Lower Digestive Tract Bleeding in a Patient with Behçet's Disease: A Case Report

Behçet's disease is a chronic, multisystemic, and relapsing inflammatory pathology that frequently manifests with oral and genital ulcers and ocular and skin lesions. It rarely exhibits gastrointestinal involvement, which varies depending on the affected gastrointestinal segment; these have in common the predominance of ulcerated lesions and, consequently, a greater risk of bleeding from the digestive tract. A clinical case of a 28-year-old female patient who consulted for a clinical picture of melenic stools and oral ulcers is described. As a crucial clinical history, she had been diagnosed with Behçet's disease since adolescence, associated with severe gastrointestinal complications. An esophagogastroduodenoscopy was performed with findings of antral erythematous gastropathy and a colonoscopy with a report of ulcerated ileitis. Treatment with azathioprine and corticosteroids was indicated, significantly improving the clinical picture.

La enfermedad de Behçet es una patología inflamatoria crónica, multisistémica y recidivante que se manifiesta frecuentemente con úlceras orales y genitales, y lesiones oculares y cutáneas. En raras ocasiones presenta compromiso gastrointestinal y este varía dependiendo del segmento gastrointestinal afectado; estas enfermedades tienen en común el predominio de lesiones ulceradas y, consecuentemente, un mayor riesgo de sangrado de las vías digestivas. Se describe un caso clínico de una paciente femenina de 28 años que consultó por un cuadro clínico de deposiciones melénicas y úlceras orales. Como antecedente clínico de importancia presentó diagnóstico de enfermedad de Behçet desde la adolescencia asociado a complicaciones gastrointestinales graves. Se realizó una esofagogastroduodenoscopia con hallazgos de gastropatía eritematosa antral y una colonoscopia con reporte de ileítis ulcerada. Se indicó el tratamiento con azatioprina y corticoides con una mejoría significativa del cuadro clínico.

CHAMPS score in predicting mortality of patients with acute nonvariceal upper gastrointestinal bleeding

SUMMARY OBJECTIVE: The aim of this study was to evaluate the performance of the Charlson Comorbidity Index ≥2, in-hospital onset, albumin <2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥2, steroid use score in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding and compare it with the Glasgow-Blatchford score; the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score; the age, blood tests, and comorbidities score; and Complete Rockall score. METHODS: The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were obtained from the hospital automation system by using the classification of disease codes and analyzed in this retrospective study. Adult patients with endoscopically confirmed nonvariceal upper gastrointestinal bleeding were included in the study. Patients with bleeding from the tumor, bleeding after endoscopic resection, or missing data were excluded. The prediction accuracy of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score was calculated using the area under the receiver operating characteristic curve and compared with that of Glasgow-Blatchford score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, the age, blood tests, and comorbidities score, and Complete Rockall score. RESULTS: A total of 805 patients were included in the study, and the in-hospital mortality rate was 6.6%. The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score (area under the receiver operating characteristic curve 0.812, 95%CI 0.783-0.839) was better than Glasgow-Blatchford score (area under the receiver operating characteristic curve 0.683, 95%CI 0.650-0.713, p=0.008), and similar to the the age, blood tests, and comorbidities score (area under the receiver operating characteristic curve 0.829, 95%CI 0.801-0.854, p=0.563), the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score (area under the receiver operating characteristic curve 0.794, 95%CI 0.764-0.821, p=0.672), and Complete Rockall score (area under the receiver operating characteristic curve 0.761, 95%CI 0.730-0.790, p=0.106). CONCLUSION: The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score in predicting in-hospital mortality for our study population is better than Glasgow-Blatchford score and similar to the the age, blood tests, and comorbidities score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, and Complete Rockall score.

Variación estacional de la hemorragia digestiva alta / Seasonal variation of upper gastrointestinal bleeding

Introducción: La hemorragia digestiva alta representa una de las causas más frecuentes de morbilidad y mortalidad en los servicios de cirugía general y específicamente es la primera causa de mortalidad en el servicio, por lo que constituye una emergencia médico-quirúrgica. Objetivo: Identificar la existencia de un patrón estacional en la incidencia de hemorragia digestiva alta en época invernal y estimar la frecuencia de algunos factores de riesgo de esta enfermedad. Métodos: Se realizó un estudio descriptivo, de series temporales, de pacientes afectados por esa enfermedad que acudieron al Hospital Dr. Miguel Enríquez en el periodo comprendido entre diciembre de 2017 y enero de 2020. La muestra quedó conformada por 151 pacientes que presentaron como diagnóstico de ingreso hemorragia digestiva alta. Resultados: Predominó el sexo masculino y los mayores de 60 años. La temporada de mayor incidencia de esta complicación digestiva fue la invernal (diciembre, enero y febrero). Los factores de riesgo que predominaron fueron los hábitos tóxicos y la ingestión de AINES y ASA. La forma de presentación más frecuente fue la melena y la principal etiología la úlcera péptica duodenal. Conclusiones: Los casos con hemorragia digestiva alta predominaron en la temporada invernal y los factores de riesgo más frecuentes fueron los hábitos tóxicos y el uso de AINES en relación con el periodo estacional(AU)

