Effect of acute upper gastrointestinal bleeding manifestations at admission on the in-hospital outcomes of liver cirrhosis: hematemesis versus melena without hematemesis.

OBJECTIVES: Patients with acute upper gastrointestinal bleeding (AUGIB) often manifest as hematemesis and melena. Theoretically, hematemesis will carry worse outcomes of AUGIB. However, there is little real-world evidence. We aimed to compare the outcomes of hematemesis versus no hematemesis as a clinical manifestation of AUGIB at admission in cirrhotic patients. METHODS: All cirrhotic patients with AUGIB who were consecutively admitted to our hospital from January 2010 to June 2014 were considered in this retrospective study. Patients were divided into hematemesis with or without melena and melena alone without hematemesis at admission. A 1:1 propensity score matching analysis was performed. Subgroup analyses were performed based on systemic hemodynamics (stable and unstable) and Child-Pugh class (A and B+C). Sensitivity analyses were conducted in patients with moderate and severe esophageal varices confirmed on endoscopy. Primary outcomes included five-day rebleeding and in-hospital death. RESULTS: Overall, 793 patients were included. Patients with hematemesis at admission had significantly higher five-day rebleeding rate (17.4 versus 10.1%, P = 0.004) and in-hospital mortality (7.9 versus 2.4%, P = 0.001) than those without hematemesis. In the propensity score matching analyses, 358 patients were included with similar Child-Pugh score (P = 0.227) and MELD score (P = 0.881) between the two groups; five-day rebleeding rate (19.0 versus 10.6%, P = 0.026) and in-hospital mortality (8.4 versus 2.8%, P = 0.021) remained significantly higher in patients with hematemesis. In the subgroup and sensitivity analyses, the statistical results were also similar. CONCLUSIONS: Hematemesis at admission indicates worse outcomes of cirrhotic patients with AUGIB, which is useful for the risk stratification of AUGIB.

Severity and Outcomes of Upper Gastrointestinal Bleeding With Bloody Vs. Coffee-Grounds Hematemesis.

OBJECTIVES: Numerous reviews indicate bloody hematemesis signifies more severe bleeding than coffee-grounds hematemesis. We assessed severity and outcomes related to bleeding symptoms in a prospective study. METHODS: Consecutive patients presenting with hematemesis or melena were categorized as bloody emesis (N=1209), coffee-grounds emesis without bloody emesis (N=701), or melena without hematemesis (N=1069). We assessed bleeding severity (pulse, blood pressure) and predictors of outcome (hemoglobin, risk stratification scores) at presentation, and outcomes of bleeding episodes. The primary outcome was a composite of transfusion, intervention, or mortality. RESULTS: Bloody and coffee-grounds emesis were similar in pulse ≥100 beats/min (35 vs. 37%), systolic blood pressure ≤100 mm Hg (12 vs. 12%), and hemoglobin ≤100 g/l (25 vs. 27%). Risk stratification scores were lower with bloody emesis. The composite end point was 34.7 vs. 38.2% for bloody vs. coffee-grounds emesis; mortality was 6.6 vs. 9.3%. Hemostatic intervention was more common (19.4 vs. 14.4%) with bloody emesis (due to a higher frequency of varices necessitating endoscopic therapy), as was rebleeding (7.8 vs. 4.5%). Outcomes were worse with hematemesis plus melena vs. isolated hematemesis for bloody (composite: 62.4 vs. 25.6%; hemostatic intervention: 36.5 vs. 13.8%) and coffee-grounds emesis (composite: 59.1 vs. 27.1%; hemostatic intervention: 26.4 vs. 8.1%). CONCLUSIONS: Bloody emesis is not associated with more severe bleeding episodes at presentation or higher mortality than coffee-grounds emesis, but is associated with modestly higher rates of hemostatic intervention and rebleeding. Outcomes with hematemesis are worsened with concurrent melena. The presence of bloody emesis plus melena potentially could be considered in decisions regarding timing of endoscopy.

Importance of Heparin Provocation and SPECT/CT in Detecting Obscure Gastrointestinal Bleeding on 99mTc-RBC Scintigraphy: A Case Report.

