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Alhamid A, Aljarad Z, Chaar A, Grimshaw A, Hanafi I. Endoscopic therapy for gastrointestinal angiodysplasia. Cochrane Database Syst Rev 2024; 9:CD014582. [PMID: 39297500 PMCID: PMC11411905 DOI: 10.1002/14651858.cd014582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of the different endoscopic management approaches for gastrointestinal angiodysplasia in symptomatic adults.
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Affiliation(s)
- Ahmad Alhamid
- Department of stem cell biology, Nagasaki University, Graduate school of biomedical sciences, Atomic Bomb Disease Institute, Nagasaki, Japan
| | - Ziad Aljarad
- Department of Internal Medicine, Faculty of Medicine, Aleppo University, Aleppo, Syrian Arab Republic
| | | | - Alyssa Grimshaw
- Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Ibrahem Hanafi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
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Defarges A, Stiller J, Solomon JA. Gastrointestinal angiodysplasias diagnosed using video capsule endoscopy in 15 dogs. J Vet Intern Med 2023; 37:428-436. [PMID: 36866722 DOI: 10.1111/jvim.16677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/16/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Angiodysplasia (AGD) is rarely diagnosed in dogs with gastrointestinal bleeding (GIB) and is reported in case reports in dogs. OBJECTIVE Describe signalment, clinical and diagnostic features of dogs with gastrointestinal (GI) AGD diagnosed by video capsule endoscopy (VCE). ANIMALS Dogs with overt or suspected GIB which underwent VCE. METHODS Dogs for which a VCE was submitted for overt or suspected GIB from 2016 to 2021 were selected retrospectively. Medical records and full-length VCE recordings where AGDs were initially detected, were reviewed by 2 trained internists. AGD was considered definitive if 2 readers detected it. Signalment, clinical signs, blood work, medications, concurrent diseases, findings of previous conventional endoscopy, and surgical exploration (if applicable) of dogs with AGD were recorded. RESULTS Definitive AGD was diagnosed in 15 of 291 (5%) dogs (12 males, 3 females). Twelve (80%) had overt GIB, 11 (73%) had hematochezia, and 6 (40%) had microcytic and hypochromic anemia. AGD was missed by conventional endoscopy in 9/9 dogs and exploratory surgery in 3/3 dogs. Thirteen capsules were administered by mouth (1 incomplete study), and 2 via endoscopy directly into the duodenum. AGD was visualized in the stomach of 3 dogs, in the small intestine of 4, and in the colon of 13 dogs. CONCLUSION AND CLINICAL IMPORTANCE Although rare, AGD should be considered in dogs with suspected GIB after a negative conventional endoscopy or surgical exporation. Video capsuel endoscopy appears to be a sensitive test to identify AGD within the GI tract.
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Affiliation(s)
- Alice Defarges
- University of Guelph, Ontario Veterinary College, Guelph, Ontario, Canada
| | - Jenny Stiller
- Universität Leipzig Veterinärmedizinische Fakultät Klinik, Leipzig, Germany
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ARI D, ERDOĞAN Ç, YÜKSEL M, YEŞİL B, TURAN GÖKÇE D, BACAKSIZ F, KAYAÇETİN E. Using the Charlson comorbidity index as a prognostic factor of lower gastrointestinal system bleeding: the experience of a tertiary center. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1178982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Lesions in the gastroinestinal (GI) tract that are distal to the Treitz ligament are what cause the lower gastrointestinal bleeding (LGB) system. The purpose of this study was to investigate and compare the Charlson Comorbidity Index (CCI), mortality rates, length of hospital stays, need for intensive care, need for blood products, and surgical rates in patients with acute LGB.
Material and Method: Retrospective research was done on patients who had lower GI bleeding and had been seen in our gastroenterology clinic between 2015 and 2021. We looked into the impact of CCI on patients' follow-up after LGB.
Results: The mean age of the 210 patients who had lower GI bleeding was 67.70±13.67 years. For all of the patients, the median CCI value was 4.00. (2.00-5.00). While 16 study participants (group 1) passed away, 194 participants (group 2) were released from the hospital. The variance in the median CCI values between the two groups was statistically significant (p>0.001). The results of a multivariate logistic regression analysis revealed that CCI was a reliable predictor of mortality (p>0.001).
Conclusion: It was found that CCI was an accurate predictor of mortality. CCI ought to be regarded as a crucial factor in the treatment of patients who are bleeding from their lower gastrointestinal tract.
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Affiliation(s)
- Derya ARI
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Çağdaş ERDOĞAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Mahmut YÜKSEL
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | | | - Dilara TURAN GÖKÇE
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Ferhat BACAKSIZ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, DİYARBAKIR GAZİ YAŞARGİL SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Ertuğrul KAYAÇETİN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
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Johnson AM, Chovwen PE, Akpan EJ, Patel A. Aortic Valve Stenosis, a Precipitating Factor of Recurrent Bleed in Colonic Angiodysplasia: A Literature Review. Cureus 2021; 13:e15903. [PMID: 34322347 PMCID: PMC8310456 DOI: 10.7759/cureus.15903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Angiodysplasia (also known as angioectasia) is a lesion characterized by abnormal, dilated small blood vessels in the mucosa and submucosal layers of the GI tract. With the estimated low incidence of active GI bleeding from these lesions, angiodysplasia can be challenging to diagnose. The presence of aortic stenosis has increased the recognition rate of angiodysplasia, especially in the elderly. Despite the associations between aortic stenosis and angiodysplasia (Heyde's syndrome) revealed in several studies, the etiology of Heyde syndrome is still debatable, which has led to the proposition of several hypotheses that are reviewed in this article. This activity will help review the meaning of Heyde's syndrome, epidemiology, proposed pathophysiology, diagnosis, and management by surveying articles published between 1955 and 2021 on PubMed. We used search terms such as "colonic angiodysplasia," "arteriovenous malformation," "Heyde syndrome," "refractory gastrointestinal bleed," "aortic valve stenosis," and "acquired von Willebrand disease." Findings revealed an association between aortic stenosis and lower gastrointestinal (GI) bleed.
