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ABSTRACT Background Variceal hemorrhage (VH) is a medical emergency. Prompt endoscopic variceal ligation (EVL) is therapeutic. Terlipressin is used in VH and continued for 2—5 days even after EVL. As hemostasis is primarily achieved by EVL, the benefit of continuing trelipressin after EVL is unknown. Objective To evaluate the efficacy of continuing terlipressin after EVL to prevent re-bleed and mortality. Methods In this pilot study, after EVL 74 patients of VH were randomized into two treatment groups TG2 & TG5, received terlipressin (1 mg IV bolus q 4 hourly) for 2 days and 5 days respectively and one control group (TG0), received 0.9% normal saline (10 mL IV bolus q 4 hourly) and followed up for 8 weeks. Results A total of 9 (12.6%) patients had re-bleed with maximum 4 (5.6%) patients in TG5 group followed by 3 (4.2%) in TG2 and 2 (2.8%) in TG0 groups (P=0.670). The overall mortality was 15 (21.1%) patients, 6 (8.5%) patients in TG0 group, followed by 5 (7.0%) in TG5 and 4 (5.6%) in TG2 group (P=0.691). Adverse drug reactions were significantly higher in treatment groups with maximum 18 (24.32%) patients in TG5, followed by 8 (10.8%) in TG2 and 2 (2.7%) in TG0 groups (P=0.00). Duration of hospital stay was also significantly higher in treatment group, 6.63 (±0.65) days in TG5 followed by 3.64 (±0.57) in TG2 and 2.40 (±0.50) days in TG0 groups (P=0.00). Conclusion The rational for continuing terlipressin after EVL is doubtful as it didn't have any benefit for the prevention of re-bleed or mortality; rather it increased the risk of adverse drug reactions and duration of hospital stay. Further randomized clinical trials are encouraged to generate more evidence in support or against continuing terlipressin after EVL.
RESUMO Contexto A hemorragia varicosa (HV) é emergência médica. A ligadura endoscópica imediata das varizes (LEV) é terapêutica. A terlipressina é usada em HV e contínua por 2—5 dias mesmo após a LEV. Como a hemostasia é alcançada principalmente pela LEV, o benefício do uso contínuo da terlipressina após o evento é desconhecido. Objetivo Avaliar a eficácia da terlipressina contínua após a LEV para evitar o ressangramento e a mortalidade. Métodos Neste estudo piloto, após a LEV, 74 pacientes com HV foram randomizados em dois grupos de tratamento TG2 & TG5, que receberam terlipressina (1 mg EV em bolus a cada 4 horas) durante 2—5 dias, respectivamente, e um grupo controle (TG0), que receberam soro fisiológico normal de 0,9% (10 mL EV em bolus a cada 4 horas) e foram seguidos por 8 semanas. Resultados Um total de 9 (12,6%) pacientes tiveram ressangramento, 4 (5,6%) no grupo TG5, seguidos por 3 (4,2%) no TG2 e 2 (2,8%) no grupo TG0 (P=0,670). A mortalidade geral de pacientes foi de 15 (21,1%), 6 (8,5%) no grupo TG0, seguidos por 5 (7,0%) no TG5 e 4 (5,6%) no TG2 (P=0,691). As reações adversas de medicamentos foram significativamente maiores em grupos de tratamento em 18 (24,32%) pacientes no TG5, seguidos por 8 (10,8%) no TG2 e 2 (2,7%) em grupo TG0 (P=0,00). A duração da internação hospitalar também foi significativamente maior no grupo de tratamento, 6,63 (±0,65) dias no TG5, seguido por 3,64 (±0,57) em TG2 e 2,40 (±0,50) dias em grupos TG0 (P=0,00). Conclusão O uso racional para a continuação da terlipressina após a LEV é duvidoso, pois não teve qualquer benefício para a prevenção de ressangramento ou mortalidade; pelo contrário, aumentou o risco de efeitos adversos e duração da internação hospitalar. Outros ensaios clínicos randomizados são necessários para gerar mais evidências em apoio ou contra a terlipressina contínua após a LEV.
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ABSTRACT BACKGROUND: Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. OBJECTIVE: This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. METHODS: In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. RESULTS: The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). CONCLUSION: Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.
