Síndrome de Heyde: Estratégias Terapêuticas e Seguimento de Longo Prazo / Heyde's Syndrome: Therapeutic Strategies and Long-Term Follow-Up

Resumo Fundamentos A síndrome de Heyde é a associação de estenose aórtica importante com episódio de sangramento gastrointestinal por lesões angiodisplásicas. Pouco é conhecido sobre os fatores associados a novos sangramentos e desfechos em longo prazo. Além disso, a maioria dos dados é restrita a relatos de casos e pequenas séries. Objetivo Avaliar o perfil clínico, laboratorial e ecocardiográfico de pacientes com síndrome de Heyde submetidos a intervenção valvar ou tratamento medicamentoso. Métodos Coorte prospectiva de 24 pacientes consecutivos entre 2005 e 2018. Foram avaliados dados clínicos, laboratoriais, ecocardiográficos e relacionados à intervenção valvar e a desfechos após o diagnóstico. Valor de p<0,05 foi considerado estatisticamente significante. Resultados Metade dos 24 pacientes apresentou sangramento com necessidade de transfusão sanguínea na admissão. Angiodisplasias foram encontradas mais frequentemente no cólon ascendente (62%). Intervenção valvar (cirúrgica ou transcateter) foi realizada em 70,8% dos pacientes, e 29,2% foram mantidos em tratamento clínico. Novos episódios de sangramento ocorreram em 25% dos casos, e não houve diferença entre os grupos clínico e intervenção (28,6 vs. 23,5%, p=1,00; respectivamente). A mortalidade no seguimento de 2 e 5 anos foi de 16% e 25%, sem diferença entre os grupos (log-rank p = 0,185 e 0,737, respectivamente). Conclusões Pacientes com síndrome de Heyde tiveram alta taxa de sangramento com necessidade de transfusão sanguínea na admissão, sugerindo ser uma doença grave e com risco elevado de mortalidade. Não encontramos diferenças entre os grupos submetidos ao tratamento clínico e à intervenção valvar em relação a taxas de ressangramento e mortalidade tardia.

Abstract Background Heyde's syndrome is the association of severe aortic stenosis with episodes of gastrointestinal bleeding due to angiodysplastic lesion. Little is known about the factors associated with new episodes of bleeding and long-term outcomes. Furthermore, most data are restricted to case reports and small case series. Objective To assess the clinical, laboratory and echocardiography profile of patients with Heyde's syndrome who underwent valve intervention or drug therapy. Methods Prospective cohort of 24 consecutive patients from 2005 to 2018. Clinical, laboratory and echocardiography data were assessed, as well as those related to valve intervention and outcomes after diagnosis. A P <0.05 was used to indicate statistical significance. Results Half of the 24 patients presented with bleeding requiring blood transfusion on admission. Angiodysplasias were more frequently found in the ascending colon (62%). Valve intervention (surgical or transcatheter) was performed in 70.8% of the patients, and 29.2% remained on drug therapy. News episodes of bleeding occurred in 25% of the cases, and there was no difference between clinical and intervention groups (28.6 vs 23.5%, p = 1.00; respectively). Mortality at 2-year and 5-year was 16% and 25%, with no difference between the groups (log-rank p = 0.185 and 0.737, respectively). Conclusions Patients with Heyde's syndrome had a high rate of bleeding requiring blood transfusion on admission, suggesting that it is a severe disease with high mortality risk. No difference was found between clinical and intervention group regarding the rate of rebleeding and late mortality.