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Affiliation(s)
| | | | - Ezekiel J Akpan
- Medicine, All Saints University College of Medicine, Kingstown, VCT
| | - Anna Patel
- Gastroenterology and Hepatology, Community First Medical Center, Chicago, USA
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5
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Tamura R, Moldovan C, Gopal M. Tranexamic acid for bleeding in a child with extensive small bowel angiodysplasia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Saurin JC, Jacob P, Pioche M. Treatment of digestive angiectasia: time for prospective, randomized, therapeutic studies. Endosc Int Open 2019; 7:E1778-E1779. [PMID: 31830146 PMCID: PMC6904236 DOI: 10.1055/a-0990-9773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Jean-Christophe Saurin
- Gastroenterology Unit, E. Herriot Hospital, Hospices Civils de Lyon, Lyon, France,Corresponding author Jean-Christophe Saurin Gastroenterology UnitE. Herriot HospitalHospices Civils de Lyon5 Place d’Arsonval69437 Lyon cedex 03France+33472110147
| | - Philippe Jacob
- Gastroenterology Unit, E. Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Pioche
- Gastroenterology Unit, E. Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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Kathi PR, Tama M, Kundumadam S, Gulati D, Ehrinpreis MN. Esophageal arteriovenous malformation, a rare cause of significant upper gastrointestinal bleeding: Case report and review of literature. Intractable Rare Dis Res 2018; 7:196-199. [PMID: 30181941 PMCID: PMC6119666 DOI: 10.5582/irdr.2018.01068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Gastrointestinal (GI) arteriovenous malformations (AVMs) are a well-known source of bleeding with colon being the most common site, but they can also occur in rare locations like the esophagus which may present with life threatening bleeding. We report the case of a 51-year-old male with end stage renal disease (ESRD) presenting with hematemesis and acute on chronic anemia. Further investigation showed an esophageal AVM which is an unusual location and it was successfully treated with an endoscopic clip instead of argon plasma coagulation (APC) due to its challenging location and esophageal wall motion from breathing. The patient continued to be asymptomatic without any upper and lower GI bleeding during his 20 months follow up period after the endoscopic management. Review of literature showed only 10 cases of AVMs involving esophagus and the average age of presentation was 52 years with a male predominance. We also provide an overview of those cases in the discussion section below.
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Affiliation(s)
- Pradeep Reddy Kathi
- Department of Internal Medicine, Wayne state University School of Medicine, Detroit, Michigan, USA
- Address correspondence to:Dr. Pradeep Reddy Kathi, Internal Medicine, Wayne state University School of Medicine, 4201 Saint Antoine street, UHC 2E, Detroit, Michigan 48201, USA. E-mail:
| | - Maher Tama
- Division of Gastroenterology, Department of Internal Medicine, Wayne state University School of Medicine, Detroit, MI, USA
| | - Shankerdas Kundumadam
- Department of Internal Medicine, Wayne state University School of Medicine, Detroit, Michigan, USA
| | - Dhiraj Gulati
- Department of Gastroenterology, Rush Copley Medical Center, Aurora, IL, USA
| | - Murray N Ehrinpreis
- Division of Gastroenterology, Department of Internal Medicine, Wayne state University School of Medicine, Detroit, MI, USA
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Farrands PA, Taylor I. Management of Acute Lower Gastrointestinal Haemorrhage in a Surgical Unit Over a 4-Year Period. J R Soc Med 2018; 80:79-82. [PMID: 3494123 PMCID: PMC1290675 DOI: 10.1177/014107688708000207] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over a 4-year period 107 patients, 5% of all emergency admissions, were admitted to one surgical unit with significant lower gastrointestinal haemorrhage (requiring more than a 2-unit transfusion of blood). Twenty-three individuals required more than 3 units of blood, and 7 life-saving surgery. All subjects undergoing surgery required more than 3 units of blood in the first 24 hours of admission. Arteriography was diagnostic in 5 of the 9 subjects in whom it was performed. Arteriography was positive if performed in the first 24 hours of admission. A flow chart of the management of patients with lower gastrointestinal haemorrhage is presented.
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Aoyama T, Fukumoto A, Shigita K, Asayama N, Mukai S, Nagata S. Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions. Dig Dis Sci 2018; 63:723-730. [PMID: 29372478 DOI: 10.1007/s10620-018-4930-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/11/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities. AIMS We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively. METHODS We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores. RESULTS Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023). CONCLUSIONS Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan.
| | - Akira Fukumoto
- Department of Endoscopy, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Kenjiro Shigita
- Department of Endoscopy, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Naoki Asayama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Shinichi Mukai
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
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Ng KS, Nassar N, Soares D, Stewart P, Gladman MA. Acute lower gastrointestinal haemorrhage: outcomes and risk factors for intervention in 949 emergency cases. Int J Colorectal Dis 2017; 32:1327-1335. [PMID: 28712008 DOI: 10.1007/s00384-017-2844-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Outcomes of acute lower gastrointestinal haemorrhage (ALGIH) are mostly derived from studies performed in the sub-acute/elective rather than the emergency department (ED) setting. The aims of this study were to determine the incidence and outcomes of patients presenting to a tertiary hospital ED with ALGIH and to identify associated clinicopathological risk factors. METHOD A retrospective observational cohort study of consecutive patients presenting with ALGIH to a tertiary hospital ED was performed. Primary outcome measures included mortality and hospital (including high dependency [HDU]) admission. Secondary outcome measures included rates of (i) blood transfusion, (ii) radiological/endoscopic investigation(s) and (iii) therapeutic intervention. RESULTS ALGIH accounted for 949 (512 M, mean age 62.3 years) of 130,262 (0.73%) ED presentations, of which 285 patients (30.1%) were on anti-platelet/coagulant therapy. There were five deaths (0.5%). Hospital admission was required in 498 patients (52.5%), of which 19 (3.8%) required HDU monitoring. Hospital admission was twice as likely in males and four times more likely in patients >75 years old and those taking multiple anti-platelet/coagulant therapy (P < 0.05). Blood product transfusion was required in 172 patients (34.5%), specialist investigations in 230 (46.2%) and therapeutic intervention in 51 (10.2%) (surgery in 24 [4.8%]; endoscopic haemostasis in 20 [4.0%] and angiographic embolisation in 9 [1.8%] patients). CONCLUSION ALGIH accounts for 1% of all ED presentations, with half requiring hospital admission. Mortality and surgical intervention rates are low and although most patients can be managed supportively, access to interventional radiology/endoscopy is important.