RESUMO CONTEXTO: Tradicionalmente, a doença úlcera péptica era a causa mais comum de sangramento digestivo alto, mas com a mudança da epidemiologia, outras etiologias do sangramento do trato digestivo alto estão emergindo. Muitas pontuações têm sido descritas para prever resultados e a necessidade de intervenção na hemorragia gastrointestinal superior, mas a comparação prospectiva entre elas é escassa. OBJETIVO: Este estudo foi planeado para determinar o padrão etiológico de pacientes com hemorragia digestiva alta e comparar os escores de Glasgow Blatchford, o Rockall pré-endoscopia, o AIMS65 e o Early Warning modificado (MEWS) como preditores do resultado. MÉTODOS: Neste estudo prospetivo de coorte, 268 pacientes com sangramento digestivo alto foram acompanhados durante 8 semanas. Os escores Glasgow Blatchford, Rockall pré-endoscopia, AIMS65 e MEWS foram calculados para cada paciente, e a área sob a curva (AUC-ROC) para cada pontuação foi comparada. RESULTADOS: A etiologia mais comum para a hemorragia gastrointestinal alta foi varizes gastroesofágicas 150 (63,55%), seguida de úlcera péptica 29 (12,28%) e de doença erosiva de mucosa 27 (11,44%). No total, 38 (15,26%) doentes voltaram a sangrar e 71 (28,5%) doentes morreram. No total, 126 (47%) doentes necessitaram de transfusão de componentes sanguíneos, 25 (9,3%) necessitaram de ventilação mecânica e 2 (0,74%) destes doentes necessitaram de intervenção cirúrgica. O escore de Glasgow Blatchford foi o melhor na previsão da necessidade de transfusão (corte - 10, AUC-ROC =0,678). Enquanto o AIMS65 com uma pontuação de ≥2 foi o melhor na previsão de ressangramento (AUC-ROC =0,626) e mortalidade (AUC-ROC =0,725). CONCLUSÃO: O sangramento gastrointestinal alto mais comum é de origem varicosa em centro de referência terciária. O AIMS65 é o melhor escore simples, com uma pontuação de ≥2 para prever o ressangramento e a mortalidade.
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Background@#Lower Gastrointestinal bleeding (LGIB) is a serious and urgent condition which can be assessed using several different modalities. Tc-99m tagged RBC scintigraphy has been established as a diagnostic tool in Nuclear Medicine but several other modalities, including CT-based imaging (i.e. angiography) currently exist. @*Objective@#The objective of this study is to compare Tc-99m tagged RBC scintigraphy with CT-based imaging studies in terms of clinical utility and diagnostic outcomes. @*Methods@#A systematic review of available literature was done, with the goal of creating a meta-analysis focusing on the reported diagnostic outcomes - mainly sensitivity and specificity on the presence of a LGIB. Aside from this, a systematic review of the clinical utility and the differences of each test were discussed, including non-quantifiable advantages. The literature search was conducted following the guidelines of PRISMA, with searches from PubMed, Medline, and other pertinent databases. Quality assurance was done using the QUADAS tool. Statistical analyses of sensitivity, specificity, and a summary receiver operating characteristics plot were computed for the meta-analysis.@*Results@#Pooled sensitivity and specificity for RBC scintigraphy were 0.886 and 0.119, respectively. Pooled sensitivity and specificity for CT-based imaging were 0.729 and 0.660, respectively. CT based imaging also showed higher localization and faster completion times. RBC scintigraphy had a longer acquisition window.@*Conclusion@#Both Tc99m-tagged RBC scintigraphy and CT-based imaging have important clinical utility, with each modality having different advantages that the other test cannot provide.
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Computed Tomography AngiographyABSTRACT
Lipoma is a rare mesenchymal tumour of stomach (less than 1% of gastric tumours) to present as gastrointestinal bleed. We report a case of upper gastrointestinal bleed from a gastric lipoma in a 42 year male patient who underwent distal gastrectomy for resection of the large submucosal tumour situated in antropyloric region. Most common age of presentation of gastric lipoma is fifth or sixth decade of life and most of these are located in submucosal plane (90% cases) and in antropyloric region (75% cases). Gastric lipomas can be diagnosed by endoscopic means but most often with CT scan which shows characteristic fat attenuation. Small asymptomatic incidentally diagnosed can be safely observed while larger symptomatic tumours are treated by endoscopic or surgical resection which offers cure from this benign lesion.
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Background: Acute upper gastrointestinal hemorrhage (UGIH) is a common condition worldwide frequently leads to hospital admission also has a significant associated morbidity and mortality, especially in the elderly. A systematic diagnostic and definite therapeutic approach is essential to establish a diagnosis, relevant to specific investigations for appropriate treatment in tertiary medical care center.Methods: A comparative trial was done on n=109 cases with an objective to find out the different causes of UGI bleed in population, to assess the requirement of blood transfusion in patients with massive GI Bleed and to compare the treatment outcome of Proton pump inhibitors over Tranexamic acid and Octreotide in non-variceal UGI bleed. The cases were assigned to three different groups by lottery system. Proton pump inhibitors (Omeprazole), Somatostatin (Octreotide), Anti-fibrinolytic (Tranexamic acid), outcome was assessed after complete treatment and follow up.Results: Out of 150 cases, 109 were diagnosed with non-variceal GI bleed, 35 cases were treated with Omeprazole out of which 11.42% cases received blood transfusion, and 4 had history of re bleeding, Mean Duration of stay in hospital was 4.4±1.75, when compared to the other two group the duration of hospitalization was least as the P value was <0.0001.Conclusions: In this study it was demonstrated the use of PPI in case of Non-Variceal Bleeding significantly reduces the need of blood transfusion. Even it reduces the cases of re bleeding and duration of hospital stay.
