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Concept: Hematemesis

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GOALS:: To evaluate sources of upper gastrointestinal bleeding (UGIB) at an urban US hospital and compare them to sources at the same center 20 years ago, and to assess clinical outcomes related to source of UGIB. BACKGROUND:: Recent studies suggest changes in causes and outcomes of UGIB. STUDY:: Consecutive patients with hematemesis, melena, and/or hematochezia undergoing upper endoscopy with an identified source at LA County+USC Medical Center from January 2005 to June 2011 were identified retrospectively. RESULTS:: Mean age of the 1929 patients was 52 years; 75% were male. A total of 1073 (55%) presented with hematemesis, 809 (42%) with melena alone, and 47 (2%) with hematochezia alone. The most common causes were ulcers in 654 patients (34%), varices in 633 (33%), and erosive esophagitis in 156 (8%), compared with 43%, 33%, and 2% in 1991. During hospitalization, 207 (10.7%) patients required repeat endoscopy for UGIB (10.6% for both ulcers and varices) and 129 (6.7%) died (5.2% for ulcers; 9.2% for varices). On multivariate analysis, hematemesis (OR=1.38; 95% CI, 1.04-1.88) and having insurance (OR=1.44; 95% CI, 1.07-1.94) were associated with repeat endoscopy for UGIB. Varices (OR=1.53; 95% CI, 1.05-2.22) and having insurance (OR=4.53; 95% CI, 2.84-7.24) were associated with mortality. CONCLUSION:: Peptic ulcers decreased modestly over 2 decades, whereas varices continue as a common cause of UGIB at an urban hospital serving lower socioeconomic patients. Inpatient mortality, but not rebleeding requiring endoscopy, was higher with variceal than nonvariceal UGIB, indicating patients with variceal UGIB remain at risk of death from decompensation of underlying illness even after successful control of bleeding.

Concepts: Hospital, Colonoscopy, Gastroenterology, Peptic ulcer, Esophagogastroduodenoscopy, Upper gastrointestinal bleeding, Hematemesis, Melena

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Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy’s lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

Concepts: Gastroenterology, Peptic ulcer, Esophagogastroduodenoscopy, Hematemesis, Melena

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Melena is a symptom of upper gastrointestinal bleeding and usually indicates bleeding proximal to the ligament of Treitz. However, whether melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding (OGIB) is unknown and the objective of this study.

Concepts: Digestive system, Gastroenterology, Small intestine, Suspensory muscle of the duodenum, Hematemesis, Melena

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A Dieulafoy’s lesion is defined as a dilated, aberrant, submucosal artery that erodes overlying mucosa in the absence of an underlying ulcer, aneurysm or intrinsic mural abnormality. It is a rare cause of upper gastrointestinal (GI) bleed with a very high mortality rate if it goes unidentified. It is most commonly located in the lesser curvature of the stomach but is extremely rare in the oesophagus. We are reporting a 55-year-old man who had massive haematemesis. Emergent endoscopy showed Dieulafoy’s lesion in the distal oesophagus. It was sclerosed using endoscopic therapy. Patient’s symptoms of GI bleeding resolved, and he was discharged home in a stable manner. Although a Dieulafoy’s lesion is exceedingly rare in the oesophagus, it is associated with a high mortality if undiscovered. Its amenability to life-saving endoscopic therapy prompts us to keep this as a possible differential diagnosis of an upper GI bleed.

Concepts: Mortality rate, Colonoscopy, Gastroenterology, Stomach, Esophagogastroduodenoscopy, Upper gastrointestinal bleeding, Gastrointestinal bleeding, Hematemesis

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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.