We presented a pediatric case with a history of intermittent melena for 3 years because of angiodyplasia of small intestine. The results of frequent upper gastrointestinal endoscopies and colonoscopies as well as both Tc-red blood cell (RBC) and Meckel's scintigraphies for several times were negative in detection of bleeding site. However, Tc-RBC scintigraphy with single-photon emission computed tomography (SPECT)/computed tomography (CT) after heparin augmentation detected a site of bleeding in the distal ileum which later was confirmed during surgery with final diagnosis of angiodysplasia.It could be stated that heparin provocation of bleeding before Tc-RBC scintigraphy accompanied by fused SPECT/CT images should be kept in mind for management of intestinal bleeding especially in difficult cases.

Aorto-enteric fistulas: a physiopathological approach and computed tomography diagnosis.

Infection of an abdominal aortic prosthesis with an enteroprosthetic fistula is a very serious, life-threatening complication, leading sometimes to severe functional consequences, the most serious being amputation. Since the symptoms, if there are any, are often rather non-specific, diagnosis is frequently difficult and has always to be based on a whole series of justifications. Early diagnosis is essential and this fistula should be the first possibility considered in a patient with an abdominal aortic prosthesis who is presenting rectorrhagia or melaena (even if only to a slight degree), sepsis and/or abdominal pain. Although rare, the clinical existence of hypertrophic osteoarthropathy may assist diagnosis. A CT scan is the examination of choice, the criteria providing evidence of a fistula being the presence of gaseous images in a periprosthetic fluid collection, thickening and/or retraction of the intestinal walls in contact, the existence of a false aneurysm, and finally, very rarely, extravasation of contrast agent into the intestinal lumen. The differential diagnoses that may mimic a fistula need to be well known, and can include retroperitoneal fibrosis, an infectious aneurysm, inflammatory or infectious aortitis, and above all, a 'simple' prosthesis infection without fistulisation.

Esofagitis eosinofílica: a propósito de un caso / No disponible

La esofagitis eosinofílica es una enfermedad inusual y emergente en los últimosaños que se caracteriza por un infiltrado de más de 20 eosinófilos por campo de gran aumentoen la biopsia del tejido esofágico. Se describe en todas las edades aunque aparentementees más frecuente en niños. La etiología no está clara pero se sugiere que la atopiao las alergias juegan un rol importante en el desarrollo de la enfermedad. Lapresentación clínica es variada: la disfagia y la impactación alimentaria son las más frecuentes.No existe un tratamiento específico. Los corticoides tópicos deglutidos son losfármacos de elección, pero en niños con alergia alimentaria el tratamiento se basa endietas de exclusión. Presentamos el caso clínico de un niño de 12 años con antecedentede dermatitis atópica y alergia que es hospitalizado por presentar un cuadro de melenacon urticaria aguda. A su vez, se hace una breve revisión del diagnóstico y el tratamientode esta patología(AU)

Eosinophilic esophagitis is an unusual and emerging disease in the last years that is recognizedby the presence of more than 20 eosinophils per high-powered field on esophageal tissuebiopsy. It is described in all ages although apparently is more frequent in children. It is suggestedthat atopy or allergic mechanisms play an important role in the development of this diseasebut the etiology is not clear yet. The more frequent symptoms are dysphagia and food impactionamong the varied clinical manifestations. No specific treatments exist but topical swallowedsteroids are the first choice although an exclusion diet is preferred in children with foodallergy. We report the case of a 12-year-old child, suffering from atopic dermatitis and otherallergies, admitted to hospital for an episode of melena and urticaria and discuss the diagnosisand the treatment of this pathology(AU)

Bleeding Meckel's diverticulum in an adult.

Bleeding Meckel's diverticulum tends to be a complication of ectopic gastric mucosa. It has been known that the gastric acid and digestive fluid produced from the ectopic gastric mucosa cause peptic ulcer, which leads to bleeding. When the ectopic gastric mucosa is entirely formed by the pyloric gland, however, ulcer formation may result from factors other than gastric acid and digestive fluid. This is a report of an adult case of bleeding Meckel's diverticulum with ectopic gastric mucosa in whom mechanical stimulation was suggested as a cause of the erosion and ulceration, resulting in bleeding.

Biphasic diurnal periodicity in bleeding from peptic ulcer.