El síndrome de Heyde / Heyde syndrome / Síndrome de Heyde

Desde que Edward Heyde vislumbró en 1958 una misteriosa asociación entre estenosis aórtica y hemorragia digestiva han transcurrido seis décadas y se ha suscitado no poca controversia. En la época en que fue propuesta, el estatus técnico y metodológico de la ciencia médica y una interpretación sesgada de su idea original impidieron obtener un sustento estadístico y fisiopatológico que le otorgara un amplio reconocimiento como entidad clínica individual. Los avances en varias disciplinas permitieron demostrar que su frecuencia de presentación excede el efecto del azar, además de esclarecer con precisión y elegancia sus mecanismos fisiopatológicos. Su consolidación como síndrome nos revela una verdadera encrucijada entre la cardiología, la gastroenterología, la hematología y el laboratorio, especialidades involucradas tanto en su proceso de comprensión como en su manejo práctico en la actualidad. Sin embargo, a pesar de tener una incidencia no desdeñable y adquirir un papel central en la conducción clínica de la estenosis aórtica, esta entidad parece haber pasado de ser resistida a relativamente ignorada. Con el objetivo de contribuir a su visibilidad, la presente revisión ofrece un panorama integral sobre el tema, incluyendo una perspectiva histórica de los principales aportes en pos de su conocimiento y un abordaje en profundidad de sus mecanismos, las claves de su detección clínica y su impacto en el manejo de la estenosis aórtica y otras entidades con fisiopatología afín.

Since Edward Heyde perceived in 1958 a mysterious association between aortic stenosis and gastrointestinal bleeding, six decades have passed and no little controversy has arisen. At the time it was proposed, the technical and methodological status of medical science and a biased interpretation of his original idea prevented obtaining a statistical and pathophysiological support that would grant it wide recognition as and individual clinical entity. Advances in several disciplines allowed to demonstrate that its frequency of presentation exceeds the effect of chance, besides clarifying with precision and elegance its pathophysiological mechanisms. Its consolidation as a syndrome reveals a true crossroads between Cardiology, Gastroenterology, Hematology and Laboratory, specialties involved both in its understanding process and in its practical management today. However, despite having a not negligible incidence and acquiring a central role in the clinical conduction of aortic stenosis, this entity seems to have gone from being resisted to relatively ignored. With the objective of contributing to its visibility, this review offers a comprehensive overview of the subject, covering the main historical contributions to its knowledge and approaching in depth its mechanisms, the keys to its clinical detection and its impact on the management of aortic stenosis and other entities with related pathophysiology.

Desde que Edward Heyde imaginou em 1958 uma misteriosa associação entre estenose aórtica e hemorragia gastrointestinal, seis décadas se passaram e não houve pouca controvérsia. Na época em que foi levantada, o estado técnico e metodológico da ciência médica e uma interpretação tendenciosa de sua ideia original impediram a construção de um apoio estatístico e fisiopatológico que lhe concederia amplo reconhecimento como entidade clínica individual. Avanços em diversas disciplinas permitiram demonstrar que sua frequência de apresentação excede o efeito do acaso, além de esclarecer com precisão e elegância seus mecanismos fisiopatológicos. Sua consolidação como síndrome revela uma verdadeira encruzilhada entre Cardiologia, Gastroenterologia, Hematologia e Laboratório, especialidades envolvidas tanto em seu processo de compreensão quanto em sua gestão prática hoje. No entanto, apesar de ter uma incidência não desprezível e adquirir um papel central no manejo clínico da estenose aórtica, esta entidade parece ter passado de resistida para relativamente ignorada. Com o intuto de contribuir para sua visibilidade, esta revisão oferece um panorama abrangente do tema, revendo as principais contribuições históricas ao seu conhecimento e abordando em profundidade seus mecanismos, as chaves para sua detecção clínica e seu impacto na gestão da estenose aórtica e outras entidades com fisiopatologia relacionada.

Enteroscopia asistida por balón simple en el manejo de la patología del intestino delgado: Experiencia de la Unidad de Intestino Delgado de la Clínica Anglo Americana durante el periodo de diciembre del 2012 a diciembre del 2018 / Single balloon enteroscopy in the management of small bowel pathology: Experience of the Small Bowel Unit - British American Hospital from December 2012 to December 2018