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Affiliation(s)
- Kheng-Seong Ng
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Deanne Soares
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Patrick Stewart
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Marc A Gladman
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia. .,Adelaide Medical School, Faculty of Health & Medical Sciences, The University of Adelaide, Medical School South, Frome Road, Adelaide, 5005, Australia.
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Abstract
Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.
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Affiliation(s)
- Amy Leuthauser
- Department of Emergency Medicine, Bay of Plenty District Health Board, Tauranga Hospital, Cameron Road, Private bag 12024, Tauranga 3142, New Zealand.
| | - Benjamin McVane
- Department of Emergency Medicine, Icahn School of Medicine, Mount Sinai Hospital, 1 gustav levy place, New York, NY 10028, USA
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Yamada A, Niikura R, Kobayashi Y, Suzuki H, Yoshida S, Watabe H, Yamaji Y, Hirata Y, Koike K. Risk factors for small bowel angioectasia: The impact of visceral fat accumulation. World J Gastroenterol 2015; 21:7242-7247. [PMID: 26109811 PMCID: PMC4476886 DOI: 10.3748/wjg.v21.i23.7242] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 01/25/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate visceral fat accumulation in association with the risk of small bowel angioectasia.
METHODS: We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding (OGIB) from January 2009 to September 2013. The visceral fat area (VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records. Logistic regression analysis was used to evaluate associations.
RESULTS: Capsule endoscopy revealed small bowel angioectasia in 18/198 (9.1%) patients with OGIB. Compared to patients without small bowel angioectasia, those with small bowel angioectasia had a significantly higher VFA (96 ± 76.0 cm2vs 63.4 ± 51.5 cm2, P = 0.016) and a higher prevalence of liver cirrhosis (61% vs 22%, P < 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia (22% vs 9%, P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio (OR) for each 10-cm2 increment = 1.1; [95% confidence interval (CI): 1.02-1.19; P = 0.021] and liver cirrhosis (OR = 6.1, 95%CI: 2.2-18.5; P < 0.001) were significant risk factors for small bowel angioectasia.
CONCLUSION: VFA is positively associated with the prevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.
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Increased incidence of angiodysplasia of the gastrointestinal tract and bleeding in patients with continuous flow left ventricular assist devices (LVADs). Int J Artif Organs 2013; 36:449-54. [PMID: 23897227 DOI: 10.5301/ijao.5000224] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Continuous flow left ventricular assist devices (cfLVADs) are used in clinical practice for the management of end-stage heart failure. Axial flow cfLVADS have been associated with increased rates of adverse gastrointestinal events such as bleeding angiodysplasia. The purpose of this study was to determine the incidence of bleeding gastrointestinal tract angiodysplasia and the profile of patients supported with the centrifugal cfLVAD, referred for endoscopy. METHODS A retrospective analysis of 66 patients implanted with Ventrassist (n = 33) and Heartware (n = 33) centrifugal continuous flow LVADs was performed. All patients were on warfarin, aspirin and/or clopidogrel. Endoscopy was performed in all patients with either active gastrointestinal bleeding (n = 6) or anemia with positive fecal occult blood (n = 6). RESULTS Bleeding gastrointestinal angiodysplasia was demonstrated in 5 out of the 12 (41.6%) patients who underwent endoscopy from the cohort of 66 cfLVAD supported patients (7.6%). The incidence of bleeding angiodysplasia was higher than the age-standardized rate of andiodysplasia from literature (0.8%). Active gastrointestinal bleeding in one other patient was due to diverticulosis. The five patients with bleeding angiodysplasia tended to be older than the remaining 61 patients (58.8 ± 10.3 vs 49.6 ± 15.7 years, p = 0.2). CONCLUSIONS We found excess bleeding angiodysplasia in patients on centrifugal cfLVAD support. It may be appropriate to screen for angiodysplasia particularly in older patients prior to support by centrifugal cf LVADs. Reasons for the higher rate of bleeding angiodysplasia in cfLVAD patients warrant further study.
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Abdoon H. Angiodysplasia in a Child as a Cause of Lower GI Bleeding: Case Report and Literature Review. Oman Med J 2012; 25:49-50. [PMID: 22125700 DOI: 10.5001/omj.2010.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 11/17/2009] [Indexed: 11/03/2022] Open
Abstract
Angiodysplasia or vascular ectasia of the colon is a rare but important cause of recurrent lower gastro-intestinal bleeding in children and should be kept in mind as a diagnostic possibility. This case reports of intermittent rectal bleeding with early presentation caused by angiodysplasia. Therefore, early diagnosis of this rare lesion is important to avoid a possible fatal outcome, and thus the pediatrician should be aware of this lesion as a rare cause of intestinal bleeding in children.
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Affiliation(s)
- Hamed Abdoon
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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Yannam GR, Yu DC, Kelly DR, Chen MK, Beierle EA. Angiodysplasia (vascular malformations) of the colon presenting as an acute abdomen. J Pediatr Surg 2012; 47:e37-40. [PMID: 23084229 DOI: 10.1016/j.jpedsurg.2012.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 06/02/2012] [Accepted: 06/24/2012] [Indexed: 10/27/2022]
Abstract
Angiodysplasia (vascular malformations) of the colon is extremely rare in children, and, as in adults, present with lower gastrointestinal hemorrhage. Here we report an unusual pediatric case of angiodysplasia of the terminal ileum and cecum presenting as an acute abdomen with radiological features suggestive of lymphoma.