Introduction: The High Digestive Hemorrhage represents one of the most frequent causes of morbidity and mortality in the General Surgery Services and it is specifically the first cause of mortality in our service. It constitutes a very frequent medical-surgical emergency. Objective: To determine the existence of a seasonal pattern in the incidence of HDA in winter and its relationship with risk factors. Methods: A descriptive and retrospective study was carried out with a longitudinal design in which patients affected by HDA were studied. These patients were assisted at "Dr. Miguel Enriquez Hospital" between December 2017 and January 2020. The study group was composed of all the patients who came to our emergency services with manifestations of bleeding from the upper digestive tract. The sample was made up of 151 patients who presented a diagnosis of HDA at the time of their admission. Results: The predominant sex was male and the age over 60 years old. The season with the highest incidence of this digestive complication was winter (December, January and February). The risk factors that predominated in our study were toxic habits and ingestion of AINES, ASA. The predominant form of presentation of the HDA were tarry stools, being the Duodenal Peptic Ulcer the main etiology. Conclusions: Cases with Upper Digestive Bleeding predominated in the winter season and the most frequent risk factors were toxic habits and the use of NSAIDs in relation to the seasonal period(AU)

Paciente con síndrome de Eisenmenger complicado por sangrado digestivo alto / Patient with Eisenmenger syndrome complicated by upper digestive bleeding

El Síndrome de Eisenmenger es un desorden multisistémico caracterizado por hipertensión pulmonar con inversión o bidireccionalidad del flujo a través de una comunicación intracardiaca o aortopulmonar. Se presenta el caso de un paciente masculino de 48 años de edad con antece- dentes de Hipertensión Pulmonar e Insuficiencia Cardíaca en tratamiento, quien acude por cuadro de melenas, decaimiento e inestabilidad hemodinámica. Al examen físico se ausculta soplo sistólico ascendente en foco pulmonar, abdomen distendido con presencia de onda ascíti- ca. En los exámenes complementarios; la radiografía convencional de tórax mostró aumento de la trama vascular pulmonar, además de encontrarse alteraciones electrocardiográficas. El paciente mostró una evolución desfavorable produciéndose falla cardíaca, que dio lugar al posterior fallecimiento debido a un paro cardiorrespiratorio.

Eisenmenger Syndrome is a multisystemic disorder identified by pulmonary hypertension with reversal or bidirectional flow through intracardiac or aortopulmonary communication. The case of a 48-year-old male patient with a history of Pulmonary Hypertension and Heart Failure in treatment is presented, who comes due to mane of mane, decay, and hemodynamic instability. The physical examination auscultated systolic murmur ascending in pulmonary focus, distended abdomen with presence of ascites wave. In the complementary exams, conventional chest x-ray, increased pulmonary vascular weft, in addition to finding electrocardiographic abnormalities. The patient seemed an unfavorable evolution, producing a heart failure, which resulted in subse- quent death due to cardiorespiratory arrest.

Sangrado digestivo alto como complicación en un paciente lúpico con síndrome de Eisenmenger / High digestive bleeding as a complication in a lupus patient with Eisenmenger syndrome

El síndrome de Eisenmenger es un trastorno multisistémico caracterizado por hipertensión pulmonar con inversión o bidireccionalidad del flujo a través de una comunicación intracardiaca o aortopulmonar. El propósito de este estudio es dar a conocer las características generales del síndrome de Eisenmenger. Se presenta el caso de un paciente masculino de 48 años de edad con diagnóstico de lupus eritematoso sistémico de 6 años de evolución con hipertensión pulmonar e insuficiencia cardiaca en tratamiento, que acude por cuadro de melenas, decaimiento e inestabilidad hemodinámica. Al examen físico destaca la presencia de un abdomen distendido y edemas de los miembros inferiores. Se realizaron exámenes complementarios hasta llegar al diagnóstico de síndrome de Eisenmenger. A pesar de presentar múltiples complicaciones en el curso del lupus eritematoso sistémico no se encontraron reportes que asociaran al lupus con el síndrome de Eisenmenger. El diagnóstico en la infancia de las cardiopatías congénitas cianóticas y la realización de la cirugía correctora constituyen la principal medida preventiva de aparición del síndrome de Eisenmeger(AU)