Objetivo: Describir la experiencia en el uso de la enteroscopia asistida por balón simple para el diagnóstico y manejo de la patología del intestino delgado en pacientes con anatomía normal y alterada por cirugía en la Clínica Anglo Americana. Material y método: El presente es un estudio descriptivo - retrospectivo que incluye a todos los pacientes que acudieron a la Unidad de Intestino Delgado de la Clínica Anglo Americana, para realizarse una enteroscopia asistida por balón durante el periodo comprendido entre diciembre del 2012 a diciembre del 2018. Resultados: Se realizaron 80 procedimientos de enteroscopia asistida por balón simple, 49 fueron realizados por via anterógrada y 31 por vía retrógrada. La edad promedio fue 60,78 años (20 a 88 años). 48 pacientes (60%) eran varones. El tiempo de inserción media fue 80 minutos para la vía anterógrada (55 - 141 minutos) y 110 minutos para la vía retrógrada (55 -180 minutos). La principal indicación para realizar la enteroscopia por balón simple fue hemorragia digestiva oscura, 45 casos (56,25%). Se realizaron 6 estudios de enteroscopias asistida por balón en pacientes con anatomía alterada (7,5%). Setenta de los ochenta procedimientos (87,5%) fueron realizados con sedación administrada por enfermería supervisada por gastroenterólogo en base a midazolam, petidina y propofol, no se presentó ninguna complicación respiratoria o hemodinámica. Los diagnósticos obtenidos más frecuentes por enteroscopia fueron: angiodisplasias de intestino delgado (20%), úlceras yeyuno ileales (17,5%) y neoplasias a nivel del intestino delgado (7,5%). La complicación que se presentó con más frecuencia posterior a la enteroscopia fue el íleo paralítico, 2 casos, y se asoció a no utilizar insuflación con dióxido de carbono durante el procedimiento. Conclusiones: La hemorragia digestiva oscura fue la principal indicación para realizar una enteroscopia asistida por balón simple. Los diagnósticos más frecuentes fueron angiodisplasias, úlceras yeyuno ileales y neoplasias a nivel del intestino delgado. La complicación más frecuente fue el íleo paralítico y se asoció a no utilizar insuflación con dióxido de carbono durante el procedimiento.

Objetive: To describe our experience with single balloon enteroscopy in the management of small bowel disease in British American Hospital, Lima - Perú. Material and methods: Descriptive and prospective study. We include all patients that come to perform a single balloon enteroscopy in small bowel unit of British American Hospital within December 2012 to December 2018. Results: We performed 80 procedures of single balloon enteroscopy, 49 were done by oral approach, 31 by rectal approach. Mean age were 60.78 years-old (20 - 88 years). 48 patients (60%) were male. The mean insertion time for oral approach was 80 minutes (55-141 minutes), and for rectal approach was 110 minutes (55-180 minutes). The main indication for single balloon enteroscopy was obscure gastrointestinal bleeding. 6 enteroscopies were performed in patients with altered surgical anatomy (7.5%). 70 of 80 procedures (87.5%) were performed with gastroenterology-administered sedation, using midazolam, pethidine and propofol, without any respiratory or hemodinamic complication. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure. Conclusion: Obscure gastrointestinal bleeding was the main indication for single balloon enteroscopy. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure

Flebectasia yeyunal como causa de hemorragia digestiva media masiva / Jejunal phlebectasia as a cause of massive gastrointestinal hemorrhage

Las anormalidades vasculares del tracto gastrointestinal son una causa común de sangrado digestivo. La mayoría se localizan al alcance de la endoscopía digestiva alta y/o colonoscopía, una vez descartado ello, obliga a considerar al intestino delgado como causa de la hemorragia. El manejo exitoso de una hemorragia digestiva depende principalmente de la localización oportuna de la fuente del sangrado, sin embargo esta tarea puede ser difícil, cuando la causa no está al alcance de los métodos convencionales. Presentamos el caso de un paciente varón de 21 años cuyo diagnóstico fue una flebectasia yeyunal sangrante, luego de una cuidadosa evaluación de los hallazgos de la cápsula endoscópica y laparoscopía.

Vascular abnormalities of the gastrointestinal tract are a common cause of gastrointestinal bleeding. Most of them are located within the reach of the upper endoscopy or colonoscopy, although once discarded, it forces to consider small bowel as the source of bleeding. The successful management of a gastrointestinal bleeding depends mainly on the timely location of the source of bleeding. Nevertheless this task can be difficult when the cause is not within the reach of conventional methods. We present a case of a 21 year-old men in which the diagnosis of bleeding yeyunal phlebectasia was made by the findings of the capsule endoscopy and laparoscopy.

