Upper gastrointestinal haemorrhage: predictive factors of in-hospital mortality in patients treated in the medical intensive care unit.

This prospective, cohort study assessed the independent predictors of in-hospital mortality in patients with acute upper gastrointestinal haemorrhage admitted to the medical intensive care unit (MICU) at the University Clinical Centre Maribor, Slovenia. Using univariate, multivariate and logistic regression methods the predictors of mortality in 54 upper gastrointestinal haemorrhage patients (47 men, mean ± SD age 61.6 ± 14.2 years) were investigated. The mean ± SD duration of treatment in the MICU was 2.8 ± 2.9 days and the mortality rate was 31.5%. Significant differences between nonsurvivors and survivors were observed in haemorrhagic shock, heart failure, infection, diastolic blood pressure at admission, haemoglobin and red blood cell count at admission, and lowest haemoglobin and red blood cell count during treatment. Heart failure (odds ratio 59.13) was the most significant independent predictor of in-hospital mortality. Haemorrhagic shock and the lowest red blood cell count during treatment were also important independent predictive factors of in-hospital mortality.

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy in the elective treatment of recurrent variceal bleeding.

The present study was designed to compare elective transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic sclerotherapy (EST) in terms of their efficacy in preventing recurrent bleeding from gastro-oesophageal varices in patients with advanced liver cirrhosis and portal hypertension. Of 96 patients with at least three gastro-oesophageal variceal rebleeds, 50 were treated with elective TIPS and 46 with EST. Recurrent variceal bleeding was significantly more frequent in patients receiving EST treatment compared with those receiving TIPS (45.7% versus 6.3%, respectively). Cumulative 1- and 4-year survival in the TIPS group was 83.0% and 73.5%, respectively, compared with 69.8% and 39.8% in the EST group, respectively. The rate of portosystemic encephalopathy was 33.3% in the TIPS group and 37.0% in the EST group. Elective TIPS was more effective than EST in the prevention of gastro-oesophageal variceal rebleeding in cirrhotic patients, it improved survival and it was associated with a similar rate of portosystemic encephalopathy.

Splenic rupture in systemic amyloidosis - case presentation and review of the literature.

INTRODUCTION: Splenic rupture and hemorrhage into the abdominal cavity is an extremely unusual and rare complication of internal disease. Hemopathies, inflammatory or infiltrative diseases affecting the spleen are possible causes for such a complication. Splenomegaly is a factor, which may significantly increase the risk of rupture. CASE REPORT: The authors present the case of a 52-year-old patient with established systemic amyloidosis. In the past he had received treatment for undefined hepatic disease and anemia, which was established during the treatment of pathological vertebral fractures. Unfortunately, during the initial treatment he did not consent to a liver biopsy, which would have determined the etiology of the disease. Systemic infiltrative disease, affecting the spleen and other organs, was confirmed posthumously. Described are those forms of amyloidosis which usually represent an unfavorable course of the disease. CONCLUSION: Presented is a patient with a rare form of primary amyloidosis and fatal complication, spleenic rupture.

Emphysematous gastritis -- case report and review of the literature.

Emphysematous gastritis is a rare form of phlegmonous gastritis caused by invasion of the stomach wall by gas-forming bacteria. This clinical entity was first described by Fraenkel in 1889. The authors report the case of a 58-year-old patient with end-stage renal failure under treatment with hemodialysis for the past year. He was admitted on account of pain in the lower abdomen. During the diagnostic procedure, emphysematous gastritis and acute cholecystitis were confirmed. An acute abdomen developed and an emergency laparotomy was performed. During the procedure, the necrotic gallbladder was removed. The patient died on the following day due to multiorgan failure and septic shock. According to the literature, emphysematous gastritis is generally a fatal disease. Air in the wall of the stomach is a rare finding with a broad differential diagnosis.

Acute hemorrhage into the peritoneal cavity--a complication of chronic pancreatitis with pseudocyst: a case report from clinical practice.

Acute hemorrhage due to a pseudocyst of the pancreas is a dangerous complication of chronic pancreatitis (CP). Without operative treatment, mortality is as high as 90%. Immediate recognition of this complication as well as urgent operative treatment allowing the survival of 70% of patients is imperative. Described is the case of a patient with CP and pseudocyst in which hyperamylasemia and unclarified anemia developed following sudden abdominal pain. The suspicion of hemorrhage into the peritoneal cavity was confirmed by selective visceral angiography showing hemorrhage from the splenic artery in the region of the hilus of the spleen. Operative treatment was successful. During the procedure, a ligature was applied to the hemorrhaging splenic artery and a splenectomy was carried out with 2500 ml of bloody contents being removed from the abdominal cavity. Acute hemorrhage into the peritoneal cavity as a complication of chronic pancreatitis with pseudocyst (CPP) requires immediate identification, confirmation by visceral angiography, and urgent operative treatment.