Eisenmenger syndrome is a multisystemic disorder characterized by pulmonary hypertension with inversion or bidirectional flow through intracardiac or aortopulmonary communication. To publicize the general characteristics of Eisenmenger syndrome. The case of a 48-year-old male patient with a diagnosis of 6-year-old systemic lupus erythematosus with pulmonary hypertension and cardiac insufficiency in treatment is presented, which is due to mane of mane, decay and hemodynamic instability. The physical examination highlights the presence of a distended abdomen and edema of the lower limbs. Complementary examinations were made to reach the diagnosis of Eisenmenger syndrome. Despite presenting multiple complications in the course of systemic lupus erythematosus, no reports were found that associated lupus with Eisenmenger syndrome. Diagnosis of cyanotic congenital heart disease in childhood and corrective surgery are the main preventive measures for the appearance of Eisenmenger syndrome(AU)

Diagnóstico y tratamiento de pacientes con telangiectasia hemorrágica hereditaria (síndrome de Rendu-Osler-Weber) en un hospital universitario en Colombia / Diagnosis and treatment of patients with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) at a university hospital in Colombia

Resumen Introducción: la telangiectasia hemorrágica hereditaria (THH) es una enfermedad vascular hereditaria caracterizada por epistaxis, sangrado digestivo y anemia crónica; en muchos casos hay malformaciones arteriovenosas de órganos sólidos. El diagnóstico se realiza con base en datos clínicos, hallazgos endoscópicos e imagenológicos. La detección temprana con enfoque multidisciplinario y tratamiento de las complicaciones impacta en morbimortalidad de la enfermedad. Objetivos: describir las características demográficas, clínicas y desenlaces de pacientes con diagnóstico de THH en un hospital universitario. Métodos: estudio tipo serie de casos en pacientes evaluados entre 2012 hasta el 2017. Resultados: se obtuvieron registros de 18 casos, 11 (61,1 %) hombres, con edad mediana de 56 años (rango intercuartílico [IQR]: 52-64). Los casos son provenientes de Colombia y algunos países caribeños. En todos los pacientes el diagnóstico se estableció mediante los criterios de Curazao. El número de ingresos hospitalarios tuvo una mediana de 6 días (IQR: 2,5-20,5). Los ingresos fueron en relación a sangrado en todos los casos, 61 % de los pacientes requirió transfusión de hemoderivados. En el 61 % de los pacientes se identificó compromiso en el órgano sólido mediante imágenes. Conclusiones: la THH es una enfermedad de expresión clínica variable. En nuestro estudio las manifestaciones gastrointestinales fueron las causas de ingreso más frecuentes. Se requirió con frecuencia transfusión de hemoderivados. Los pacientes requirieron múltiples estudios para identificar la extensión de la enfermedad y el compromiso de órgano sólido. El tratamiento se basó en el manejo endoscópico y médico, especialmente a base de bevacizumab y octreotida.

Abstract Introduction: Hereditary hemorrhagic telangiectasia (HHT or Osler-Weber-Rendu syndrome) is a hereditary vascular disease characterized by recurrent epistaxis, gastrointestinal bleeding and chronic anemia. Many cases have arteriovenous malformations of solid organs. Diagnosis is based on clinical data, endoscopy and imaging. Early detection and treatment of complications with a multidisciplinary approach impacts the disease's morbidity and mortality. Objectives: The objective of this study was to describe the demographic, clinical and outcome characteristics of patients diagnosed with HHT at a university hospital. Methods: This is a case series of patients evaluated between 2012 and 2017. Results: Records of 18 cases were obtained. The patients were from Colombia and other Caribbean countries. All diagnoses were established using the Curaçao criteria. Eleven patients 11 (61.1%) were men, and the median patient age was 56 years (IQR 52-64). The median number of hospital admissions was 6 (33.3%) (IQR 2.5-20.5), and all admissions were related to bleeding. Sixty-one percent of patients required transfusion of blood products, and the compromises of solid organs were found in the same number of patients by imaging studies. Conclusions: The clinical expression of THH varies, but in our study gastrointestinal manifestations were the most frequent causes of hospital admission. They frequently required transfusion of blood products and patients required multiple studies to identify the extent of the disease, and solid organ compromise. Treatment was based on endoscopic and medical management, especially administration of bevacizumab and octreotide.