Perioperative approach of patient with takotsubo syndrome / Abordagem perioperatória de doente com síndrome de takotsubo

Abstract Introduction: Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy. It is characterized by an acute onset of symptoms and electrocardiographic abnormalities mimicking an acute coronary syndrome in the absence of obstructive coronary artery disease. Any anesthetic-surgical event corresponds to a stressful situation, so the anesthetic management of patients with TCM requires special care throughout the perioperative period. We describe the anesthetic management of a patient with a confirmed diagnosis of TCM undergoing segmental colectomy. Case report: Female patient, 55 years old, ASA III, with history of takotsubo syndrome diagnosed 2 years ago, scheduled for segmental colectomy. The patient, without other changes in preoperative evaluation, underwent general anesthesia associated with lumbar epidural and remained hemodynamically stable during the 2 h of surgery. After a brief stay in the Post-Anesthesia Care Unit, she was transferred to the Intermediate Care Unit (IMCU), with epidural analgesia for postoperative period. Conclusion: TCM is a rare disease which true pathophysiology remains unclear, as well as the most appropriate anesthetic-surgical strategy. In this case, through a preventive approach, with close monitoring and the lowest possible stimulus, all the perioperative period was uneventful. Because it is a rare disease, this report could help to raise awareness about TCM.

Resumo Introdução: A miocardiopatia takotsubo (MT) é uma miocardiopatia induzida pelo estresse. Caracteriza-se por um início agudo de sintomas e alterações eletrocardiográficas que mimetizam uma síndrome coronária aguda na ausência de doença arterial coronária obstrutiva. Qualquer evento anestésico-cirúrgico corresponde a uma situação de estresse, pelo que a abordagem anestésica dos doentes com MT exige um cuidado especial em todo o período perioperatório. Descrevemos a abordagem anestésica de uma doente com diagnóstico confirmado de MT submetida a colectomia segmentar. Caso clínico: Paciente do sexo feminino, 55 anos, ASA III, com antecedentes de síndrome de takotsubo diagnosticada havia dois anos, encaminhada para colectomia segmentar. A paciente, sem outras alterações na avaliação pré-operatória, foi submetida a anestesia geral associada a epidural lombar e manteve-se hemodinamicamente estável durante as duas horas do procedimento cirúrgico. Após uma breve permanência na Unidade de Cuidados Pós-Anestésicos foi transferida para a Unidade de Cuidados Intermédios (UCIM) com analgesia peridural para o pós-operatório. Conclusão: A MT é uma doença rara, cuja verdadeira fisiopatologia continua por esclarecer, assim como a estratégia anestésico-cirúrgica mais apropriada. Nesse caso, por causa de uma abordagem preventiva, com monitoração rigorosa e o menor estímulo possível, todo o perioperatório decorreu sem intercorrências. Sendo uma doença rara, o seu relato poderá contribuir para o avanço do conhecimento sobre a MT.

A Case of Spontaneous Bacterial Peritonitis Following Argon Plasma Coagulation for Angiodysplasias in the Colon / 대한소화기학회지

Spontaneous bacterial peritonitis (SBP) is the most common infection in liver cirrhosis patients, and is not a result of surgery or intra abdominal infection. Argon plasma coagulation (APC) is an endoscopic procedure used with a high-frequency electrical current for control of bleeding from gastrointestinal vascular ectasias including angiodysplasia and gastric antral vascular ectasia. This procedure is known to be safe because it uses a noncontact method. Therefore, tissue injury is minimal and up to two to three millimeters. However, we experienced a case of SBP occurring immediately after performance of APC for control of severe bleeding from angiodysplasia in the colon in a patient with liver cirrhosis and hepatocellular carcinoma.

