Search

Purpose: Mortality associated with acute Gastrointestinal (GI) hemorrhage in intensive care units (ICU) has remained high in patients suffering from hemodynamic instability. Prompt recognition and rapid assessment of bleeding severity are crucial to improve survival. Central venous pressure (CVP) monitoring is commonly used for early recognition of intravascular imbalances, but its effectiveness in predicting fluid responsiveness is often questioned. Echocardiography (echo) is a rapid, noninvasive method to repeatedly assess cardiac function and fluid responsiveness. This study investigated the impact of CVP and echo measurements on the outcomes of critically ill patients with GI hemorrhage. Methods: The study was based on the Medical Information Mart for Intensive Care IV (MIMIC- IV) database. Patients were divided into four groups according to the usage of CVP and/or echo. The primary outcomes were 7-day, 14-day, 28-day, and overall mortalities after ICU admission. Cox Proportional-Hazards Models were used to elucidate the relationship between CVP/ Echo monitoring and mortality. The severity of illness of patients were adjusted by qSOFA score, SOFA score and base deficit level at admission. Results: Among 1705 eligible patients, 82 patients had both CVP and echo, 85 had CVP only, and 116 had Echo only. The results of survival analysis indicated that, comparing with those without either CVP or echo, the echo utilization was associated with improved mortalities at all time points during ICU stay for patients with moderate GI hemorrhage, and the combined use of CVP and echo was associated with lower 7-day,14-day and overall mortalities for patients with severe GI hemorrhage. Conclusion: Early usage of CVP and echo monitoring or echo alone are associated with lower mortality in the short and long-term when compared to patients without either measurement. Clinicians should consider goal-directed resuscitation guided by echo with/without CVP in patients with GI hemorrhage early after admission to ICU.

Although the diagnosis of visceral pseudoaneurysm is unusual, it requires emergent attention due to the risk of rupture. We describe a 70-year-old man with a gastroduodenal artery pseudoaneurysm that manifested as recurrent hemorrhage. We highlight the possible etiologies, clinical presentations, diagnostic tools, and treatment options for this condition. In this instance, the patient was successfully treated by selective angioembolization. A visceral pseudoaneurysm should be considered in patients with abdominal pain and GI hemorrhage. At present, angioembolization is a first-line therapy.

Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.

Direct oral anticoagulants (DOACs) have rapidly become the drug class of choice for anticoagulation therapy in secondary care. It is known that gastrointestinal hemorrhage are potential side effects of the DOAC drug class. In this study we have investigated the relevance of molecular structure and on/off‐target pharmacology as a predictor of adverse drug reactions (ADRs) for the DOAC drug class. Use of the Reaxys MedChem module allowed for data mining of all possible reported off‐target effects of the DOAC class members. For the first time, the MHRA Yellow card database in combination with prescribing rates in the United Kingdom (data for n = 30 566 936 DOAC Rx (up to 2017) and ADR data n = 22 275 (up to 2018)) were used for our data comparison of DOACs. From the underlying reported data, we were able to rank the DOACs in terms of the likely adverse events we would expect to observe. We identified potential risks of ADRs based on the DOACs pharmacology including the expected GI hemorrhage, but also the unexpected risk of stroke, pulmonary embolism and kidney injury. Statistically significant (P

Secondary aortoduodenal fistula (AEF), although less rare than its primary form, is an uncommon and frequently lethal cause of gastrointestinal (GI) bleeding. We report a case of fatal GI hemorrhage in a woman with a remote history of endovascular graft repair of an abdominal aortic aneurysm. Postmortem examination included computed tomography (PMCT) and CT angiography (PMCTA), which revealed air in the aorta, loss of the fat plane between the aorta and duodenum, and direct extravasation of contrast from the aorta into the duodenum. To our knowledge, this is the first published report of secondary AEF diagnosed by PMCT and confirmed with PMCTA. We propose a set of imaging criteria by which PMCTA can be used to supplant traditional anatomical dissection in the medicolegal investigation of deaths due to AEF.

