Acute gastrointestinal bleeding

Diagnosis and intervention in pediatric GI bleeding is the shared responsibility of pediatric endoscopists, radiologists, and surgeons. Brisk hemorrhage, though alarming, is most often self-limited; few cases require urgent surgery before diagnostic evaluation is accomplished. The choice between endoscopic and radiographic evaluation varies with the differential diagnoses being considered and with local referral patterns. Many imaging options exist for assessing GI bleeding in children, but these options are generally narrowed by clinical history and age-appropriate differential possibilities.     

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is responsible for 1% to 2% of all hospital admissions in the United States annually. An awareness of common and uncommon pathologies will allow the clinician to develop a plan for the diagnostic evaluation that will lead to a diagnosis and localization of the bleeding site. Successful diagnosis and subsequent treatment are dependent on selecting the diagnostic tests that pinpoint the bleeding source accurately and in the most cost-effective manner.     

Lower gastrointestinal tract bleeding

Lower GI bleeding can be slow and chronic or massive and fatal. ED evaluation of these patients begins with history directed at determining the severity and amount of bleeding, and eliciting symptoms of volume depletion. Physical examination determines orthostasis, exclusion of an upper GI source for bleeding, and rectal examination. Laboratory evaluation is directed at determining baseline status of hemoglobin/hematocrit and platelet adequacy, as well as assessing concomitant medical problems. Although many of these patients are elderly, resuscitation is vigorous and should not be deterred by other medical problems. Differential diagnosis can be broad in the ED, but the vast majority of bleeding is caused by diverticulosis or angiodysplasia. Diagnostic capabilities are limited in the ED, but our skill at stabilization and resuscitation has helped decrease morbidity and mortality in acute lower GI bleeding.     

Life-threatening gastrointestinal bleeding in Crohn disease

Massive gastrointestinal bleeding is a very rare complication in Crohn's disease. Its occurrence has been quoted as 1-2% in the literature. A case of a 16-year old boy is reported here, who had a three-year history of Crohn's disease. After a three-day's therapy of bronchopneumonia a massive rectal bleeding began and an emergency operation had to be made. Site of the bleeding was localised by intraoperative colonoscopy and an ileocolic resection was made. The patient recovered and has done well since. Some characteristics, diagnostic and therapeutic problems of the massive bleeding in Crohn's disease are discussed.     

Jejunal schwannoma in neurofibromatosis: an unusual cause of massive gastrointestinal bleeding

A patient who had the "fairy ring" finding shows another new radiographic presentation of pulmonary sarcoidosis that clinicians can add to the list of signs of the disease.     

Laser therapy for gastrointestinal bleeding

Lasers are important in the development of endoscopic treatment of gastrointestinal bleeding. Laser therapy was the first endoscopic therapy for hemostasis to be assessed in large numbers of randomized controlled trials. The evidence for efficacy of laser treatment of bleeding is greater than for any other endoscopic treatment method. No other therapy for GI bleeding has been as rigorously tested.     

Thermal therapy for gastrointestinal bleeding

Thermal therapies were the initial forms of endoscopic treatment for GI bleeding more than 20 years ago. Other new technologies have emerged, but thermal treatment with multipolar coagulation or heat probe therapy remains as good as newer techniques. Initial hemostasis rates continue to be 90% or greater. However, rebleeding in about 15% remains a problem. The devices are safe and generally affordable.     

Risk factors for gastrointestinal bleeding

Gastrointestinal bleeding sometimes causes life-threatening state. It is important to understand the underlining risk factors for prevention and treatment of this condition. In 1997, 81 patients with massive gastrointestinal bleeding were admitted to the life-saving center in Kyoto First Red Cross Hospital. In these patients, 14 subjects (17%) had been receiving hemodialysis. Eight patients (10%) were taking anti-coagulant or antiplatelet drugs. Eight patients (10%) had hypertension and were given calcium antagonists. Seven subjects (9%) had liver cirrhosis and/or hepatocellular carcinoma. Because these patients often fall into life-threating state, we must pay special attention to the prevention and cure for gastrointestinal bleeding. For example, it may be necessary to change to heparin free hemodialysis for patients having active bleeding. In anticoagulated patients, it may be required that sufficient hemostatic therapy without risking thromboembolic sequelae. In addition to careful managements, we have better to consider the eradication therapy for all of these high risk groups with Helicobacter pylori infection.     

Collagen diseases and gastrointestinal bleeding

The main lesion of the collagen diseases involves blood-connective tissue, so every collagen disease is a accompanied by gastrointestinal bleeding to some degrees. The concept of systemic vasculitis had been confused, but recently, the criteria for each disease has been established. In addition to these vasculitis, antiphospholipid syndrome, amyloidosis, NSAIDs, steroid and secondary infection caused by the use of immunosuppressant are the candidates for the cause of gastrointestinal bleeding in the collagen diseases. In this paper, we described concisely about the gastrointestinal bleeding in SLE, RA, and systemic vasculitis.     