Sangramento gastrintestinal por angiodisplasia e estenose aórtica: síndrome de Heyde / Gastrointestinal bleeding due to angiodysplasia in a patient with severe aortic stenosis: Heyde's syndrome

Existe uma associação frequente entre estenose valvar aórtica e sangramento gastrintestinal, também conhecida como síndrome de Heyde. A base fisiopatológica dessa síndrome parece ser uma deficiência adquirida do fator de von Willebrand, que leva ao sangramento de malformações arteriovenosas angiodisplásicas. As alternativas de tratamento incluem a localização de pontos de sangramento e a cauterização, mas tal opção terapêutica está associada a alta recorrência. A substituição da válvula parece oferecer a melhor esperança de resolução a longo prazo do sangramento e deve ser considerada na maioria das vezes. Relatamos aqui o caso de uma paciente de 79 anos com estenose aórtica e sangramento gastrintestinal devido à angiodisplasia duodenal, tratada por implante transcateter de válvula aórtica.

There is a frequent association between aortic valve stenosis and gastrointestinal bleeding, also known as Heyde's syndrome. The pathophysiologic basis for this syndrome seems to be an acquired von Willebrand factor deficiency, leading to bleeding of angiodysplastic arteriovenous malformations. Treatment options include the location and cauterization of bleeding points, which is associated to high recurrence rates. Valve replacement appears to offer the best hope of long-term resolution of bleeding, and should be considered in most cases. We report a 79 year-old patient with aortic stenosis and gastrointestinal bleeding due to duodenal angiodysplasia treated by transcatheter aortic valve implantation.

Radiología intervencional en hemorragia digestiva / Interventional radiology in gastrointestinal bleeding

Gastrointestinal (GI) hemorrhage is characterized into upper and lower bleeding, divided anatomically by the ligament of Treitz. 85 percent of GI bleeding will resolve with supportive measures alone, whil interventions are reserved for those patients failing this treatment. In this first instance upper GI bleeding will go to the endoscopist with high rates of success in both finding the site of hemorrhage and treating. Upper GI bleeders will usually only come to interventional radiologist (IR) when endoscopy fails. Acute lower GI bleeding is more difficult because it is more intermittent, and the efficacy of endoscopy (especially in the unprepared bowel) is much less. Consequently, in most practices the first interventionalist involved in this cohort are the IRs. This presentation will detail which patients should undergo embolization, when and how.

La hemorragia gastrointestinal (HG) se divide en hemorragia alta y baja en base al ligamento de Treitz. Ochenta y cinco por ciento de la HG cesa espontáneamente; las intervenciones están reservadas para aquellos pacientes en que falla el manejo conservador. En primera instancia, la HG alta es de manejo endoscópico con una alta tasa de éxito en el diagnóstico y tratamiento. Los pacientes con HG alta deberán ser intervenidos por radiología intervencional (RI) cuando la endoscopia falla. La HG baja aguda es compleja debido a su intermitencia, y la eficacia de la endoscopia (especialmente en el intestino no preparado) es mucho menor. Consecuentemente, en la mayoría de los casos la RI estará involucrada como primer peldaño en este algoritmo. Esta presentación detalla qué pacientes requieren embolización, cuándo y cómo.

GIST Yeyunal con Sangrado Digestivo de Origen Oscuro / Jejunal GIST with obscure gastrointestinal bleeding