OBJECTIVE: To evaluate if there was periodicity in the manifestations of gastrointestinal bleeding (hematemesis and melena). METHOD: This is a multicenter prospective study carried out in the Endoscopy Units of eight hospitals. At the time of the emergency endoscopy, the following data were collected: age, sex, endoscopic diagnosis, solar hour of the first hematemesis (vomiting of bright red or tarry black material) and of the first melena (black or bloody soft stools), and any drugs taken during the week before the bleeding episode, regardless of the dose. RESULTS: 806 patients were studied. Bleeding was from peptic ulcer in 405 patients (50%), from esophageal varices in 197 (24%), and from other sources in the remainder. Analysis using single cosinor statistics showed a nonrandom distribution in bleeding from peptic ulcer, whether presenting first with hematemesis (p = 0.02) or melena (p = 0.03). There were two peaks at 6:45 AM and 6:45 PM for hematemesis and at 7:25 AM and 7:25 PM for melena, representing a biphasic diurnal (ultradian) rhythm. CONCLUSIONS: This study shows that bleeding due to peptic ulcer has a biphasic diurnal periodicity. This has potential importance for the pathogenesis of bleeding, for the management of gastrointestinal hemorrhage and the administration of drugs known to cause peptic ulcer bleeding.

[Bleeding of gastric ulcers. Epidemiologic, clinical and functional characteristics]. / Il sanguinamento da ulcera gastrica. Caratteristiche epidemiologiche, cliniche e funzionali.

The frequency of gastrointestinal haemorrhage due to gastric ulcer has been assessed in 254 personally observed patients suffering from this endoscopically verified pathology. 56 patients, namely 22% of the cases, presented haematemesis and/or melena of the ulcerative lesion. This subgroup was compared with 65 patients with endoscopically verified gastric ulcer without previous bleeding episodes from the lesion in their clinical history, in respect of certain epidemiological, clinical and biohumoral features. The purpose of the study was to check the possible existence of clinical and/or physiopathological differences between subjects with bleeding gastric ulcer and the population of non-bleeding ulcer patients. In 80% of patients studied, the gastric ulcerous disease started with digestive haemorrhage and it was not accompanied by dyspeptic-painful symptomatology in 20% of cases. The pain symptomatology does not appear to be influenced by the intake of non-steroid anti-phlogistic drugs. No significant difference emerges between the two groups considered as regards epidemiological features and biohumoral data (PG I, gastrin, B.A.O. and M.A.O.).

Appearance, properties, and origin of altered human hemoglobin in feces.

Altered hemoglobin (Hb) has been found in the feces as a sequel to an upper gastrointestinal bleed. Active Hb antigen of increased anodic mobility was detected on immunoelectrophoresis of melena stools using a goat anti-Hb. The Hb derivative was also identified in polyacrylamide gel electrophoresis using 412 nm. absorbance. The alteration could be simulated in vitro by incubation of hemolysate with duodenal juice or purified carboxypeptidase B alone, or by a mixture of carboxypeptidases A and B. Treatment of hemolysate or purified Hb with acid, gastric juice, pepsin, pancreatic juice, bile, trypsin, or chymotrypsin failed to produce the characteristic alteration. Instead, no change, or production of alpha and beta chains, or gradual but complete elimination of the Hb antigen was seen. This latter all or none pattern is presumed to prevail in the large bowel on the basis of incubations of hemoglobin-feces mixtures. Individuals documented to be bleeding into the colon were found to have at least a portion of their Hb antigen in the unaltered form by immunoelectrophoresis. This finding may be of value in identifying the general origin of a gastrointestinal bleed.

Comparative study between endoscopy and radiology in acute upper gastrointestinal haemorrhage.

A total of 158 patients with acute upper gastrointestinal haemorrhage were studied, and the 53 patients on whom emergency endoscopies were performed were compared with the remaining 105. The cause of the bleeding was found in 51 of the endoscopy group and 39 of the control group. Three patients in the endoscopy group and 16 controls died. In the endoscopy group the correct preoperative diagnosis was made in all cases and there was less delay before operation. In the control group five patients had no diagnosis before operation, the preoperative diagnosis was wrong in nine, and five had laparotomies during which no cause of bleeding was found. The patients in the endoscopy group who did not have operations had a shorter stay in hospital than the controls.