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Affiliation(s)
- Govardhana R Yannam
- Pediatric Surgery Division, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Intestinal angiodysplasia: an uncommon cause of gastrointestinal bleeding in children. Pediatr Neonatol 2011; 52:214-8. [PMID: 21835367 DOI: 10.1016/j.pedneo.2011.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 09/21/2010] [Accepted: 09/24/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Angiodysplasia of the gastrointestinal (GI) tract is recognized as an important cause of lower GI bleeding in elderly. It usually involves the cecum and right colon in adults. Unlike the adult group, there has been little experience with the pediatric population. METHODS From July 2004 to October 2008, patients presenting at the Mackay Memorial Hospital with GI hemorrhage diagnosed as angiodysplasia by helical computed tomographic angiography were reviewed. RESULTS Eighteen patients (14 boys and 4 girls) with mean age of 7.1 years (range, 1 month to 17 years) were diagnosed. The time from initial clinical onset to diagnosis of angiodysplasia ranged from 1 week to 11 years, most around 1-2 weeks. All patients except one had anemia and an average hemoglobin level of 7.9 ± 2.1g/dL. The most commonly involved areas were ascending colon and terminal ileum. Four patients received surgery treatment with resection of affected segments. CONCLUSIONS In pediatric patients, angiodysplasia is a rare cause of GI bleeding and may be delayed in diagnosis. This diagnosis should be considered when patients have recurrent GI bleeding. In this study, the final surgical and pathological diagnosis was made in 6 of 18 patients. In six patients, computed tomographic angiography had 66% diagnostic accuracy for angiodysplasia (four of six patients who received operation were compatible with angiodysplasia by confirmation of histology).
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DeBenedet AT, Saini SD, Takami M, Fisher LR. Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy? Dig Dis Sci 2011; 56:1776-81. [PMID: 21153439 DOI: 10.1007/s10620-010-1506-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 11/17/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB. METHODS We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs. RESULTS 1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs. CONCLUSIONS Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.
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Affiliation(s)
- Anthony T DeBenedet
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Johnson-Wimbley TD, Graham DY. Diagnosis and management of iron deficiency anemia in the 21st century. Therap Adv Gastroenterol 2011; 4:177-84. [PMID: 21694802 PMCID: PMC3105608 DOI: 10.1177/1756283x11398736] [Citation(s) in RCA: 203] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Iron deficiency is the single most prevalent nutritional deficiency worldwide. It accounts for anemia in 5% of American women and 2% of American men. The goal of this review article is to assist practitioners in understanding the physiology of iron metabolism and to aid in accurately diagnosing iron deficiency anemia. The current first line of therapy for patients with iron deficiency anemia is oral iron supplementation. Oral supplementation is cheap, safe, and effective at correcting iron deficiency anemia; however, it is not tolerated by some patients and in a subset of patients it is insufficient. Patients in whom the gastrointestinal blood loss exceeds the intestinal ability to absorb iron (e.g. intestinal angiodysplasia) may develop iron deficiency anemia refractory to oral iron supplementation. This population of patients proves to be the most challenging to manage. Historically, these patients have required numerous and frequent blood transfusions and suffer end-organ damage resultant from their refractory anemia. Intravenous iron supplementation fell out of favor secondary to the presence of infrequent but serious side effects. Newer and safer intravenous iron preparations are now available and are likely currently underutilized. This article discusses the possible use of intravenous iron supplementation in the management of patients with severe iron deficiency anemia and those who have failed oral iron supplementation.
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Affiliation(s)
| | - David Y. Graham
- Michael E. DeBakey VA Medical Center, Room 3A-320 (111D), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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21
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Chait MM. Lower gastrointestinal bleeding in the elderly. World J Gastrointest Endosc 2010; 2:147-54. [PMID: 21160742 PMCID: PMC2998909 DOI: 10.4253/wjge.v2.i5.147] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 04/09/2010] [Accepted: 04/16/2010] [Indexed: 02/06/2023] Open
Abstract
Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.
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Affiliation(s)
- Maxwell M Chait
- Maxwell M Chait, The Hartsdale Medical Group, 180 East Hartsdale Avenue, Hartsdale, New York, NY 10530, United States
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22
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Lee J, Costantini TW, Coimbra R. Acute lower GI bleeding for the acute care surgeon: current diagnosis and management. Scand J Surg 2010; 98:135-42. [PMID: 19919917 DOI: 10.1177/145749690909800302] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Lower gastrointestinal bleeding is a common cause for hospital admission that results in significant morbidity and mortality. After initial resuscitation of the patient, the diagnosis and treatment of lower gastrointestinal bleeding remains a challenge for acute care surgeons. Identifying the source of bleeding can be difficult since many patients bleed intermittently or stop bleeding spontaneously. It is therefore important for the acute care surgeon to be familiar with the different diagnostic and therapeutic modalities and their advantages and disadvantages in order to guide the management of the acutely bleeding patient. This review summarizes the current methods available for the diagnosis and treatment of acute lower gastrointestinal bleeding and proposes an algorithm for the management of these patients.
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Affiliation(s)
- J Lee
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California-San Diego School of Medicine, San Diego, California, USA
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23
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Thalidomide for the treatment of chronic gastrointestinal bleeding from angiodysplasias: a case series. Eur J Gastroenterol Hepatol 2009; 21:1347-50. [PMID: 19730385 DOI: 10.1097/meg.0b013e32832c9346] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mucosal angiodysplasias, either inherited or acquired, can cause gastrointestinal bleeding, sometimes refractory to treatment. From earlier case reports, thalidomide has been described to possess some benefits in this disease, but its benefits and risks nevertheless remain unclear. OBJECTIVES This pilot study assesses the efficacy, safety, and side-effect of thalidomide in the treatment of patients with chronic gastrointestinal bleeding from angiodysplasias. METHODS Patients with chronic angiodysplasia bleeding and requiring ongoing transfusion were eligible for this open nonrandomized study. Thalidomide was started with 50 mg/day and then increased incrementally by 50 mg every week up to 200 mg/day, if tolerated, and continued for 6 months. Adverse events, hemoglobin, blood chemistry, and blood transfusion were monitored during the treatment and for 6-months posttreatment. RESULTS Seven patients were recruited in this study. Four patients discontinued thalidomide within 3-8 weeks, because of fatigue (two patients), peripheral neuropathy (one patient), and skin rash (one patient). All side-effects resolved when thalidomide was discontinued. These four patients required the same volume of blood transfusions per month as pre-study. In contrast, the three patients who continued 100-200 mg/day of thalidomide for 6 months did not require any transfusions during the 6 months of medication. During 6-months posttreatment of these three patients, one maintained response without any transfusion for 2 months, then required 1 U of blood every 4 weeks, one patient required 2 U of blood every 3-4 weeks, and one patient died from diabetes complications. CONCLUSION Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy, but it has a high discontinuation rate because of its side-effects.