Background. Our aim was to assess the risk of gastrointestinal (GI) hemorrhage associated with diabetes among patients taking low-dose aspirin (≤325 mg/day). Methods. A systematic search was conducted for publication in English and Chinese using term equivalents for “GI hemorrhage”, “aspirin”, and “diabetes mellitus” up till April 2020. Electronic databases include PUBMED, EMBASE, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP Database. Two independent authors searched databases and reviewed abstracts for comprehensive studies keeping adequate study quality. Data of weighted odds ratios were statistically evaluated and potential bias was checked. Results. Among 446 publications, eight case-control researches, including 1601 patients, were deemed for this meta-analysis. Patients with diabetes were associated with a higher risk of GI hemorrhage than patients without diabetes: the summary ORs were 3.10 (95% CI, 2.35–4.09). The heterogeneity of the reports was not significant (Chi2=3.39, P=0.85; I2=0%). Conclusion. The meta-analysis showed that aspirin users with diabetes were more likely to have GI hemorrhage. Hence, when treating diabetics with aspirin, the increased risk of GI bleeding should be taken in consideration.

Background/Aims: Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates. Methods: First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012. Results: The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression. Conclusion: Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.

Testicular cancer is the most common malignancy in men aged 20–35 years, usually presenting with painless scrotal swelling. Metastases, should they occur, frequently involve retroperitoneal lymph nodes, which drain the testes. Gastrointestinal (GI) metastases are rare, and metastatic disease may not initially be considered in a young man presenting with GI hemorrhage. This case demonstrates the importance of evaluating for a primary underlying malignancy, especially if other causes of GI hemorrhage have been ruled out. Testicular primary should additionally be considered in men because early intervention may often lead to improved clinical outcomes.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to control traumatic intra-abdominal or pelvic hemorrhage. There are few case reports of REBOA use in nontraumatic gastrointestinal (GI) hemorrhage. A 53-year-old man with pancreatic cancer status post Whipple procedure presented with GI hemorrhage from the gastroduodenal artery. Endoscopy and angioembolization were unsuccessful at stopping the hemorrhage. REBOA was used to stabilize the patient until definitive surgical control. REBOA is a potentially lifesaving measure in cases of massive abdominal or pelvic hemorrhage. REBOA can be used as an adjunct in unstable patients with GI bleeding until definitive GI, interventional radiology, or surgical control.

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital.

Background: Small bowel bleeding accounts for 5–10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

Interventional radiology (IR) can play a key role in the management of gastrointestinal (GI) bleeding, especially when endoscopy fails or if the patient is a poor surgical candidate. IR can locate as well as treat the bleeding site. In most algorithms, endovascular therapy by IR is used after endoscopy, but it can be considered a first-line intervention when visualization is likely to be poor, as with an unprepped colon with high suspicion of a lower GI bleed, or if the patient is unstable and endoscopic yield is felt to be low, such as in a briskly bleeding patient. In the case of upper GI bleeds, a distinction should be made between variceal and non-variceal bleeding sources as arterial interventions on the former would not be applicable. Proper utilization of IR requires a multidisciplinary approach and good communication among providers such that the bleeding patient gets the most appropriate therapy with the most efficient use of time.

Meckel diverticulum is the most common gastrointestinal (GI) anomaly, occurring in 2% of the population. This condition often presents symptomatically similar to acute appendicitis in children. The most common presentation is GI hemorrhage, followed closely by obstruction due to intussusception. Laparoscopy is the standard in both diagnosing and treating a complicated Meckel diverticulum.

COVID-19 pandemic caused a major crisis, affecting and straining health care systems, including some very advanced ones. The pandemic may have also indirectly affected access to health care for patients with other conditions, not related to COVID-19, even in countries not overwhelmed by an outbreak.We analyzed and compared visits to the emergency room (ER) department during the same calendar period of 2019 and 2020 (from March 1 to March 31 of each year) in our hospital, a medium size, tertiary center, located in the center of Athens, which is not a referral center for COVID-19.Total ER visits were reduced by 42.3% and the number of those requiring hospitalization by 34.8%. This reduction was driven by lower numbers of visits for low risk, non-specific symptoms and causes. However, there was a significant decrease in admissions for cardiovascular symptoms and complications (chest pain of cardiac origin, acute coronary syndromes, and stroke) by 39.7% and for suspected or confirmed GI hemorrhage by 54.7%. Importantly, number of ER visits for infections remained unchanged, as well as the number of patients that required hospitalization for infection management; only few patients were diagnosed with COVID-19.During the initial period of the pandemic and lock-down in Greece, there was a major decrease in the patients visiting ER department, including decrease in the numbers of admissions for cardiovascular symptoms and complications. These observations may have implications for the management of non-COVID-19 diseases during the pandemic.