Angiodysplasia in a jejunal diverticulum as an unusual cause of lower gastrointestinal bleeding

Recent findings of indoor exposure studies of chlorpyrifos indicate that young children are at higher risks to the semivolatile pesticide than had been previously estimated [Gurunathan et al., Environ Health Perspect 106:9-16 (1998)]. The study showed that after a single broadcast use of the pesticide by certified applicators in apartment rooms, chlorpyrifos continued to accumulate on children's toys and hard surfaces 2 weeks after spraying. Based on the findings of this and other research studies, the estimated chlorpyrifos exposure levels from indoor spraying for children are approximately 21-119 times above the current recommended reference dose of 3 microg/kg/day from all sources. A joint agreement reached between the U.S. Environmental Protection Agency and the registrants of chlorpyrifos-based products will phase out a number of indoor uses of the pesticide, including broadcast spraying and direct uses on pets. While crack and crevice treatment of insects (such as cockroaches and termites) by chlorpyrifos will still continue, it appears prudent to explore other insect control options, including the use of baits, traps, and insect sterilants and growth regulators. To ensure global protection, adequate dissemination of appropriate safety and regulatory information to developing regions of the world is critical, where importation and local production of chlorpyrifos-based products for indoor uses may be significant.     

Acute upper gastrointestinal bleeding in southern Saudi Arabia

PATIENT: A 62-year-old former miner with silicosis of the lungs but otherwise in good general condition presented with a solid nodule in the nasal left lid area for a duration of three months. Because of a central ulceration the reference diagnosis was basalioma. The tumour infiltrated the nasal part of the upper and lower eyelid and the tear ducts so that these were unrinseable. Similar lesions have been present since two years in other skin regions. METHODS: Two cutaneous biopsies confirmed the diagnosis of a Mycosis fungoides without detectable expression of the CD30-antigen. Medical investigation finally revealed hepatosplenomegaly and cervical, inguinal and abdominal lymph node involvement. A lymph node biopsy three months after presentation again showed a T-cell-lymphoma which was CD30-positive now. THERAPY: Systemic polychemotherapy was started. The lid lesions completely resolved, and the tear ducts were rinseable again.     

Endoscopic injection treatment of gastrointestinal bleeding in hemophiliacs

The aims of this prospective study were to determine the patterns of gastrointestinal (GI) bleeding in hemophiliacs and to assess the hemostatic effect of injection therapy with alcohol. During a 5-year period (1990-1994) 89 hemophiliacs were admitted to our department with acute GI bleeding. Among these patients duodenal ulcer was found endoscopically to be the most common (42.7%) cause of hemorrhage; gastric ulcer was the source of the bleeding in only three patients (3.4%). A group of 46 patients met the criteria of active or recent bleeding and underwent injection therapy with alcohol. The injected bleeding lesions were duodenal ulcer in 32 patients, duodenal erosion in 2, gastric ulcer in 3, and other gastric lesions (Mallory-Weiss tear, Dieulafoy lesion, stomal ulcer, erosions) in 9 patients. Initial hemostasis was achieved in 100% and permanent hemostasis in 82.6%. Rebleeding was observed in eight patients (17.4%), with five of them successfully treated by reinjections. Three patients (6.5%) required emergency surgery. The mortality rate in the group of injected patients was 2.2%. One patient died of stroke on day 10 after partial gastrectomy. All injected patients were given replacement therapy with factor VIII or IX for 2 days (29 patients) or 7 to 14 days (17 patients). Analysis of the hemostatic effect achieved in these two subgroups indicate that short-term replacement therapy (2 days) may be sufficient to ensure adequate hemostasis in hemophiliacs. The results of the present study indicate that injection therapy with alcohol is an effective, safe, proved method to control GI bleeding in hemophiliacs.     

Computer-generated correspondence for patients attending an open-access chest pain clinic

AIM: To determine whether general practitioners (GPs) prefer structured computer-generated or standard dictated outpatient clinic letters. DESIGN: Questionnaire survey of all GPs referring patients to an open-access chest pain clinic at a district general hospital in London. The GPs were asked to compare three twinned examples of structured computer-generated and unstructured dictated letters. RESULTS: Of 93 respondents (response rate 77.5%), 75 (80.6%) preferred the computer-generated letter and 16 (17.2%) preferred the dictated letter (p < 0.0005). The preferred features of the computer-generated letter were its clear presentation, subheadings, and concise information. The computer-generated letter scored significantly higher than the dictated letter: for clarity, mean 8.2 vs 6.5 (p < 0.0005); content, mean 8.5 vs 6.9 (p < 0.0005); and readability, mean 8.2 vs 6.8 (p < 0.0005). The GPs in the survey considered a mean delay of 3.4 days to be acceptable for receiving the letter from the chest pain clinic. CONCLUSION: GPs prefer structured computer-generated letters to unstructured dictated letters for patients referred to an open-access chest pain clinic. Computer-generated correspondence allows rapid feedback of information to the referring GP, one of the key requirements of open-access clinics.     

The role of nuclear medicine in acute gastrointestinal bleeding

In most patients with upper gastrointestinal (GI) bleeding endoscopy will locate the site and cause of bleeding, and also provide an opportunity for local therapy. The cause of lower GI bleeding is often difficult to attribute, even when pathology is found by colonoscopy or barium enema. Nuclear medicine techniques can be used to identify the site of bleeding in those patients in whom the initial diagnostic procedures are negative or inconclusive. Methods using transient labelling of blood (e.g. 99Tcm-sulphur colloid) produce a high target-to-background ratio in positive cases, give quick results and localize bleeding sites accurately, but depend upon bleeding being active at the time of injection. Techniques using stable blood labelling (e.g. 99Tcm-labelled red blood cells) may be positive even with intermittent bleeding but may take several hours to produce a result and are less precise in localization. In order for these methods to become more widely accepted by physicians and surgeons, and for them to be cost-effective, patients should be carefully selected. The most useful application is in patients with recurrent or prolonged bleeding, those with inconclusive endoscopy or barium studies, and those who are high-risk surgical candidates.