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Gross lower gastrointestinal bleeding in patients on anticoagulant and/or antiplatelet therapy: endoscopic findings, management, and clinical outcomes. J Clin Gastroenterol 2009; 43:36-42. [PMID: 18698263 DOI: 10.1097/mcg.0b013e318151f9d7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Gross gastrointestinal (GI) bleeding is a serious complication of anticoagulant/antiplatelet drug therapy. This study compares the frequencies of colorectal pathologies, endoscopic and resuscitative management measures, and clinical outcomes of patients hospitalized with lower GI bleeding (LGIB) while using anticoagulants/antiplatelets with those of patients not using them. METHODS A retrospective review of the records of 166 admissions for patients with gross LGIB over 12 years was conducted. The colonoscopic findings, management measures, and clinical outcomes were compared between 2 groups. Group A composed of 100 patients using any antiplatelet/anticoagulant, and group B 66 patients not using any such drugs. Independent t tests and chi were used to test for association between taking antiplatelet/anticoagulant and other variables. RESULTS Patients in group A were older and had more comorbidities than patients in group B. Severe LGIB occurred in 55.1% and 35.4% in groups A and B, respectively (P=0.01). Severity was not related to old age or the presence of comorbidities. A higher percentage of patients in group A had a hospital stay > or =6 days (44% vs. 27.3%; P<0.03), required blood transfusions (68% vs. 51.5%; P=0.03), and had in-hospital complications (37% vs. 22.7%; P=0.052). The most common source of bleeding was diverticulosis in both groups. Colorectal abnormalities were present in most patients; and in those using warfarin, colon cancer was common. CONCLUSIONS Use of antiplatelets/anticoagulant drugs is an independent predictor of severe LGIB and is associated with adverse outcomes. Colonoscopy is required in patients who bleed while using such drugs.
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Abstract
Diverticulosis of the colon is a very common condition. Described as early as the 17th century, most of the information we now have is based on much of the work during the 20th century. Age, sex, race, and geography all play a specific role in the development of diverticula. It is the merging of these factors that changes the prevalence of diverticula and their manifestations. Symptomatic diverticula can lead to serious complications requiring both medical and surgical interventions to treat these complications when they occur. This review will focus on the history and epidemiology of diverticulosis in regard to age, sex, race, geography, and the epidemiology of complicated diverticular disease.
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Affiliation(s)
- Jerry Martel
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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26
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Mariani G, Pauwels EK, AlSharif A, Marchi S, Boni G, Barreca M, Bellini M, Grosso M, de Bortoli N, Mumolo G, Costa F, Rubello D, Strauss HW. Radionuclide Evaluation of the Lower Gastrointestinal Tract. J Nucl Med 2008; 49:776-87. [DOI: 10.2967/jnumed.107.040113] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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27
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Abstract
Lower GI bleeding is a very broad topic, which can encompass situations from a small amount of red blood on tissue paper associated with formed brown stool, to life-threatening severe haemorrhage. Much of the literature on this topic focuses on acute bleeding necessitating hospitalisation and urgent intervention. The literature that is available focuses primarily on medical intervention and support, which will be covered in another review in this series. Causes for lower GI bleeding include diverticular disease, vascular ectasia, ischemic, inflammatory or infectious colitis, colonic neoplasia (including post polypectomy bleeding), anorectal causes (including haemorrhoids, fissures and rectal varices), and small bowel lesions (Crohn's, vascular ectasia, Meckel's diverticula, and small bowel tumours). Different clinical series identified these lesions in varying frequencies. Factors associated with the development of acute lower GI bleeding include advanced age and use of non-steroidal anti-inflammatory medication. Colonoscopy is the single most frequent intervention in evaluating all the patients with lower GI bleeding. Determining the precise impact of colonoscopy on the outcome of lower GI bleeding is difficult due to the retrospective nature of many studies, and the frequent inability to definitively establish the exact bleeding site.
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Affiliation(s)
- Gregory Zuccaro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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28
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Weldon DT, Burke SJ, Sun S, Mimura H, Golzarian J. Interventional management of lower gastrointestinal bleeding. Eur Radiol 2008; 18:857-67. [PMID: 18185932 DOI: 10.1007/s00330-007-0844-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 11/16/2007] [Accepted: 12/10/2007] [Indexed: 01/08/2023]
Abstract
Lower gastrointestinal bleeding (LGIB) arises from a number of sources and is a significant cause of hospitalization and mortality in elderly patients. Whereas most episodes of acute LGIB resolve spontaneously with conservative management, an important subset of patients requires further diagnostic workup and therapeutic intervention. Endovascular techniques such as microcatheter embolization are now recognized as safe, effective methods for controlling LGIB that is refractory to endoscopic intervention. In addition, multidetector CT has shown the ability to identify areas of active bleeding in a non-invasive fashion, enabling more focused intervention. Given the relative strengths and weaknesses of various diagnostic and treatment modalities, a close working relationship between interventional radiologists, gastroenterologists and diagnostic radiologists is necessary for the optimal management of LGIB patients.
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Affiliation(s)
- Derik T Weldon
- Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa, IA 52242-1107, USA
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29
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30
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den Ouden H, van Tuyl SAC, Groenen M, Stolk MFJ, Kuipers EJ. New endoscopic techniques for obscure gastrointestinal bleeding. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:597-600. [PMID: 17853955 PMCID: PMC2657990 DOI: 10.1155/2007/194794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The case of a postmenopausal woman with a congenital aortic stenosis is presented. She presented with severe iron deficiency anemia. After negative extensive gastrointestinal analysis, she was treated with octreotide for six months. After cessation of octreotide, anemia rapidly recurred. A second capsule endoscopy and a double balloon enteroscopy were performed, and an intestinal vascular malformation was found. After surgical segment resection, the patient had stable, normal levels of hemoglobin and no complaints after 14 months of follow-up.