Oral rehydration solution (ORS) is safe and effective for the prevention and treatment of dehydration in children. It has been commercially available as a small packaging unit that needs to be taken with a specified amount of water. Intake of incorrectly formulated ORS results in side effects, such as electrolyte imbalance and upper gastrointestinal (GI) disturbance. We experienced a case of severe GI hemorrhage from gastric and duodenal ulcers in a previously healthy child following intake of incorrectly formulated ORS. GI hemorrhage in children is often life threatening and reaching a diagnosis may be challenging. Commercially manufactured packets of powdered oral rehydration salts have been widely used and GI hemorrhage associated with an improperly diluted ORS has been rarely reported. Caution and education for proper preparation of ORS are imperative.

Iron deficiency (ID) and iron deficiency anemia (IDA) are important signs of gastrointestinal (GI) hemorrhage. Therefore, the evaluation of the GI tract should be a part of the diagnostic protocol in patients with IDA. GI hemorrhage is not a disease but a symptom, which might have different underlying causes. ID and IDA have significant negative impacts on the life quality and work ability, and they may lead to frequent hospitalization, delay of discharge, and increased healthcare costs. Therefore, an optimal management of the disease causing GI hemorrhage should include iron replacement therapy, along with the treatment of the underlying condition. IDA in inflammatory bowel disease (IBD) has received particular attention owing to its high prevalence, probably due to a number of other factors such as chronic hemorrhage, reduced dietary iron intake, and impaired absorption of iron. Historically, in IBD and in patients with GI hemorrhage, the diagnosis and management of IDA have been suboptimal. Options for iron replacement include oral and intravenous (IV) iron supplementation. Oral iron supplementation frequently results in GI side effects, and theoretically, it may exacerbate IBD activity; therefore, IV iron supplementation is usually considered in patients not responding to or not complying with oral iron supplementation or patients having low hemoglobin concentration and requiring prompt iron repletion. The aim of this report was to review the diagnostic and therapeutic considerations of IDA in IBD and GI hemorrhage with a multidisciplinary group of experts and to formulate necessary practical recommendations., NA

The benefits of using anticoagulants for stroke prevention in atrial fibrillation patients with prior GI bleed can outweigh the risks. Selecting warfarin or a direct oral anticoagulant with a similar incidence of GI bleeding compared to warfarin should be considered to minimize the risk for bleeding.

This section provides a comprehensive procedural report for embolization for management of acute non-variceal gastrointestinal hemorrhage procedure with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.

During the transitioning through puberty, adolescents present with varied gynaecological issues, among which puberty menorrhagia is a significant complaint. The most common underlying cause of puberty menorrhagia is anovulation, other causes being endocrine dysfunction, PCOS and bleeding disorders. Congenital prothrombin deficiency is an extremely rare inherited coagulopathy, affecting one in two million of general population. Depending on the severity of deficiency they present with myriad bleeding tendencies, including epstaxis, soft tissue bleeds, GI hemorrhage, intracranial hemorrhage, menorrhagia, excessive post traumatic and post-surgical bleeding. Here, we present a very rare case of congenital prothrombin deficiency presenting primarily with puberty menorrhagia.

Henoch-Schönlein purpura (HSP) is considered a benign disease of children. We report a severe case of HSP in an adult causing renal failure and gastrointestinal (GI) hemorrhage. Despite aggressive treatment with corticosteroids, cyclophosphamide, and plasmapheresis, the patient developed massive GI bleeding from 2 Dieulafoy lesions and died weeks after bowel resection. Although uncommon, when massive GI hemorrhage occurs, actively bleeding Dieulafoy lesions, although uncommon, should be suspected and evaluated early.