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Introduction: The AIMS 65 score is a new bedside scoreproposed for the assessment of liver function which issimple and more independent. Different scores have beenrecommended to predict outcomes in the setting of uppergastrointestinal bleeding (UGIB), limited comparative studieshave been published between simplified versions of olderscores and recent scores. In this present study, we aimed toretrospectively compare the performance of AIMS 65 scorewith Child-Pugh score, MELD score and ALBI score forpredicting the outcome in patients with upper GI bleed inchronic liver disease.Material and Methods: Data of patients with chronic Liverdisease secondary to ethanol were retrospectively reviewed.Child Pugh score, MELD score, ALBI score and AIMS 65score were calculated for the patients and results . ROC curvesderived from comparison with outcome and were analysed.Results: In our study conducted on 112 patients, the agedistribution was between 20-85 years with mean age ofpatients being 46.47 ± 10.9 years, sex ratio Male: Female:105:7 with mortality rate of 33.92%. The Area under curves ofROC of AIMS65, Child Pugh score, MELD score, ALBI scorewas 0.779, 0.864, 0.763 and 0.777 respectively.Conclusion: AIMS 65 is a simple and non-endoscopic scorefor the prediction of in hospital mortality. No statisticaldifference was observed between AIMS-65 and other scoressuch as Child Pugh score, ALBI and MELD score.
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Objective To evaluate the safety and efficiency of composite microporous polysaccharide pow-der in non-varicose veins of gastrointestinal bleeding treatment. Methods We retrospectively analyzed 35 cases of the past 2 years in this hospital. Those patients were clinical diagnosed with non-varicose veins of gastrointestinal bleeding and received composite microporous polysaccharide powder in hemostasis. Results All 35 patients stopped bleeding after treatment with combined treatment of composite microporous polysaccharide powder spray. All vital signs were smooth and steady such as oxyhemoglobin saturation and heart rate,without complications like irritability,deterioration of inflammation and delayed hemorrhage. Conclusion The combined utilization of com-posite microporous polysaccharide powder provided rapid and effective hemostasis in therapy of non-varicose veins of gastrointestinal bleeding,which is an effective,simple and safe operation and to be worth of being generalized.
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Alimentary tract duplication cysts are rare congenital anomalies, most commonly located in the ileum, but may present anywhere from mouth to anus.Clinically, they may be asymptomatic, incidentally diagnosed or may present with obstruction, volvulus, intussusception or gastrointestinal bleed. Here we report a case of a one year old male child presenting in gasping state and shock. Despite the initial strong suspicion of Meckel's diverticulum and tubercular abdomen, the final diagnosis remained elusive till exploratory laparotomy was performed which revealed a duplication cyst of ileum with perforation into the umbilicus. Duplication cyst should always be kept as a differential diagnosis so that early intervention can help in better management.
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Child , Humans , Male , Abdomen , Ascites , Diagnosis , Diagnosis, Differential , Early Intervention, Educational , Ileum , Intestinal Volvulus , Intussusception , Laparotomy , Meckel Diverticulum , Mouth , Shock , UmbilicusABSTRACT
Formic acid is a commonly available compound, available commercially for the purpose of coagulating rubber. It is a highly corrosive agent. Consumption of this pungent liquid has resulted in dire consequences, based on the available literature. There have been a few reports of accidental/suicidal consumption of formic acid in the past. This is one such case report of an accidental poisoning with formic acid, with successful management and recovery.
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Background: Upper gastrointestinal bleeding is a common medical and surgical emergency. The aim of the study is to comprehend the aetiology of upper gastrointestinal bleeding by endoscopy and to evaluate the different endoscopic modalities for the management of upper gastrointestinal bleed. Methods: In 117 haemo-dynamically stable patients with the history of upper gastro-intestinal bleed endoscopy was done and possible site and cause of bleeding determined .The bleeding was stopped using one or more of the undermentioned modalities- Endoscopic Sclerotherapy (ES) using absolute alcohol, Endoscopic Varicael ligation (EVL), Injection Epinephrine (1:100,000) Results: Out of 84 patients bleeding was stopped in 81(96.42%) by endoscopic intervention. Among 72 (85.71%) patients of oesophageal varices treated with ES, re-bleed occurred in 2 (2.38%) patients. While out of 12 (14.28%) non variceal patients, rebleed occurred in 1 (8.30%) patient. Conclusion: Most of the upper gastrointestinal bleed patients who presented in our setup were having varices. On the basis of lower rates of re-bleeding, mortality, complications and need for fewer endoscopic treatments, ligation should be considered as the endoscopic treatment of choice for patients with oesophageal variceal bleeding.