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Affiliation(s)
- Henk den Ouden
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - SAC van Tuyl
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Mark FJ Stolk
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
- Correspondence and reprints: Dr Mark FJ Stolk, Department of Gastroenterology, St Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands. Telephone 31-30-609-91-11, fax 31-30-605-63-57, e-mail
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31
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Abstract
Lower gastrointestinal (GI) hemorrhage is a significant cause of morbidity and mortality, particularly in elderly patients. Lower endoscopic evaluation is established as the diagnostic procedure of choice in the setting of acute lower GI hemorrhage.
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Affiliation(s)
- Brenna Casey Bounds
- Harvard Medical School, Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Blake 453D, Boston, MA 02114, USA.
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32
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Edelman DA, Sugawa C. Lower gastrointestinal bleeding: a review. Surg Endosc 2007; 21:514-20. [PMID: 17294304 DOI: 10.1007/s00464-006-9191-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 11/20/2006] [Indexed: 02/06/2023]
Abstract
Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.
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Affiliation(s)
- David A Edelman
- Department of Surgery, Wayne State University, Detroit, MI, USA
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33
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Olmos JA, Marcolongo M, Pogorelsky V, Herrera L, Tobal F, Dávolos JR. Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia. Dis Colon Rectum 2006; 49:1507-16. [PMID: 17024322 DOI: 10.1007/s10350-006-0684-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Angiodysplasia is a frequent cause of colonic bleeding. Argon plasma coagulation was reported to be useful in endoscopic hemostasis. However, the long-term outcomes have been poorly evaluated. This study was designed to assess the long-term outcomes of bleeding patients with colonic angiodysplasia treated by argon plasma coagulation. METHODS A cohort of 100 patients with gastrointestinal bleeding caused by colonic angiodysplasia was studied prospectively. The endoscopic intervention was considered successful if there was no further overt bleeding and hemoglobin concentration was stabilized (primary end point). Secondary end points were the requirement of blood transfusions, the need for surgery, bleeding-related mortality, and overall mortality. RESULTS Overt bleeding resolved and hemoglobin levels were stabilized without transfusions or iron therapy in 85 of 100 patients (85 percent) after a median follow-up of 20 (range, 6-62) months. Transfusion requirements ceased in 90 percent of patients and only one required surgery. No patient died because of hemorrhage. In the subgroup of patients with anemia, mean hemoglobin levels increased from 9.3 (range, 5.5-12.2) g/dl before treatment to 12.6 (range, 7.4-16.7) g/dl after treatment (P < 0.01). The probability of remaining free of rebleeding at one and two year follow-up was 98 percent (95 percent confidence interval, 96-100) and 90 percent (95 percent confidence interval, 83-97), respectively. Among 118 procedures, only two complications were observed (1.7 percent). CONCLUSIONS Endoscopic argon plasma ablation therapy is useful in the management of bleeding from colonic angiodysplasia.
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Affiliation(s)
- Jorge Atilio Olmos
- Gastroenterology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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34
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Affiliation(s)
- Michael F McGee
- Department of Surgery, Case Western Reserve University School of Medicine, Case Medical Center, Cleveland, OH 44106, USA
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35
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Johnston D, Macpherson DS, Barrie WW, Eaton AC, Brossy JJ, Vessey MP, Kalache A, Chetty U, Wang CC, Forrest APM, Roberts MM, White CM, Price JJ, Findlay JM, Gillespie G, Gunn A, Fraser I, Quick C, Johnstone M, Tutt GO, Buysschaert M, Kestens PJ, Lambotte L, Marchand E, Lambert AE. Correspondence. Br J Surg 2005. [DOI: 10.1002/bjs.1800680824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- David Johnston
- University Department of Surgery, The General Infirmary, Leeds LS1 3EX
| | - D S Macpherson
- Department of Surgery, Leicester General Hospital, Leicester LE5 4PW
| | - W W Barrie
- Department of Surgery, Leicester General Hospital, Leicester LE5 4PW
| | - A C Eaton
- Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PD
| | - J-J Brossy
- Department of Surgery, Somerset Hospital, 8051 Cape, South Africa
| | - M P Vessey
- Department of Community Medicine, and General Practice, University of Oxford, Oxford OX1 3QN
| | - A Kalache
- Department of Community Medicine, and General Practice, University of Oxford, Oxford OX1 3QN
| | - U Chetty
- University Department of Clinical Surgery, The Royal Infirmary, Edinburgh, EH3 9YW
| | - C C Wang
- University Department of Clinical Surgery, The Royal Infirmary, Edinburgh, EH3 9YW
| | - A P M Forrest
- University Department of Clinical Surgery, The Royal Infirmary, Edinburgh, EH3 9YW
| | - M M Roberts
- University Department of Clinical Surgery, The Royal Infirmary, Edinburgh, EH3 9YW
| | - C M White
- 4 Hall Close, Bramhope, Leeds LS16 9JQ
| | - J J Price
- 4 Hall Close, Bramhope, Leeds LS16 9JQ
| | | | | | - A Gunn
- Ashington Hospital, West View, Ashington, Northumberland NE63 0SA
| | - Ian Fraser
- Department of Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX
| | - Clive Quick
- Department of Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX
| | - Michael Johnstone
- Department of Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX
| | - George O Tutt
- Henson, Wise and Otteman, Surgical Associates PC, 1015 Robertson, Fort Collins, Colorado 80524, USA
| | - M Buysschaert
- Departments of Internal Medicine and Surgery, University Hospital St Luc, B 1200 Brussels, Belgium
| | - P J Kestens
- Departments of Internal Medicine and Surgery, University Hospital St Luc, B 1200 Brussels, Belgium
| | - L Lambotte
- Departments of Internal Medicine and Surgery, University Hospital St Luc, B 1200 Brussels, Belgium
| | - E Marchand
- Departments of Internal Medicine and Surgery, University Hospital St Luc, B 1200 Brussels, Belgium
| | - A E Lambert
- Departments of Internal Medicine and Surgery, University Hospital St Luc, B 1200 Brussels, Belgium
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36
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Abstract
Lower gastrointestinal bleeding is one of the most common gastrointestinal indications for hospital admission, particularly in the elderly. Diverticulosis accounts for up to 50% of cases, followed by ischemic colitis and anorectal lesions. Though most patients stop bleeding spontaneously and have favorable outcomes, long-term recurrence is a substantial problem for patients with bleeding from diverticulosis and angiodysplasia. The management of LGIB is challenging because of the diverse range of bleeding sources, the large extent of bowel involved, the intermittent nature of bleeding, and the various complicated and often invasive investigative modalities. Advances in endoscopic technology have brought colonoscopy to the forefront of the management of LGIB. However, many questions remained to be answered about its usefulness in routine clinical practice. More randomized controlled trials comparing available diagnostic strategies for LGIB are needed.