Píloro doble. Presentación de un caso y revisión de la literatura / Double pylorus. Case report and literature review

RESUMEN El doble píloro es una comunicación anormal entre el antro gástrico y el bulbo duodenal y representa un raro hallazgo endoscópico. Se presentó un paciente de 80 años de edad, con antecedentes de hipertensión arterial, fumador inveterado, tomador de aspirina, que presentó melena aproximadamente 15 días antes del ingreso. La videoendoscopia reveló la existencia de dos orificios similares en el antro, que se comunicaban con el bulbo duodenal de manera independiente que fueron catalogados como píloros. La comunicación se constató con el paso del endoscopio a su través. Se impuso tratamiento médico con inhibidores de la bomba de protones y la evolución fue favorable. Es el cuarto caso reportado en la literatura en nuestro país y el primero en la provincia de Matanzas.

ABSTRACT Double pylorus is an abnormal communication between the gastric antrum and the duodenal bulb and represents a rare endoscopic finding. It is presented the case of a patient aged 80 years, with a background of arterial hypertension, inveterate smoker, taking aspirin, who presented melena about 15 days before the admission. The video-endoscopy revealed the existence of two similar orifices in the antrum that were independently communicating with the duodenal bulb and they went catalogued like pylori. The communication was proved by passing the endoscope through it. He was treated with IBP (the Spanish acronym for proton bomb inhibitors) and the evolution was favorable. It is the fourth case reported in the literature in Cuba and the first one in Matanzas.

Clip Ovesco® como tratamiento de rescate en lesión de Dieulafoy duodenal con sangrado activo / Ovesco clip as a rescue treatment of duodenal Dieulafoy lesion with active bleeding

Las lesiones de Dieulafoy se definen como una anomalía vascular que producen un sangrado en la mucosa proveniente de una arteria submucosa anormalmente larga y tortuosa que se ubican principalmente en estómago (80%), con poca frecuencia a nivel duodenal y constituyen el 6% de los sangrados gastrointestinales no asociados a varices y del 1% al 2% de todos los sangrados gastrointestinales. Reportamos el caso de un paciente masculino de 60 años que ingresó por hematemesis, melena y signos de hipovolemia con hemoglobina de 9 g/dl, que luego de realizar su compensación hemodinámica se le realizó una endoscopía alta que evidenció una lesión de Dieulafoy con sangrado activo severo en la segunda porción duodenal realizándosele inyección con adrenalina al 1:10 000 sobre los bordes de la lesión, pero al no lograrse una hemostasia adecuada se le tuvo que realizar la colocación de un clip ovesco con hemostasia efectiva que se corroboró 24 horas después, a través de una segunda endoscopía para poder egresar al paciente sin complicaciones, ni resangrado.

Dieulafoy's lesions are vascular anomalies that produce gastrointestinal bleeding of the mucosa from an abnormally long and tortuous submucosal artery. It is found predominately in the stomach (80%) and less frequently in the duodenum. They constitute the 6% of all non-variceal bleeding and the 1 to 2% of all gastrointestinal bleeding source. We report a case of a 60-year-old man with hematemesis, melena and signs of hypovolemic shock with a hemoglobin level of 9 g/dL. After adequate fluid resuscitation, an upper endoscopy showed an actively bleeding Dieulafoy lesion in the second portion of the duodenum. After epinephrine injection over lesion borders, an adequate hemostasis was not achieved. An over-the-scope clip was placed. Follow-up endoscopy 24 hours later showed an effective hemostasis and the patient was discharged without complications or re-bleeding.

Manejo del paciente portador de sangrado digestivo alto en el servicio de urgencias / Upper digestive bleeding patient management in the emergency department