Reportamos el caso de una mujer de 84 años con antecedentes de arritmia cardiaca y hemorroides. Tenía múltiples hospitalizaciones y transfusiones por anemia ferropénica sintomática; los estudios endoscópicos solo demostraron divertículos y pequeños pòlipos de colon. Posteriormente fue hospitalizada por presentar heces sanguinolentas de color rojo vinoso; la endoscopia alta indicó gastritis y la colonoscopia mostró pequeñas úlceras colónicas, un pólipo colónico y múltiples divertículos. Meses después, reingresó con hemorragia de origen oscuro; en esa ocasión se demostraron: gastritis, erosiones antrales, pequeños pólipos colónicos y úlceras colónicas en vías de cicatrización; la cápsula endoscópica mostró probable angiodisplasia en yeyuno medio, la enteroscopia anterógrada detectó en yeyuno proximal algunas lesiones eritematosas sin evidencia de sangrado activo. Volvió a ser hospitalizada por melena y dolor abdominal, la endoscopia alta mostró angiodisplasias gástricas y duodenales que fueron tratadas. El último ingreso indicó un tiempo de enfermedad de dos años, el episodio se caracterizó por presentar deposiciones rojo vinosas y anemia. La endoscopia mostró angiodisplasia gástrica, que fue tratada con termocoagulación con argón plasma. En el examen no presentó signos de descompensación hipovolémica. Enfocado como un problema de hemorragia digestiva de origen oscuro se repitieron varios exámenes endoscópicos sin resultados. Resangró estando hospitalizada, se realizó cápsula endoscópica que demostró sangrado agudo en yeyuno, se complementó con nueva enteroscopia anterógrada que mostró lesiones ulceradas de yeyuno, se marcó el área con tinta china y se indicó laparotomía exploratoria. En la intervención quirúrgica se encontró en borde antimesentérico de yeyuno, una tumoración redondeada (6x6x4.5 cm) de crecimiento extraluminal, que comprometía la pared sin adherirse a otras estructuras; se realizó resección del tumor y anastomosis yeyuno-yeyunal. El estudio histológico -con inmunohistoquímica- del espécimen mostró que se trataba de un Tumor Estromal Intestinal (GIST), de riesgo intermedio, patrón histológico fusiforme, con escasas mitosis, dependiente de la capa muscular propia del intestino delgado. En conclusión el presente caso se trata de una mujer con un GIST yeyunal cuya presentación clínica fue una hemorragia de origen oscuro que constituyó un problema diagnóstico y que gracias al advenimiento de los nuevos procedimientos endoscópicos (enteroscopia y cápsula endoscópica) fue localizada y posteriormente extirpada quirúrgicamente.

We report the case of a woman of 84 years with a history of cardiac arrhythmia and hemorrhoids. She had multiple hospitalizations and transfusions for symptomatic iron deficiency anemia, endoscopic studies showed only small diverticula and colon polyps. He was later hospitalized with bloody stools red wines, upper endoscopy and colonoscopy showed gastritis, small colonic ulcers, colonic polyp and multiple diverticula. Readmitted with bleeding of obscure origin, on that occasion showed gastritis, antral erosions, small ulcers, colon polyps and colon ulcers in the process of healing, capsule endoscopy showed angiodysplasia in jejunum, anterograde enteroscopy detected some erythematous lesions in proximal jejunum without evidence of bleeding. Again hospitalized for melena and abdominal pain, upper endoscopy revealed gastric and duodenal angiodysplasia were treated. The last entry indicated a time of two years disease, the current episode with wine-red colored stools, Hb: 8.4 g, for which he received two units of PG. Endoscopy showed gastric angiodysplasia, which was treated with thermocoagulation (argon plasma). In the entrance examination showed no signs of hypovolaemic decompensation. Approached as a problem of obscure gastrointestinal bleeding were repeated several endoscopic examinations without results. She re-bled being hospitalized, capsule endoscopy was performed showing acute bleeding in the jejunum, complemented by new anterograde enteroscopy that showed ulcerated lesions of the jejunum, the area was marked with indian ink. Exploratory laparotomy was indicated. In the surgical intervention it was in edge antimesentérico of yeyuno, a round tumor (6x6 cm) of extraluminal growth, which compromised the wall without sticking to other structure, Resection of the tumor and jejuno-jejunal anastomosis was realized. The histological study with immunohistochemistry showed an Intestinal Stromal Tumor (GIST), intermediate risk, histological pattern fusiform, with scarce mitosis; the lesion was dependent on the muscularis propria of the small intestine. In conclusion, this case involves a woman with a jejunal GIST whose clinical presentation was hemorrhage of unknown origin which was a diagnostic problem and thanks to the advent of new endoscopic procedures (enteroscopy and capsule endoscopy) could locate the place of injury and subsequent surgery.

Uso de talidomida en sangrado recurrente por angiodisplasias gastrointestinales: Caso clínico / Thalidomide for recurrent gastrointestinal bleeding caused by angiodysplasia: Report of one case

Chronic hemodialysis patients may have recurrent bleeding from gastrointestinal angiodysplasia, that often is diffusely located in the digestive tract or in places difficult to reach with traditional endoscopes. Therefore, they cannot be locally treated or removed. We report a 70 years old man on chronic hemodialysis, with severe and persistent anemia due to bleeding from angiodysplasia of the small bowel. Despite administration of high doses of erythropoiesis stimulating agents, intravenous iron, folate, B6 and B12 vitamins, his hemoglobin levels were < 6.5g/dL, becoming totally dependent on transfusions ofred blood cells (up to 46 units per year). Recurrent bleeding was refractory to conventional management and we decided to use thalidomide at doses of 50-100 mg/day achieving rapid control of gastrointestinal bleeding and significant increase of hemoglobin levels, not requiring further transfusions.

