ABSTRACT
Background and aim: Gastrointestinal (GI) bleeding is deemed "obscure" when upper and lower GI endoscopy reveal no bleeding site. While the term "overt" is used in cases where visible blood passage is observed or reported, cases without macroscopic bleeding stigmata are defined "occult". Although small bowel origin accounts for only about 5% of all GI bleedings, it makes up the majority of obscure GI bleedings. Diagnostic work-up and treatment of small bowel GI bleedings can be challenging, especially when overt bleeding symptoms are absent. Material(s) and Method(s): We report the case of a frail patient with multiple comorbidities and evidence of bleeding small bowel angiodysplastic lesions on videocapsule assisted enteroscopy (VCE). Device assisted enteroscopy (DAE), planned in order to treat the bleeding lesions, was delayed after the patient contracted SARSCoV- 2 infection. Eight weeks after, in the absence of clinical signs of bleeding, a device for real time luminal blood detection (HemoPillR acute, Ovesco) was applied to guide timing of enteroscopy. Result(s): The 71 year old male patient was on dual anti platelet therapy and had persistent clinical features of iron deficiency anemia (Hemoglobin 8,0g/dl). Upper and lower GI endoscopy were negative for potential bleeding sources. VCE showed three small lesions suspect for angiodysplasia within 1 to 13 minutes after pylorus passage. Upon recovery from SARS-CoV-2 infection and congestive heart failure with respiratory insufficiency, we administered HemoPillRacute orally, without previous bowel preparation. The measurement showed a peak HemoPillR-Index (HI max) at 1h 47min after capsule administration (Fig. 1) and was therefore indicative of a small bowel bleeding site, best approachable by antegrade oral route, in keeping with the prior VCE findings. On subsequent DAE, performed through spiral enteroscopy, the small bowel angiodysplastic lesions were successfully treated. [Figure presented] Conclusion(s): Our case report illustrates how a novel telemetric blood detection measurement was able to confirm luminal blood presence and successfully guide timing of therapeutic DAE in a patient with obscure-occult GI bleeding, without the need for repetition of VCE.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.
ABSTRACT
Since early December 2019, an outbreak of pneumonia of unknown etiology has been reported in Wuhan, China The pathogen was then named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) by WHO, and the illness caused by it was termed as the Coronavirus Disease 2019 (COVID-19). Currently, the disease has rapidly spread to the whole world and become an international public health emergency. Although the SARS novel coronavirus (SARS-CoV-2) or COVID-19 is a viral illness, in fact it is systemic illness in which most of the organ systems are affected with varying degree. There are various patterns of cardiovascular involvement in COVID 19. First, cardiovascular disease present as pre-existing comorbidity which becomes apparent or becomes more complicated and decompensated during COVID 19. Second, cardiovascular system involvement results due to systemic inflammatory response during the course COVID 19. Third, cardiovascular system can be affected during treatment due to the side effects of some medication or secondary hospital-acquired infections and complications. Arrhythmias, acute coronary syndrome (ACS), myocarditis, Heart Failure and cardiomyopathy are the most common cardiovascular disease in COVID-19. The Fourth Universal Definition of Myocardial Infarction defines myocardial injury (acute or chronic) as cTn concentrations >99th percentile upper reference limit (URL). In COVID-19, cardiac injury is believed to be through multiple overlapping factors such as severe inflammatory response with uncontrolled cytokine activation and/or direct injury due to Virus infiltration in cardiomyocytes through angiotensin-converting enzyme 2 (ACE 2) receptors. Increases in cardiac biomarkers, especially, cardiac troponin (cTn) are common in patients with COVID-19, particularly in patients with underlying cardiovascular conditions and severe COVID-19 presentations, and are associated with worse outcomes and mortality. Thus, it is evident that cardiac injury plays a significant role in the disease progression and outcome associated with COVID-19. Thus, it is reasonable to include the indicators of cardiac injury in the patient's diagnosis, triaging, treatment, and prognosis, while recognizing that their abnormality may not be related to direct coronary involvement. Incorporation of cardiac biomarkers measurement (cTn and/or B-type natriuretic peptide [BNP]) to a set of other inflammatory and thrombotic markers may facilitate the understanding of COVID-19 stages, risk profiles, and disease phenotypes. Baseline measurements can facilitate stage classification and initial triage, and serial measurements help with short- and long-term risk stratification (likelihood for survival and/or adverse events). This information is likely to be most beneficial in patients in whom disease stage and risk status is uncertain, as well as in patients in whom risk is particularly high. In both cases, cardiac biomarkers can help with decisions about COVID19 patients' triage, management, therapeutic treatment and level of care.