Gastrointestinal (GI) bleeding is a common clinical condition that is increasingly seen in an aging population and frequently requires hospitalization and intervention, with significant morbidity and mortality. Obscure GI bleeding (OGIB) is defined as loss of blood with no source identified after upper endoscopy and colonoscopy. Whether an obscure site of bleeding is clinically evident or silent, it constitutes a diagnostic and therapeutic challenge for the clinician. Gastroenterology and radiology provide the essential diagnostic tools used to evaluate suspected OGIB, each with its strengths and weaknesses. Small bowel series and conventional enteroclysis have a limited role in OGIB. Computed tomographic (CT) enterography and CT enteroclysis are noninvasive techniques with promising results in evaluation of small bowel disease and silent OGIB. CT angiography is a useful triaging tool for diagnosing or excluding active GI hemorrhage, localizing the site of bleeding, and guiding subsequent treatment. Tagged red blood cell scanning is the most sensitive technique for detection of active GI bleeding and allows imaging over a prolonged period, making it useful for detecting intermittent bleeding. Capsule endoscopy has emerged as an important tool for investigating OGIB, but it may soon have competition from double-balloon enteroscopy, a diagnostic technique that can also facilitate therapy.

The physician is central to deciding whether a patient requires acute inpatient hospital treatment and is also responsible for appropriately documenting the record which permits accurate diagnostic-related grouping (DRG) coding. An area of particular concern both nationally and in New York State has been patients admitted with gastrointestinal (GI) disorders; specifically, DRGs 174 (GI hemorrhage with complication) and 182 (esophagitis, gastroenteritis, and miscellaneous digestive disorders age > 17 with complication comorbidity). A baseline sample of 600 cases from fiscal year (FY) 2006 was selected from 20 hospitals and underwent review for both admission necessity and DRG assignment. The results were disseminated to the hospitals. In addition, hospitals with a >10% error rate were required to implement an improvement plan. A re-measurement sample of 300 cases was taken from FY 2007 for review. The aggregate error rate was 13.3% at baseline and decreased to 8.0% on re-measurement (P

We present the case of a 67-year-old female with melena and hypotension who was found to have a bleeding splenic artery pseudoaneurysm subjacent to a large gastric ulcer on computed tomographic angiography. The lesion was angiographically occult on standard anteroposterior and oblique projections. The offending vessel was identified on intraprocedure cone-beam computed tomography (CT). This case illustrates the value of intraprocedure cone-beam CT as a problem-solving tool for the interventional radiologist.

PURPOSE There is no gold-standard regarding the diagnostic work-up and therapy of an acute gastrointestinal (GI) hemorrhage. In most cases endoscopy provides the diagnosis but in a low percentage this modality is not feasible or negative. Purpose of this study was to evaluate the role of multi-phase Multi-Slice-Computertomography (MSCT) as a modality to diagnose and locate the site of acute GI hemorrhage in case of unfeasible or technically difficult endoscopy. MATERIALS AND METHODS 58 patients, presenting with clinical signs of lower GI hemorrhage, were examined through a 24-month period. Preliminary endoscopy was either negative or unfeasible. Images were obtained with a four-detector row CT with an arterial (4 x 1 mm collimation, 0.8 mm increment, 1.25 mm slice width, 120 kV, 165 mAs) and portal venous series (4 x 2,5 mm collimation, 2 mm increment, 3 mm slice width, 120 kV, 165 mAs). Time interval between endoscopy and CT varied between 30 minutes and 3 hours. The results of the MSCT were correlated with clinical course and surgical or endoscopical treatment. RESULTS 20 of the 58 patients (34 %) undergoing MSCT had a bleeding site identified, thus providing decisive information for the following intervention. In case of a following therapeutic intervention there was 100 % correlation regarding the bleeding site. In 38 of the 58 patients (66 %), a bleeding site was not identified by MSCT. Twenty of these 38 patients (53 %) were stable and required no further treatment. In 18 of these 38 patients further interventional therapy was required due to continuing hemorrhage and in all of those patients the bleeding site was detected by intervention. CONCLUSION Compared to other diagnostic methods MSCT is a fast, widely-available and low-risk technique for the localization of active GI hemorrhage. The clinical use seems to be justified since in more than one third of the patients, MSCT demonstrates the site of bleeding and provides decisive information for further interventional therapy. Concerning those patients, in whom MSCT is negative (38 out of 58 patients), only every second patient requires any additional diagnostic work-up.