Concepts: Medical emergencies, Gastroenterology, Bleeding, Upper gastrointestinal bleeding, Gastrointestinal bleeding, Hematemesis

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Hematemesis and acute postsurgical upper gastrointestinal hemorrhage are common emergent on-call consultations for the interventional radiologist. Upper GI bleleding (UGIB) is a relatively frequent problem. The incidence and mortality vary among patient populations, but studies have shown an overall incidence ranging from 36-172 cases per 100,000 adults per year, with a mortality rate of 5%-14%. The incidence is significantly higher in men. Peptic ulcer disease is the predominant etiology, responsible for 28%-59% of UGIB. Other causes include varices, mucosal erosive disease, Mallory-Weiss syndrome, and malignancy. After assessment of hemodynamic status and airway stability with resuscitative efforts as needed, initial consultation with gastroenterology for endoscopic evaluation and treatment is well regarded as the initial therapeutic strategy. Angiography with embolization and interventional techniques directed at managing variceal hemorrhage have emerged as very capable second-line strategies for patients who have failed endoscopic therapy. In certain circumstances, the interventional radiologist may be called upon as the first line, notably for patients who have had recent surgical intervention or who have extraluminal hemorrhage. As the role of the interventional radiologist in the evaluation and treatment of UGIB continues to evolve, familiarity and knowledge of how to deal with these urgent and emergent clinical scenarios becomes paramount.

Concepts: Surgery, Gastroenterology, Peptic ulcer, Esophagogastroduodenoscopy, Interventional radiology, Upper gastrointestinal bleeding, Hematemesis, Melena

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The aim of this study was to review the aetiology, presentation and management of these patients with upper gastrointestinal bleeding (UGIB) at a tertiary children’s unit in the United Kingdom. This was a retrospective single-institution study on children (<16 years) who presented with acute UGIB over a period of 5 years using known International Classification of Diseases (ICD) codes. A total of 32 children (17 males, 15 females) were identified with a total median age at presentation of 5.5 years. The majority (24/32) of patients presented as an emergency. A total of 19/32 presented with isolated haematemesis, 8/32 with isolated melaena and 5/32 with a combination of melaena and haematemesis. On admission, the mean haemoglobin of patients who presented with isolated haematemesis was 11 g/dL, those with isolated melaena 9.3 g/dL and those with a combination 7.8 g/dL. Blood transfusion was required in 3/19 with haematemesis and 3/5 with haematemesis and melaena. A total of 19/32 underwent upper gastrointestinal endoscopy. Endoscopic findings were oesophageal varices (5/19) of which 4 required banding; bleeding gastric ulcer (1/19) requiring clips, haemospray and adrenaline; gastric vascular malformation (1/19) treated with Argon plasma coagulation therapy; duodenal ulcer (3/19) which required surgery in two cases; oesophagitis (5/19); and gastritis +/- duodenitis (3/19). A total of 13/32 patients did not undergo endoscopy and the presumed aetiology was a Mallory-Weiss tear (4/13); ingestion of foreign body (2/13); gastritis (3/13); viral illness (1/13); unknown (2/13). While UGIB is uncommon in children, the morbidity associated with it is very significant. Melaena, dropping haemoglobin, and requirement for a blood transfusion appear to be significant markers of an underlying cause of UGIB that requires therapeutic intervention. A multi-disciplinary team comprising gastroenterologists and surgeons is essential.

Concepts: Gastroenterology, Stomach, Peptic ulcer, Esophagogastroduodenoscopy, Endoscopy, Upper gastrointestinal bleeding, Hematemesis, Melena