Hypertension due to angiodysplasia.

Renovascular hypertension is non essential hypertension, wherein anatomically evident arterial occlusive disease and increased blood pressures are related as cause and effect. The hypertension is due to renal ischemia. Angiodysplasia is an uncommon angiopathy associated with heterogeneous histological changes that may affect the carotid circulation and the visceral and peripheral arteries.

Angiodisplasia yeyunal como causa de sangrado de origen desconocido / Jejunal angiodysplasia as a cause of obscure gastrointestinal bleeding

BACKGROUND: Obscure gastrointestinal bleeding secondary to jejunal angiodysplasia is uncommon. Diagnostic approach is difficult and represents a challenge for the surgeon because of the inaccessibility of the small bowel for evaluation. When the diagnostic work-up has been completed and the bleeding source has not been found, it is mandatory to perform a surgical exploration with transoperative enteroscopy in order to locate the source of the hemorrhage and for further treatment. CASE REPORT: We report the case of a 24-year-old male with massive gastrointestinal bleeding secondary to jejunal angiodysplasia in whom an intraoperative enteroscopy was done to locate the source of bleeding and subsequently resect the affected small bowel. There are actually some non-surgical therapies for patients with high risk of complications. When patients' conditions are optimal, surgical resection is mandatory to avoid recurrence of future bleeding.

Diagnosis and treatment of hematochezia: guideline for clinical practice.

Hematochezia as an acute and chronic lower gastrointestinal bleeding could be caused by diverticulosis, angiodysplasia, neoplasm, perianal disorders, Meckel's diverticulum, colitis (infectious and non-infectious) intussusception, and many others. Lower gastrointestinal bleeding mostly occurs in older age. Mortality caused by acute and chronic lower gastrointestinal bleeding is very high. On the other hand, there are difficulties in clinical practice to find the cause and making the diagnosis and therapy for hematochezia. Fortunately, the progress and development in medical technology, especially colonoscopy and arteriography, has assisted in clinical practice.

Curso de Atualização em Emergências Médicas: aula 5: Hemorragia digestiva aguda baixa / Updating in Medical Emergencies Course: class 5: Lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGB) is defined as trat arising below the Treitz.

Em aproximadamente 95 por cento dos casos, entretanto, é proveniente do cólon. A forma de apresentação típica da HDB é hematoquezia, e na maioria dos pacientes o sangramento tende a ser autolimitado. A incidência de HDB eleva-se com a idade, e suas diferentes causas variam de acordo com a faixa etária dos pacientes estudados.

Hemorragia digestiva baja: [revisión] / Low gastrointestinal bleeding: [review]

La hemorragia digestiva baja es una entidad que debe ser tratada por grupos multidisciplinarios interesados en esta patología, siguiendo algoritmos diagnósticos acordes a los centros donde actúan. En esta revisión se describen los aspectos fisiopatológicos de las patologías más frecuentes, como la enfermedad diverticular y las angiodisplasias. Se han revisado las ventajas y desventajas de cada uno de los procedimientos utilizados para el diagnóstico, tomando en cuenta la bibliografía nacional e internacional disponible. La parte final del trabajo pretende transmitir una visión práctica de la conducta a seguir en estos pacientes, especialmente en algunos aspectos relacionados al tratamiento quirúrgico.

Low gastrointestinal bleeding should be treated by multidisciplinary teams interested in this pathology. Proper algorithms should be used according to each institution common practice. Pathogenesis of diverticular disease and angiodysplasia are described, and a classification of low gastrointestinal bleeding is proposed. Advantages and disadvantages of the procedures used for the diagnosis and treatment have been reviewed, taken into consideration the available national and international bibliography. Finally, an overview of some practical aspects of the surgical decision and treatment is given.