An unusual clinical course of a hormone-secreting gastrointestinal tumor: a case presentation from clinical practice.

The gastrinoma was first described in 1955 by the surgeons Zollinger and Ellison. The basic characteristic of this disease is an endocrine tumor of the gastrointestinal tract, which secretes gastrin. There is a hypersecretion of gastric juice and recurrent gastric, duodenal and jejunal ulcers. Herein, the case of a 49 year-old female is presented. In 1982, two liver tumors, sized 10 and 6 cm, were discovered in the right and left lobes of the liver, respectively. A duodenal ulcer was also found. During explorative laparotomy, a liver biopsy specimen was obtained and defined pathohistologically as a metastatic, small cell epithelial tumor with an organoid endocrine pattern, morphologically corresponding to tumors of the APUD (Amine Precursor Uptake and Decarboxylation) series. The gastrinoma was verified by immunohistochemical staining. Serum gastrin values exceeded normal values by 10 times. The patient refused further treatment at that time. In the following years, she was treated conservatively several times for sequelae of ulcer disease. For the past three years, she has been treated as an outpatient, mostly for chronic diarrhea.

Endoscopic hemostasis in exulceratio simplex-Dieulafoy's disease hemorrhage: a review of 25 cases.

BACKGROUND AND STUDY AIMS: Dieulafoy's disease is a rare cause of upper gastrointestinal tract hemorrhage. The aim of the study was to evaluate the efficacy of endoscopic hemostasis and to analyze the mortality of patients with hemorrhage due to Dieulafoy's disease. PATIENTS AND METHODS: The retrospective analysis included patients from our institution who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions in the period between January 1994 and December 1996. RESULTS: Twenty-five patients were examined (18 men and 7 women, average age 52.6, SD+/-15.3, range 25-78). In 20 patients endoscopic injection sclerotherapy was performed (diluted epinephrine 1:10,000 plus polidocanol 1%) and Nd:YAG laser photocoagulation in five patients. In all patients a total of 44 interventional endoscopies were carried out. Repeated endoscopic hemostasis did not prove successful in two patients (8%, 2 men), and they were treated operatively. During the postoperative period one patient died because of multiorgan failure. The total mortality rate of all patients in which endoscopic hemostasis was done was 16% (4/25). None of the 21 surviving patients had rebleeding on long-term follow-up (mean: 29.4 months). CONCLUSIONS: Endoscopic hemostasis is a major therapeutic advance in the management of Dieulafoy's disease hemorrhage. Interventional endoscopy has decreased the need for surgical management and significantly reduced mortality.

Does endoscopic hemostasis effect the reduction of mortality in patients with hemorrhage from the digestive tract?

BACKGROUND/AIMS: Endoscopy is the method of choice for localizing the sites of hemorrhage and transendoscopic hemostatic procedures in patients with hemorrhage from the digestive tract. The aim of the study was to establish the efficacy of endoscopic hemostasis and to analyze the mortality of patients with upper digestive tract hemorrhage. METHODOLOGY: The retrospective analysis included those patients who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions with injection sclerotherapy, laser photocoagulation or electrocoagulation of the hemorrhaging spot in the period between January 1994 and May 1995. RESULTS: 1000 patients were examined, 638 men and 362 women. In only 312 patients (31.2%) the examination revealed signs of acute or recent hemorrhage. Hemostatic interventions were performed in 275 (27.5%) cases. During hospitalization at the medical wards, 14 (9/275, 5.1%) patients died. In 9 patients (9/275, 3%) with acute hemorrhage, endoscopic hemostasis did not prove successful, therefore after several unsuccessfully repeated endoscopic interventions (21 in all), the patients were treated operatively. During the postoperative period, 4 patients died due to complications. CONCLUSIONS: Despite the development of endoscopic instruments and improved methods of hemostasis, mortality due to hemorrhage from the digestive tract has not dramatically decreased. Numerous demanding endoscopic procedures are usually carried out in older patients which also suffer from other diseases. These diseases represent the risk factors for eventual surgical treatment and the ensuing complications.

The epidemiology of hemorrhage from the upper gastrointestinal tract in the mid-nineties--has anything changed?