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BACKGROUND/AIMS: To evaluate the ability of the recently proposed albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65) score to predict mortality in patients with acute upper gastrointestinal bleeding (UGIB). METHODS: AIMS65 scores were calculated in 251 consecutive patients presenting with acute UGIB by allotting 1 point each for albumin level 1.5, alteration in mental status, systolic blood pressure or =65 years. Risk stratification was done during the initial 12 hours of hospital admission. RESULTS: Intensive care unit (ICU) admission, endoscopic therapy, or surgery were required in 51 patients (20.3%), 64 (25.5%), and 12 (4.8%), respectively. The predictive accuracy of AIMS65 scores > or =2 was high for blood transfusion (area under the receiver operator characteristic curve [AUROC], 0.59), ICU admission (AUROC, 0.61), and mortality (AUROC, 0.74). The overall mortality was 10.3% (n=26), and was 3%, 7.8%, 20%, 36%, and 40% for AIMS65 scores of 0, 1, 2, 3, and 4, respectively; these values were significantly higher in those with scores > or =2 (30.9%) than in those with scores or =2 predict high in-hospital mortality.
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Humans , Blood Pressure , Blood Transfusion , Endoscopy , Gastrointestinal Hemorrhage , Hemorrhage , Hospital Mortality , Intensive Care Units , International Normalized Ratio , MortalityABSTRACT
Ulcerative colitis is a chronic inflammatory disease of unknown etiology. It is localized to the colon and spares the upper gastrointestinal tract. Ulcerative colitis can occur at any age, the peak incidence is among the age group 15-25 years and in 55-65 years. The first pediatric case was reported by Helmholz. The purpose of reporting this case of 17 year old girl with ulcerative colitis who presented with severe anemia is, to not only create awareness of ulcerative colitis among pediatric age group but also to discuss the challenges facing the diagnosis and management of the disease in a developing country like India.
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Gastrointestinal carcinoid tumors represent a group of well-differentiated tumors originating from various neuroendocrine cells located in the gastrointestinal mucosa and submucosa. Consequently, there is diversity in their clinical presentation, incidence at specific anatomic sites, biological behavior, hormone production, morphologic characteristics, and immunophenotype. Periampullary carcinoids are extremely rare and less then 100 patients have been reported in the world literature, that too mostly as case reports. We are reporting two cases of periampullary carcinoids, one of which presented with rare manifestation as gastrointestinal bleed and both are doing well after successful pancreatoduodenectomy.
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Adult , Ampulla of Vater/pathology , Ampulla of Vater/surgery , Carcinoid Tumor/complications , Carcinoid Tumor/pathology , Carcinoid Tumor/surgery , Diagnosis, Differential , Disease-Free Survival , Endoscopy , Female , Gastrointestinal Neoplasms/complications , Gastrointestinal Neoplasms/pathology , Gastrointestinal Neoplasms/surgery , Hemorrhage , Humans , Jaundice, Obstructive/diagnosis , Jaundice, Obstructive/etiology , Male , Middle Aged , PancreaticoduodenectomyABSTRACT
A retrospective analysis of the clinical profile, endoscopic features and management of 22 children (age 18 months – 18 years) diagnosed as solitary rectal ulcer syndrome is presented. The majority (81.8%) were ≥8 years of age. Rectal bleeding was the presenting feature in all the children. Mucorrhea, constipation, tenesmus and rectal prolapse were observed in 77.3%, 63.6%, 59% and 13.6% children, respectively. Colonoscopy showed classical single rectal ulcer in 68.2% and multiple ulcers in 22.7%. Polypoidal and erosive lesions were documented in 4.5% each. The medical management comprised of bowel training and high fibre diet for all children. The other modalities included oral 5-amino salicylate (59%), sucralfate enema (4.5%) and rectal mesalamine in 9%. 64% children recovered and 13.6 % had recurrence of symptoms.
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A 62 year old female who presented with features of acute duodenal perforation and associated carcinoma stomach (Ca-Stomach) is reported. Upper gastrointestinal endoscopy, biopsy and barium meal showed an adenocarinoma of cat'dia and proximal 1I3rd of stomach. Such an association of pathology is not reported earlier in the literature.