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37
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Abstract
Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.
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Affiliation(s)
- J J Farrell
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA 90095, USA.
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38
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Abstract
AIMS To investigate the pathology of colectomy specimens, from patients presenting with lower gastrointestinal haemorrhage, who had undergone preoperative mesenteric angiography. The angiography diagnoses ranged from active bleeding of unknown aetiology to angiodysplasia. METHODS AND RESULTS The macroscopic and microscopic pathology of 11 colectomy specimens was studied. All the specimens contained blood on receipt with no obvious macroscopic source of haemorrhage identified. In all cases the large bowel demonstrated diverticula with an unusual topography. These were wide-mouthed, up to 20 mm across and exhibited a partly scattered distribution across the bowel; in two cases the diverticula contained blood clot. Histology demonstrated true diverticula invested by all muscle layers, exhibiting thick-walled vessels, within the submucosa and within the muscularis propria fibres, resembling the vascular elements identified in congenital vascular malformations. The two cases that contained blood clot revealed the thick-walled vessels to have ruptured into the diverticular lumen. Histology from the background colon between the diverticula demonstrated vascular lesions fulfilling the histological criteria for angiodysplasia; these features were also represented in the true-type diverticula. Most cases showed right-sided angiodysplasia and right-sided true diverticula. However, left-sided angiodysplastic lesions were also seen in association with left-sided true-type diverticula. CONCLUSIONS We have identified the dual pathologies of angiodysplasia and multiple true-type diverticula, and suggest a topographical relationship between these two lesions. Furthermore, we propose that the thick-walled vessels within the true diverticula are congenitally abnormal, and raise the possibility that these vessels exert local haemodynamic effects, that effectively predispose the colon to acquired angiodysplastic phenomena.
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Affiliation(s)
- H S Mudhar
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK.
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39
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Olmos JA, Marcolongo M, Pogorelsky V, Varela E, Dávolos JR. Argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias. Gastrointest Endosc 2004; 60:881-6. [PMID: 15605001 DOI: 10.1016/s0016-5107(04)02221-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Angiodysplasia is a frequent cause of GI bleeding. Argon plasma coagulation has been shown to arrest bleeding, but its efficacy for prevention of recurrent bleeding has not been thoroughly evaluated. This study assessed the effectiveness and the safety of argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias. METHODS A total of 60 patients with GI bleeding caused by angiodysplasia were included. The endoscopic intervention was considered successful if there was no further overt bleeding and if the Hb level stabilized. Recurrent bleeding was defined as any detectable bleeding episode (hematemesis, melena, or hematochezia) or a decrease in Hb level. RESULTS Overt bleeding was resolved, and the Hb level stabilized without transfusion or supplemental iron therapy in 50 of the 60 patients (83%) at a median follow-up of 18 months (range 6-38 months). In the subgroup of patients with anemia, mean Hb level increased from 8.6 g/dL (range 5.1-12.2 g/dL) to 12 g/dL (range 8.0-15.2 g/dL) ( p < 0.01). The estimated probability of remaining free of recurrent bleeding at 1- and 2-year follow-up was 86%: 95% CI [73%, 93%] and 80%: 95% CI [64%, 89%], respectively. Among 72 procedures, only two were associated with a complication (2.8%). CONCLUSIONS Endoscopic argon plasma coagulation is both effective and safe for prevention of recurrent bleeding from GI angiodysplasia.
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Affiliation(s)
- Jorge Atilio Olmos
- Gastroenterology Service, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Gascón 450, 1181 Buenos Aires, Argentina
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Funaki B. Microcatheter embolization of lower gastrointestinal hemorrhage: an old idea whose time has come. Cardiovasc Intervent Radiol 2004; 27:591-9. [PMID: 15578134 DOI: 10.1007/s00270-004-0243-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early attempts of using embolization for lower gastrointestinal hemorrhage were fraught with complications, most notably ischemic colitis or bowel infarction. Embolotherapy was eventually abandoned in favor of catheter-directed vasoconstriction (i.e., vasopressin infusion). This latter therapy is time and labor intensive. With the advent of microcatheter technology, superselective embolization emerged and is rapidly becoming the endovascular therapy of choice for patients with severe lower gastrointestinal hemorrhage refractory to medical management. Numerous studies on the subject have consistently reported high clinical success with low ischemic complications. This article will review the current status of co-axial microcatheter embolization with an emphasis on the technical aspects of the procedure.
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Affiliation(s)
- Brian Funaki
- Section of Vascular and Interventional Radiology and Section of Abdominal Imaging, University of Chicago Hospitals, 5840 S. Maryland Ave MC 2026, Chicago, IL 60637, USA.
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41
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Abstract
Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10-20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.
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Affiliation(s)
- Neil Stollman
- Division of Gastroenterology, San Francisco General Hospital, and University of California San Francisco, San Francisco, CA 94110, USA.
