple splenectomy. She has presented neither bleeding nor any serious complications related to splenectomy for 1 year to date. We think uncontrollable hemorrhage from gastrointestinal vascular ectasia secondary to extrahepatic portal thrombosis in a pediatric patient can and should be treated by simple splenectomy, because patients with this complication usually have a normally functioning liver. However, it is not clear whether this procedure is effective for variceal bleeding.

Child, Preschool↗
PubMed2002

Rupture of a bleeding pancreatic pseudocyst into the stomach.

A bleeding pancreatic pseudocyst following pancreatitis is a severe complication that can lead to massive gastrointestinal bleeding. Rupture of such a pseudocyst into the stomach is rare. We report herein a case of rupture of a bleeding pseudocyst into the stomach in a patient who was successfully treated with emergency surgery. A 60-year-old Japanese man with a history of chronic alcoholic pancreatitis with a pancreatic tail pseudocyst was referred to us because of hematemesis. The cavity of the pseudocyst, which was 3 cm in size and whose wall adhered to the stomach, was enhanced by dynamic bolus computed tomography (CT) in the late arterial phase. Splenic angiography revealed a bleeding pseudocyst in the splenic hilum. Embolization of the pseudocyst failed, because of arterial spasm. A distal pancreatectomy, splenectomy, and total gastrectomy were performed. The wall of the pseudocyst consisted of the pancreatic tail, granulation tissue, and the posterior wall of the stomach. The patient's postoperative course was uneventful. In the management of massive bleeding from a pseudocyst, early diagnosis with dynamic bolus CT and angiography is essential. A bleeding pseudocyst should be considered to be a lethal complication, but it can possibly be treated with a combination of angiographic embolization and surgery.

Angiography↗
PubMed2005

The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use.

BACKGROUND: We report our preliminary experience with the use of video capsule endoscopy (VCE) in 64 patients with obscure gastrointestinal bleeding (OGIB) and suspected small intestine disease. METHODS: To be eligible for VCE, patients had to have undergone upper endoscopy, small bowel series, and colonscopy without discovering any source of bleeding. To find the best timing to perform VCE, the patients were retrospectively divided in two groups of 32 cases each: group 1 with patients who had been submitted to VCE within 15 days from OGIB diagnosis, and group 2 with patients who had been submitted to VCE at least 15 days after OGIB diagnosis. RESULTS: Lesions were found by VCE in 29 (91%) in group 1: angioectasia-like lesions of the small bowel in 12, some erosions of the ileum without signs of bleeding in 14, a polyp with erosions in 1, and a bleeding site where the surgery showed a tumor of the ileum in 2 patients. In 2 cases, VCE missed showing two small tumors that were revealed by laparoscopy in 1 case and by push enteroscopy in the other. In group 2, lesions were found by VCE in 11 (34%): angioectasia-like lesions of the small bowel in 6, some erosions in 3, a short segmental stenosis in 1, and two polyps in 1. In 1 case, VCE missed showing a small polyp in the jejunum that was revealed by push enteroscopy. In none of these cases was a bleeding site identified. VCE was well tolerated and able to acquire good images in patients with OGIB. It showed lesions in 91% of the patients in group 1 and 34% of cases in group 2. CONCLUSIONS: Our data suggest that the optimal timing to perform VCE is within a few days after the occurrence of bleeding, possibly within 2 weeks.

Adult↗
PubMed2000

Acquired ileal diverticulum: an unusual bleeding source.

Acquired ileal diverticulum is an uncommon condition and diagnosis is often difficult when bleeding occurs from this source. Here we describe two cases of ileal diverticulum with massive bleeding. Both patients presented with anal bleeding, but upper and lower gastrointestinal endoscopy did not reveal the source. Selective visceral angiography finally detected bleeding lesions in the terminal ileum. Surgical resection was performed in both patients, confirming that the bleeding arose from diverticula less than 1 cm in size. In patients with obscure gastrointestinal bleeding, an ileal diverticulum should be considered, and selective visceral angiography should be performed for precise diagnosis.

Aged↗