Introducción: el sangrado digestivo alto constituye uno de los síndromes más frecuentes en servicios de urgencias. La endoscopia oral y los medicamentos antiácidos y protectores de la mucosa gástrica, hacen menos frecuente el empleo de intervenciones quirúrgicas en el manejo del paciente con sangrado digestivo alto. La necesidad del tratamiento quirúrgico no siempre puede obviarse. Objetivo: describir las características clínicas de los pacientes con sangrado digestivo alto atendidos en el Hospital Militar Dr. Joaquín Castillo Duany. Métodos: estudio descriptivo transversal. Universo constituido por 92 pacientes con diagnóstico de sangrado digestivo alto. Variables caracterizadas: edad, sexo, tratamiento médico empleado, técnica quirúrgica utilizada, complicaciones posquirúrgicas y estadía hospitalaria. Resultados: el sangrado digestivo alto fue más frecuente en hombres, con más de 40 años de edad, se les aplicó tratamiento médico, la modalidad más frecuente fue la combinación de antiácidos. Se realizó tratamiento endoscópico al 3,2 por ciento de los pacientes, fueron intervenidos quirúrgicamente el 5,4 por ciento. La mitad de los operados padecía úlcera péptica gástrica. La técnica quirúrgica más empleada fue la gastrostomía y gastrorrafia. La estadía hospitalaria fue menor de 5 días. Conclusiones: se evidenció predominio del sangrado digestivo alto en el sexo masculino y en mayores de 40 años. El tratamiento endoscópico y las intervenciones quirúrgicas representaron un bajo porcentaje. La estadía hospitalaria fue más prolongada en pacientes con complicaciones. Los hallazgos en los que más difieren otras investigaciones radican en el incremento del empleo de la endoscopia oral, en combinación con el uso de antisecretores y en las variantes de técnicas quirúrgicas empleadas(AU)

Introduction: upper Digestive Bleeding is one of the most frequent syndromes in emergency services. Oral endoscopy, antacid and protective gastric mucosal medications make the use of surgical interventions less common in the management of upper digestive bleeding patients. However, the need for surgical treatment cannot always be overlooked. Objective: to describe the clinical characteristics of patients with upper digestive bleeding treated at the Military Hospital Dr. Joaquín Castillo Duany. Methods: cross-sectional descriptive study. A universe of 92 patients with a diagnosis of upper digestive bleeding. Variables characterized: Age, sex, medical treatment, surgical technique used, postoperative complications, and hospital stay. Results: upper digestive bleeding was more frequent in men and in patients over 40 years old. In patients in whom medical treatment was applied, the most frequent modality was the combination of anti-H2 antihistamines and proton pump inhibitors. Endoscopic treatment was performed in 3.2 percent of patients, and 5.4 pèrcent was operated on. Half of the patients underwent gastric peptic ulcer, and the most commonly used surgical technique was gastrostomy. The predominant hospital stay was less than 5 days(AU)

Neurofibromatosis tipo 1 y sangrado de intestino delgado. Reporte de caso / Neurofibromatosis type 1 and small bowel bleeding: Case report and literature review

Resumen La neurofibromatosis tipo 1, o enfermedad de von Recklinghausen, es un desorden neurocutáneo hereditario con compromiso gastrointestinal en el 5-25% de los pacientes, siendo sintomático solo el 5%; se presenta posterior a las manifestaciones cutáneas y afecta en su mayoría el yeyuno. Los síntomas de esta enfermedad son dolor abdominal, obstrucción intestinal, perforación, diarrea, masa palpable y sangrado gastrointestinal alto o bajo. A continuación se reporta el caso de una mujer con sangrado gastrointestinal manifiesto secundario a neurofibromas plexiformes en yeyuno y se realiza una breve revisión de la literatura sobre compromiso gastrointestinal.

Abstract Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneous disorder with gastrointestinal involvement in 5-25% of patients, with only 5% being symptomatic; it develops following cutaneous manifestations and mostly affects the jejunum. The symptoms include abdominal pain, intestinal obstruction, perforation, diarrhea, palpable mass and high or low gastrointestinal bleeding. The following report presents the case of a woman with manifest gastrointestinal bleeding secondary to plexiform neurofibromas in the jejunum, as well as a brief review of the literature on gastrointestinal involvement.

Lesão de Dieulafoy do fundo gástrico / Dieulafoys lesion of the gastric fundus

Hemorragia digestiva alta (HDA) é uma emergência clínica exteriorizada através de melena, hematêmese, além de alterações hemodinâmicas decorrentes de perda volêmica. Existem vários diagnósticos etiológicos causadores de hemorragias digestivas altas; dentre eles, uma causa rara é lesão de Dieulafoy, sendo relacionada acerca de 2% dos casos de HDA. Neste relato, descreveremos um caso de lesão de Dieulafoy, evidenciando a relevância desta lesão como um importante diagnóstico diferencial nas causas de hemorragia digestiva alta. O procedimento diagnóstico e o manejo atual são fundamentados pela endoscopia digestiva alta. A hemostasia endoscópica é realizada, utilizando técnicas como eletrocoagulação, injeções com adrenalina e hemoclips.