BACKGROUND/AIMS: Gastrointestinal hemorrhage is a frequent medical problem and a significant cause of morbidity and mortality. The aim of this retrospective analysis, which was carried out at our institution, was to establish the causes of hemorrhage from the upper digestive tract during a 3-year period. METHODOLOGY: The retrospective study includes those patients in which urgent endoscopic investigations of the upper digestive tract were carried out between 1 January 1994 and 31 December 1996. RESULTS: 2150 patients were investigated: 797 women and 1353 men. The average age of our patients was 57 years (a 3-97 year span, SD+/-17). In 665 patients (35.8%), endoscopic investigation of the upper digestive tube revealed signs of acute hemorrhage or traces of previous hemorrhage. Endoscopic hemostasis was carried out in 577 cases (31.1%). Sequelae of ulcer disease were the cause of hemorrhage in 46.1% of investigated patients. Frequent causes of hemorrhage were also inflammatory, hemorrhagically-erosive changes of the gastric and duodenal mucosa (21.9%), ruptured esophageal varices (9.4%), and esophageal reflux disease (8.0%). In 13.6% of patients the cause of hemorrhage did not lie in the upper digestive tract. In 50.3% of cases the gastrointestinal hemorrhage manifested itself by the discharge of melenic feces, and in 33.1% by hematemesis. 47.2% of our patients were aged over 60. CONCLUSIONS: Also in our society sequelae of ulcer disease are the most significant cause of gastrointestinal hemorrhage. Hemorrhages are frequent in elderly patients who usually have accompanying diseases.

Superior vena cava syndrome: the significance of endosonography in diagnosing enlarged mediastinal lymph nodes--a case report.

Superior vena cava syndrome is a rare, life-threatening clinical entity associated with occlusion of venous outflow from the head, neck and upper extremities. It is usually caused by an intrathoracic neoplasm, thrombosis, an aneurysm, or external compression. Benign diseases rarely cause this syndrome. Malignant neoplasms, including lymphoma, lung cancer and breast cancer frequently cause this syndrome. Herein, the case of a 63-year old patient who developed superior vena cava syndrome and dysphagia is reported. Endosonographic and CT investigation of the mediastinum confirmed enlarged lymph nodes exerting pressure on the superior vena cava and the esophagus, particularly at the level of the aortic arch. Cytologic examination of the lymph node specimen confirmed metastatic adenocarcinoma of the lung. The patient was treated by radiotherapy of the right lung and mediastinum. Patients with mediastinal tumors or enlarged lymph nodes frequently have dysphagic problems due to pressure on the esophagus. Endoscopy usually confirms a constriction of the lumen, but it cannot determine the cause. Endoscopic ultrasonography makes a precise differentiation between submucosal tumors and the causes of exterior compression possible.

How efficient is endoscopic injection sclerotherapy in peptic ulcer hemorrhage.

BACKGROUND/AIMS: Peptic ulcer hemorrhage is a common, worldwide problem and a major cause of morbidity and mortality. The aim of this study was to establish the percentage of patients with bleeding peptic ulcers who were treated surgically because endoscopy failed to stop the hemorrhage. METHODOLOGY: This retrospective analysis includes patients from our institution who underwent urgent endoscopic examination of the upper digestive tract and hemostatic interventions with injection therapy (sol. 1:10000 adrenaline and 1% polidocanol) between January, 1994 and November, 1995. RESULTS: Two hundred thirty-three patients with bleeding peptic ulcers were examined: 111 with bleeding gastric ulcers (66 males, 45 females; average age 60.21 years, SD +/- 13.94; span 28-94 years) and 122 with bleeding duodenal ulcers (95 males, 27 females; average age 55.24 years, SD +/- 17.35; span 16-88 years). In all patients, injection sclerotherapy was performed. The ulcers were classified according to Forrest's classification of bleeding activity. In 10 patients (4.2%) with acute hemorrhage (6 males; average age 63.2 years, SD +/- 5.6; span 53-70 years: 4 females, average age 61.0 years, SD +/- 11.82; span 51-81 years), endoscopic hemostasis did not prove successful and they were treated operatively. In 5 cases, the cause of hemorrhage was a gastric ulcer and in 5 others, duodenal ulcer. During the postoperative period, 5 patients died of complications. CONCLUSIONS: Endoscopic hemostasis has been a major therapeutic advancement in the management of peptic ulcer hemorrhage and has influenced surgical management. Injection sclerotherapy is a low cost, effective and safe procedure which is easy to implement in a variety of clinical settings. Early elective operation after initial endoscopic hemostasis is the wisest choice for elderly patients with co-existing disease and selected patients at high risk for recurrent bleeding.