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42
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Dauphine CE, Tan PY, Beart RW, Corman ML, Vukasin P. Self-expanding metallic stents in the management of lower gastrointestinal hemorrhage. J Laparoendosc Adv Surg Tech A 2004; 13:407-9. [PMID: 14733707 DOI: 10.1089/109264203322656504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A case of an 82-year-old woman is reported who developed a lower gastrointestinal hemorrhage secondary to metastatic ovarian carcinoma to the colon. The bleeding, associated with an incomplete obstruction of the large bowel, was successfully treated with the endoscopic insertion of two self-expanding metal stents. A technique of stent placement is presented which differs from that previously reported, where both stents were via colonoscopy and without the use of fluoroscopy.
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Affiliation(s)
- Christine E Dauphine
- Division of Colon and Rectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles County/USC Medical Center, Los Angeles, California, USA
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43
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Abstract
BACKGROUND Bleeding per rectum is a common indication for acute hospital admissions to the colorectal department. The frequencies of aetiologies in Singapore are different from those in Western populations. A retrospective analysis of the demography, pathology and management of acute bleeding per rectum was performed to determine the outcome and difference in aetiology from the West. METHODS During the 1-year period from 1 October 1995 to 30 September 1996, 547 patients were admitted to Singapore General Hospital form the emergency department for acute bleeding per rectum. There were 377 males and 170 females; the mean age was 42 years (range, 15-97 years). RESULTS Of the patients admitted, 87% wer admitted due to perianal conditions diagnosed at bedside proctoscopy, where haemorrhoids mad up 94%. One percent bled from the upper gastrointestinal tract, while 12% bled from colorectal pathology. Massive bleeding form the colorectum was uncommon. Less than one third of the 47 patients required blood transfusions. Colonoscopy was the most useful diagnostic tool for bleeding from the colorectum. The more common colonic pathologies were diverticular disease (33%), adenomas (18%), and malignancy (26%), accounting for the majority of acute patient admissions. Colonic causes of bleeding were less common and were most stable. There were differences in the frequencies of aetiologies in our population compared ot Western populations. Understanding the common pathologies and outcomes guides the management fo our patients.
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Affiliation(s)
- Benita K T Tan
- Department of General Surgery, Singapore General Hospital, 169608.
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44
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Abstract
Lower gastrointestinal bleeding is defined as blood loss that originates from a source distal to the ligament of Treitz and results in hemodynamic instability or symptomatic anemia. Although approximately 10% to 15% of patients presenting with acute severe hematochezia have an upper gastrointestinal source of bleeding identified on upper endoscopy, the most common causes of lower gastrointestinal bleeding are diverticulosis, hemorrhoids, ischemic colitis, and angiodysplasia. As with upper gastrointestinal bleeding, lower gastrointestinal bleeding ceases spontaneously in most cases.
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Affiliation(s)
- Brenna Casey Bounds
- Department of Medicine, Harvard Medical School, Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Blake 453C, Boston, MA 02114, USA.
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45
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Piccini J, Zaas A. Cases from the Osler Medical Service at Johns Hopkins University. Diffuse colonic angiodysplasia with chronic iron deficiency anemia. Am J Med 2003; 115:245-8. [PMID: 12935833 DOI: 10.1016/s0002-9343(03)00369-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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46
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2003; 11:646-648. [DOI: 10.11569/wcjd.v11.i5.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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47
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Izquierdo Muro V, Siurana Escuer R, Danús Laínez M, Macías Fernández E, Martínez de Vírgala Martínez de Bujanda C, Papo Berger M. [Value of 99mTc-Sulphur colloid scintigraphy in the diagnosis of intermittent digestive bleeding secondary to a case of jejunal angiodysplasia]. REVISTA ESPANOLA DE MEDICINA NUCLEAR 2003; 22:30-4. [PMID: 12550031 DOI: 10.1016/s0212-6982(03)72138-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
We present the case of a 74 year old female patient, with clinical criteria of liver cirrhosis caused by hepatic C virus who required several admissions in our hospital over a five month period. She was given several blood transfusions because of repeated clinical manifestation of gastrointestinal bleeding without a clear origin. Her last admission was due to intermittent melenas, secondary anemia and hemodynamic angina. The patient's study included clinical analysis, fibrogastroscopy, colonoscopy, opaque enema, spiral CT and supraortic vessels arteriography. Because all the results to diagnose and locate the patient's disease were negative, she was referred to our service for a scintigraphy study. As it was an emergency case because of the patient's serious hemodynamic condition, a 99mTc-sulphur colloid scintigraphy was chosen, the results of which showed and located active gastrointestinal bleeding requiring urgent surgical intervention. The laparotomy with intrasurgical enterotomy and fibrogastroscopy undertaken ratified gastrointestinal bleeding, and the result of the biopsy of the jejunum removed in the intervention confirmed bowel angiodysplasia. Given the low incidence of gastrointestinal bleeding secondary to bowel angiodysplasia and absence of bibliographic references regarding the diagnosis of this disease in the above mentioned site by means of 99mTc-sulphur colloid scintigraphy in particular, we consider it interesting to highlight this case, in which the capability of this nuclear medicine technique for quick and non-invasive detection and location of gastrointestinal bleeding has been highly proven.
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Affiliation(s)
- V Izquierdo Muro
- Servicio de Medicina Nuclear del Hospital Universitario Joan XXIII, Tarragona, Spain
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Balín EM, Herrera J, Ariceta J, Montón S, Abascal L, Calvo A, Juan Íñigo J, Miguel Lera J. Eficacia de un protocolo de manejo de la hemorragia digestiva baja grave. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72098-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Diverticulosis, which is an acquired condition marked by mucosal herniation through defects in the colonic wall, has been termed both a "disease of the 20th century" and a "disease of Western civilization" due to its increasing prevalence in modern times and its striking geographical variability. Both of these epidemiological observations may provide interesting insights into the pathophysiology of diverticulosis. This chapter will review the known epidemiology of diverticulosis coli and its main complications: diverticulitis and diverticular haemorrhage. Where possible, attempts will be made to place these observational reports in the context of both the cause and clinical behaviour of this disorder.
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Affiliation(s)
- Stephanie Jun
- Department of Internal Medicine, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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