Gastrointestinal (GI) diseases are often encountered in the intensive care unit (ICU) setting, either as the major cause that prompted admission to the ICU or as a comorbid complication of another primary disease process. The most common digestive disease that is seen in the ICU is acute GI bleeding; upper GI bleeding occurring five times more commonly than lower GI bleeding. This article discusses acute nonvariceal and variceal upper GI bleeding and lower GI bleeding. Prophylaxis against GI hemorrhage in the ICU setting is also discussed. Acute pancreatitis is another common cause that mandates ICU admission and is reviewed in this article. Lastly, acalculous cholecystitis is an example of a disease that is usually a comorbid complication in critically ill patients and is often a difficult diagnosis to make. Diagnosis and treatment of acalculous cholecystitis is discussed.

Although granulomatosis with polyangiitis (GPA) can affect any organ, gastrointestinal (GI) involvement is uncommon. Moreover, death from massive GI hemorrhage is a rare entity, with few cases described in the literature. In our report, we present a case of a patient with GPA who developed massive ulcerative bleeding, which ultimately proved fatal. Given the paucity of reports available, the significant potential for morbidity, and the fact that concurrent immunosuppressive therapy may themselves exacerbate the risk of bleeding, we reviewed 49 case reports of patients with GPA and GI involvement from 1982 to June 2016 in an attempt to shed light on a little seen sequelae that warrants a high index of suspicion.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective medications for the treatment of many chronically painful medical conditions. However, it is estimated that 25% of all serious adverse drug reactions involve NSAIDs, with more than 100,000 hospitalizations and 16,000 deaths occurring annually due to NSAID-induced gastrointestinal (GI) events. Advanced age; concurrent anticoagulant, aspirin, corticosteroid, or antacid use; and a history of cardiovascular disease, peptic ulcer disease, or GI hemorrhage all increase the risk of NSAID-induced gastropathy. Home care patients often have many of these characteristics. This article will provide evidence-based information about interventions that can reduce patients’ NSAID-induced gastropathy risk, including knowledge gained from a home care–specific study.

Advanced age and comorbidity as well as gastrointestinal (GI) disease contribute to the increased mortality after upper GI endoscopy in inpatients when compared to outpatients. The aim of this study was to measure comorbidity in inpatients undergoing endoscopy using the Acute Physiology and Chronic Health Evaluation (APACHE) II severity of disease classification and to assess the usefulness of the APACHE II system in predicting outcome. During a 10-week period, 155 consecutive inpatients undergoing upper GI endoscopy were prospectively scored using APACHE II. They were followed up for 30 days, the measured endpoint being death. Of these, 92 (59%) inpatients were admitted with GI hemorrhage, 14 (9%) were admitted for other reasons but subsequently bled, and 49 (32%) were endoscoped for reasons other than bleeding. The mean (SEM) APACHE II score in patients with GI bleeding was 8.0 (0.5), and in patients without bleeding was 6.5 (0.6; p = 0.07). Eighteen patients (12%) died within 30 days of endoscopy. APACHE scores were higher at 10.5 (1.2) in patients who died, compared to 7.1 (0.4) in those who lived (p < 0.01). Increased acute physiology scores led to this difference. Age and chronic health scores were similar in both groups. In the 18 patients who died, 9 had GI bleeding and their mean APACHE score was 13.8 (1.5); 9 had been endoscoped for other reasons and had a lower score of 7.2 (1.3; p < 0.01). These latter 9 deaths amounted to a 18% mortality in the nonbleeding group, which was greater than expected. APACHE II scores can help predict poor outcome in inpatients referred for endoscopy. However, the APACHE II system has limitations and failed to identify (by means of a high score) some patients without GI bleeding who subsequently died. A tool to measure comorbidity, such as the APACHE II system, is necessary when comparing groups of patients in different settings.