Upper gastrointestinal bleeding (UGBI) is a clinical emergency externalized through melena, hematemesis and hemodynamic changes due to volume loss. There are a lot of etiological diagnosis of gastroduodenal hemorrhages, including Dieulafoy which is a rare cause related about 2% of the UGBI cases. In this report we describe a case of Dieulafoy lesion highlighting the importance of this lesion as a rare and important differential diagnosis in cases of upper gastrointestinal bleeding. The current diagnostic and management is justified by endoscopy. Endoscopic hemostasis is performed using techniques such as electrocoagulation, injections of adrenaline and hemo-clips.

Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Three Year Old Male with Multiple Dieulafoy Lesions Treated with Epinephrine Injections via Therapeutic Endoscopy / 대한소아소화기영양학회지

Dieulafoy lesions, vascular anomalies typically found along the gastrointestinal tract, have been viewed as rare and obscure causes of sudden intestinal bleeding, especially in pediatric patients. Since their discovery in the late 19th century, the reported incidence has increased. This is due to an increased awareness of, and knowledge about, their presentation and to advanced endoscopic diagnosis and therapy. Our patient was a three-year-old male, without a complex medical history. He presented to the emergency department with acute hematemesis with blood clots and acute anemia requiring blood transfusion. Endoscopy revealed four isolated Dieulafoy lesions along the lesser curvature of the stomach, which were treated with an epinephrine injection. The Dieulafoy lesion, although thought to be rare, should be considered when investigating an acute gastrointestinal bleed. These lesions have been successfully treated endoscopically. Appropriate anticipation and preparation for diagnosis and therapy can lead to optimal outcomes for the pediatric patient.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

Background - Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. Objective - The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. Methods - It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. Results - The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. Conclusion - The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Contexto - A hemorragia digestiva alta implica em significativas repercussões clínicas e econômicas. O estabelecimento correto das mais recentes terapêuticas para a hemorragia digestiva alta está associado à redução na mortalidade intra-hospitalar. O uso de algoritmos para atendimento da hemorragia digestiva alta está associado com menor tempo de internação e menores custos hospitalares. Objetivos - O objetivo primário é a criação de um protocolo de atendimento da hemorragia digestiva alta, para ser utilizado em hospital terciário. Métodos - Realizada extensa revisão da literatura sobre as condutas na hemorragia digestiva alta, contidas nas bases de dados primária e secundária. Resultados - O resultado é um modelo de atendimento para os pacientes com hemorragia digestiva alta e com evidência de sangramento recente, dado por melena ou hematêmese nas ultimas 24h, que são atendidos nas salas de emergência e unidades de terapia intensiva de hospitais terciários. Neste protocolo de atendimento, desenhado de forma compacta e compreensível, fica bem evidenciado o manejo dos pacientes desde a admissão, com definição dos critérios de inclusão e exclusão, passando considerações acerca do atendimento clínico inicial, posterior direcionamento para a terapêutica endoscópica, e encaminhamento às terapias de resgate em casos de sangramento persistente ou recorrente. Destacam-se também os cuidados que devem ser tomados antes da alta hospitalar para todos os pacientes que se recuperam de um episódio de sangramento. Conclusão - A introdução de um protocolo para atendimento e tratamento de pacientes com hemorragia digestiva alta pode contribuir para uniformização de condutas médicas, diminuição no tempo de espera por medicações e serviços, no tempo de internação e nos custos hospitalares.

Availability of Blood Urea Nitrogen/Creatinine Ratio in Gastrointestinal Bleeding with Melena in Children / 대한소아소화기영양학회지

PURPOSE: The aims of our study were to evaluate the blood urea nitrogen to creatinine ratio (BUN/Cr ratio) for distinguishing between an upper and lower gastrointestinal bleeding (GIB), and differentiating between the two most common causes of upper gastrointestinal bleeding (UGIB) presenting with melena in children. METHODS: Retrospective data of patients with GIB presenting with melena were analyzed. The data from 60 cases were reviewed including demographics, laboratory findings, diagnostic modalities and results, treatments, and transfusions. RESULTS: Among the 60 cases, UGIB and lower gastrointestinal bleeding (LGIB) were found in 35 cases (58.3%) and 14 cases (23.3%), respectively. The two common causes of UGIB were varices (37.1%), and peptic ulcer diseases (PUD) (31.4%). The BUN/Cr ratio of 30 or greater was higher in UGIB than LGIB (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 1.3-37.2). In UGIB, the BUN/Cr ratio of the varices group was higher than that of the PUD group (p=0.015). The OR for the BUN/Cr ratio appeared as 1.2 per unit increase in the varices group than the PUD group (95% CI, 1.03-1.3). There was no difference between the PUD group and Meckel's diverticulum group. CONCLUSION: The BUN/Cr ratio was not uneven in differentiating UGIB from LGIB of children with melena in our study. This suggests that BUN/Cr ratio should be interpreted carefully.