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CASE DESCRIPTION A 6-year-old castrated male Boxer was evaluated for a 5-week history of frequent vomiting, melena, and signs of abdominal pain following accidental ingestion of 5 to ten 15-mg meloxicam tablets (approx ingested dose, 3.1 to 6.2 mg/kg [1.4 to 2.8 mg/lb]). CLINICAL FINDINGS Clinical signs persisted despite 3 weeks of treatment with sucralfate (41.8 mg/kg [19 mg/lb], PO, q 8 h) and omeprazole (0.8 mg/kg [0.36 mg/lb], PO, q 24 h). Results of a CBC and serum biochemical analysis were unremarkable. Abdominal ultrasonography revealed peptic ulceration, and esophagogastroduodenoscopy confirmed the presence of severe proximal duodenal ulceration. TREATMENT AND OUTCOME A radiotelemetric pH-monitoring capsule was placed in the gastric fundus under endoscopic guidance for continuous at-home monitoring of intragastric pH and response to treatment. Treatment was continued with sucralfate (as previously prescribed) and omeprazole at an increased administration frequency (0.8 mg/kg, PO, q 12 h). Intragastric pH was consistently ≥ 3.0 for > 75% of the day during treatment, with the exception of 1 day when a single dose of omeprazole was inadvertently missed. Ulceration and clinical signs completely resolved. CLINICAL RELEVANCE Continuous radiotelemetric monitoring of intragastric pH in the dog of this report was useful for confirming that treatment achieved a predetermined target pH and for demonstrating the impact of missed doses. Duodenal ulceration resolved with twice-daily but not once-daily omeprazole administration. Findings suggested that twice-daily administration of omeprazole may be necessary to achieve this target pH and that a pH ≥ 3.0 for 75% of the day may promote healing of peptic ulcers in dogs.

Concepts: Dose, Abdominal pain, Stomach, Helicobacter pylori, Peptic ulcer, Dog, Esophagogastroduodenoscopy, Hematemesis

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We describe a rare case of a 60-year-old man with known history of peptic ulcer disease who presented with melena and epigastric pain secondary to coil migration into duodenal mucosa 4 years after the initial therapeutic embolisation of the gastroduodenal artery. Upper endoscopy revealed oozing duodenal ulcer at the same site of the previously located duodenal ulcer 4 years ago and metal coil impacted at the duodenal mucosa. It is unclear if the coil migration is the effect or the cause of the bleeding duodenal ulcer. Our patient was treated by surgical intervention due to failed endoscopic haemostasis and medical management.

Concepts: Medicine, Surgery, Gastroenterology, Stomach, Peptic ulcer, Esophagogastroduodenoscopy, Hematemesis, Melena

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Background and study aims: The hemostatic powder TC-325 (Hemospray; Cook Medical, Winston-Salem, North Carolina, USA) has shown promising results in the treatment of upper gastrointestinal bleeding (UGIB) in expert centers in pilot studies. The aim of this study was to evaluate the feasibility and efficacy of TC-325 in a large prospective registry of use in routine practice. Patients and methods: The data of all patients treated with TC-325 were prospectively collected through a national registry. Outcomes were the immediate feasibility and efficacy of TC-325 application, as well as the rates of rebleeding at Day 8 and Day 30. Multivariate analysis was performed to determine predictive factors of rebleeding. Results: A total of 202 patients were enrolled and 64 endoscopists participated from 20 centers. TC-325 was used as salvage therapy in 108 patients (53.5 %). The etiology of bleeding was an ulcer in 75 patients (37.1 %), tumor in 61 (30.2 %), postendoscopic therapy in 35 (17.3 %), or other in 31 (15.3 %). Application of the hemostatic powder was found to be very easy or easy in 31.7 % and 55.4 %, respectively. The immediate efficacy rate was 96.5 %. Recurrence of UGIB was noted at Day 8 and Day 30 in 26.7 % and 33.5 %, respectively. Predictive factors of recurrence at Day 8 were melena at initial presentation and use of TC-325 as salvage therapy. Conclusion: These multicenter data confirmed the high rate of immediate hemostasis, excellent feasibility, and good safety profile of TC-325, which could become the treatment of choice in bleeding tumors or postendoscopic bleeding but not in bleeding ulcers where randomized studies are needed.

Concepts: Randomized controlled trial, Tumor, Gastroenterology, Hemostasis, Peptic ulcer, North Carolina, Upper gastrointestinal bleeding, Hematemesis