Endoscopy is the primary diagnostic and therapeutic tool used in the evaluation and treatment of patients with upper gastrointestinal bleeding. When endoscopy is unsuccessful in identifying or controlling GI hemorrhage, however, arteriography is useful in both the evaluation and treatment if upper GI hemorrhage.

A pictorial algorithm to the approach of GI hemorrhage with an evidence-based decision rule included.

Severe gastrointestinal (GI) hemorrhage is a rare complication of Crohn's disease (CD). Although several surgical and non-surgical approaches have been described over the last 2 decades this complication still poses significant diagnostic and therapeutic challenges. Given the relative infrequency of severe bleeding in CD, available medical literature on this topic is mostly in the form of retrospective case series and reports. In this article we review the risk factors, diagnostic modalities and treatment options for the management of CD presenting as GI hemorrhage.

Background: Routine postoperative GI series has been common before discharging gastric bypass patients. 78,000 operations were performed in the USA in 2002. At $75 each, the total annual expenditure for the upper GI series approaches 6 million dollars. This study examines the value of performing routine upper GI series. Materials and Methods: From 1996 to 2000, 396 open gastric bypass procedures were performed by one surgeon at the University Medical Center. 242 randomly selected charts were retrospectively reviewed for signs and symptoms possibly related to leak or obstruction. Radiology reports were compared with clinical findings. Results: 82% of patients (192/242) were discharged following unremarkable postoperative courses and normal x-rays. 18% (44/242) exhibited one or more clinical signs suspicious of leak or obstruction. These included fever, tachycardia, tachypnea, inordinate pain, elevated white cell count or GI hemorrhage. Leak was reported in 5, and obstruction in 5. 4 patients with reported leaks were re-operated: 2 were positive for unconfined leak requiring surgical treatment; 2 had negative laparotomies. The 2 patients (0.82%) with free leakage had dramatic clinical deterioration, and x-rays were confirmatory rather than diagnostic. 1 patient with a minimal confined leak was treated non-operatively. 8 films were misread as showing a leak when none was present: 2 underwent negative laparotomy, the others being correctly interpreted after review. 8 of 10 initial interpretations were falsely positive. Conclusion: Routine postoperative GI series following gastric bypass is not beneficial. All true leaks are demonstrated when x-rays are indicated. We recommend GI series only when clinically indicated. GI series had low positive predictive value for leak.

Clip application has been proven to be effective for endoscopic hemostasis. There are limited bench data on the efficacy of the over-the-scope clip (OTSC) for the treatment of spurting GI hemorrhage. We evaluated the hemodynamic efficacy of the OTSC in an established bleeding model.To evaluate the hemodynamic efficacy of the OTSC in an established bleeding model.Prospective experimental trial with historical comparison.We tested the OTSC prospectively in a validated bleeding model by using the compact Erlangen Active Simulator for Interventional Endoscopy equipped with an upper GI organ package. The artificial blood circulation system of the simulator was connected to an arterial pressure transducer. Two investigators with different endoscopic experience (4000 and 10,000 endoscopies performed) participated. Each investigator treated 16 bleeding sites in the simulator with the OTSC by using only suction (n = 8) and a novel retraction device to grasp tissue (n = 8). Systemic pressures were recorded 1 minute before, during, and 1 minute after clip application to objectify the effects of clipping on the vessel diameter.Mean and maximum reduction in vessel diameter.The application of the OTSC on the bleeding vessel led to a significant increase in systemic pressure (P.001) and decreased vessel diameter (P.001) independent of the endoscopic experience of the investigator. There was no difference in the decrease in vessel diameter based on the application technique (suction vs suction plus grasping). A historical comparison with our former trials demonstrated that the OTSC decreased the vessel diameter significantly more than other traditional endoclips.Small sample size.We could demonstrate the efficacy of the OTSC with increased hemodynamic efficiency compared with other endoscopic clip devices tested previously.

Lower GI hemorrhage is 3 times less common than upper GI hemorrhage, but more commonly seen by Interventional Radiologists due to the use of upper endoscopy as a diagnostic and therapeutic modality.