Rendimiento diagnóstico y hallazgos con la cápsula endoscópica en pacientes con sangrado digestivo de origen oscuro en la Clínica Universitaria San Juan de Dios en Cartagena, Colombia / Diagnostic Performance of, and findings from, Capsule Endoscopy for patients with Gastrointestinal Bleeding with Obscure Origins at the Clínica Universitaria San Juan de Dios in Cartagena, Colombia

Introducción: La cápsula endoscópica (CE) es, actualmente, el estudio de primera elección en la exploración del sangrado digestivo oscuro (SDO), después de una esofagogastroduodenoscopia (EGD) y una ileocolonoscopia negativas. Objetivo: Evaluar el rendimiento diagnóstico y los hallazgos en el intestino delgado en 50 pacientes con sangrado digestivo de origen obscuro en nuestra institución. Materiales y métodos: Estudio observacional descriptivo retrospectivo, en una cohorte de pacientes que consultaron por SDO a la Clínica Universitaria San Juan de Dios en la ciudad de Cartagena, del 1 enero del 2010 al 31 abril del 2013. El rendimiento diagnóstico de la CE fue definido por la presencia de lesiones altamente significativas (P2), poco significativas (P1) y normales (P0). Para el análisis de los resultados se utilizó el software STATA 11.0. Resultados: Se incluyeron 50 pacientes con SDO. De estos, 34 casos con SDO evidente (68%) y 16 con SDO oculto (32%). El 62% (31) de sexo femenino, con una edad promedio de 60,14 años, DE±20,02 (20 a 87 años). La CE se realizó de manera ambulatoria en 26 casos (52%) e intrahospitalaria en 24 casos (48%). El rendimiento diagnóstico de la CE en el SDO (lesiones P2) fue de 58% (29/50). En SDO evidente 61,74%(21/34) y en SDO oculto 50% (8/16). La preparación fue adecuada en el 92% de los casos. La exploración completa del intestino delgado se logró en el 96%. Hubo una retención de la cápsula en dos pacientes. Las lesiones P2 encontradas en el intestino delgado fueron vasculares en 51,9%, tumorales en 20,6%, parasitarias en 13,7%, en lesiones ulcerosas e inflamatorias 6,9% y en divertículos 6,9%. Las lesiones P2 responsable del SDO por fuera del intestino delgado, al alcance de una EGD y colonoscopia, se encontraron en el 24,13%(7/29), una en el esófago, 2 en el estómago, una en el duodeno y 3 en el colon derecho. Conclusión: La rentabilidad diagnóstica de la CE en nuestra serie fue del 58%. Las lesiones vasculares ...

Introduction: Capsule endoscopy (CE) is currently the study of choice for the exploration of Obscure gastrointestinal bleeding (OGIB) after obtaining negative results from esophagogastroduodenoscopy (EGD) and ileocolonoscopy. Objective: The objective of this study was to evaluate the diagnostic yield and findings from capsule endoscopy studies of the small intestines of 50 patients with gastrointestinal bleeding of obscure origin in our institution. Materials and methods: This was a retrospective, descriptive and observational study of a cohort of patients seen for OGIB at the Clínica Universitaria San Juan de Dios in Cartagena from January 1, 2010 to April 31, 2013. Diagnostic yields from CE were categorized as highly significant lesions (P2), insignificant lesions (P1), and normal (P0). STATA 11.0 software was used to analyze results. Results: Fifty patients suspected of having OGIB were included: 34 (68%) obvious cases and 16 (32%) cases of occult OGIB. Thirty-one (62%) of the patients were women 62%, and the mean patient age was 60.14 ± 20.02 years with an age range of 20 to 87 years. CE was performed on an outpatient basis in 26 cases (52 %) and in-hospital in 24 cases (48%). The diagnostic yield of CE for diagnosing OGIB (P2 lesions) was 58 % (29/50). It was 61.74 % (21/34) for obvious OGIB and 50 % (8/16) for occult OGIB. The preparation was suitable in 92% of the patients. Complete examination of the small intestine was achieved in 96% of the cases. Two patients retained the capsules. 51.9 % of the P2 lesions found were vascular, 20.6 % were tumors, 13.7 % were parasitic, and ulcerative lesions and inflammatory diverticula accounted for 6.9 % of the lesions each. P2 lesions which were responsible for OGIB, but which were outside of the ranges of EGDs and colonoscopy, were found in 24.13 % (7/29) of the patients. One was in a patient’s esophagus, two were in patients’ stomachs, one in a patient’s duodenum, and three patients had them in their right colons. Conclusion: The diagnostic yield of CE in our series was 58%. Vascular lesions (angiodysplasia) were the leading cause of bleeding which is a result that is comparable to other publications internationally and in Colombia. One striking result of our study was that the second causes of OGIB were tumors and parasitic infestations in the population studied.

Gastrointestinal Tract Involvement of Gorham's Disease with Expression of D2-40 in Duodenum / 대한소아소화기영양학회지

We present a case of a 13-year-old boy with Gorham's disease involving the thoracic and lumbar spine, femur, and gastrointestinal (GI) tract, which was complicated by recurrent chylothorax and GI bleeding. The presenting symptoms were intermittent abdominal pain, back pain, and melena. Esophagogastroduodenoscopy and colonoscopy showed no abnormal lesions, but duodenal biopsy showed marked dilation of the lymphatics in the mucosa and submucosa, which revealed positive staining with a D2-40 immunohistochemical marker. In cases of GI bleeding with osteolysis, the expression of a D2-40 marker in the lymphatic endothelium of the GI tract may help to diagnose GI involvement in Gorham's disease. To the best of our knowledge, this is the first case report to pathologically demonstrate intestinal lymphatic malformation as a cause of GI bleeding in Gorham's disease.

Analysis of gynecological misdiagnosis in four patients with small intestinal stromal tumor / 中国医师进修杂志

Objective To investigate the cause of gynecological misdiagnosis in small intestinal stromal tumor and operation principle,treatment protocol.Methods Gynecological misdiagnosis in 4 female patients with small intestinal stromal tumor admitted were retrospectively analyzed.Results Four patients had abdominal ultrasound examination,1 patient was misdiagnosed as hysteromyoma,3 patients were misdiagnosed as ovarian tumor.All patients without further abdominal CT or MRI examination,operated by gynecology first and then treated by general surgery.All of 4 patients were confirmed with small intestinal stromal tumor by pathology.Conclusions For patients who are considered with hysteromyoma or ovarian tumor have melena must be identified with small intestinal stromal tumor.Further CT examination is valuable and can reduce misdiagnosis.Operation principle and oral imatinib mesylate after operation must be insisted.

Predictive Factors for Intractability to Endoscopic Hemostasis in the Treatment of Bleeding Gastroduodenal Peptic Ulcers in Japanese Patients

BACKGROUND/AIMS: Despite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis. METHODS: We analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital. RESULTS: Durable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age > or =70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin or =2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis. CONCLUSIONS: Various factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

A Small Ruptured Splenic Artery Aneurysm Presenting as Anemia and Melena after Graft Replacement of an Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

The splenic artery is a common site of intraabdominal aneurysms. Very few patients present with symptoms before a splenic artery aneurysm ruptures. However, the symptoms vary depending on the type of aneurysm. Some patients present with hemodynamic shock, while others develop mild lumbago, anemia, or syncope. Thus, it is sometimes difficult to diagnose and treat ruptured splenic aneurysms. We report a rare case of rupture of a small splenic artery aneurysm, which remained undetected for 3 months after the appearance of the first symptoms, i.e., anemia and melena, despite conducting different examinations at our hospital. A 74-year-old man who underwent a graft replacement of an abdominal aortic aneurysm in 2006 complained of melena in May 2011. He was severely anemic, but presented with no other symptoms. A 16-mm-diameter splenic aneurysm was detected during a previous operation. The splenic artery aneurysm, as seen on computer tomography (CT) scans, showed no significant change in diameter for 5 years. The patient underwent upper and lower gastrointestinal endoscopy, capsule endoscopy, and enhanced CT at the Department of Gastroenterology to determine the site of the bleeding. However, the source of the bleeding was unclear. Finally, a diagnosis by elimination was made and the cause of the melena was identified as a ruptured splenic aneurysm. The splenic artery aneurysm was treated with coil embolization, and the patient's anemia was cured. The splenic artery aneurysm ruptured and bled into the pancreatic duct. The findings of this case suggest that a small splenic artery aneurysm rupture might not cause major symptoms like hemodynamic shock or large hematomas that can be identified on CT scans, but they may bleed into visceral organs. Therefore, interventions for the treatment of a non-symptomatic abdominal visceral artery aneurysm should be carried out promptly.