DOCSLIB.ORG

Lower and Obscure Gastrointestinal Bleeding

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Lower and Obscure Gastrointestinal Bleeding Lower And Obscure Gastrointestinal Bleeding Luis S. Marsano, MD Professor of Medicine University of Louisville and Louisville VAMC June 2012 Acute Lower Gastrointestinal Bleed Magnitude of the Problem • Incidence: 20/100,000 persons • Mortality: 3.6% (23% if starts in hospital) • Mean Age: 63‐77 • Source of Hematochezia: – 76% colon – 11% above Ligament of Treitz – 9% small bowel – 6 % unknown Etiology of Lower GI Bleeding Zuckerman G et al. Gastrointest Endosc 1999;49:228 • Diverticulosis: 33% • Colon Ca or polyps: 19% • Colitis (IBD, infectious, ischemic, radiation, vasculitis, etc.): 18% • Angiodysplasia: 8% • Other intestinal lesions (post‐polypectomy, Ao‐ enteric fistula, stercoral ulcer, etc.): 8% • Ano‐rectal: 4% • Unknown: 16% Heater Probe in Colonoscopy (Inject “Pillow” before burn; tattoo after) Lesion Probe Pressure Energy Pulses/ Site Ulcer 10 Fr Moderate 15 J 2 Stalk 10 Fr Moderate 15-20 J 2 Diverticuli 10 Fr Moderate 15 J 2 Cancer 10 Fr Moderate 20 J 2 Angiodys 7-10 Fr Light 10 J 1 plasia BICAP in Colonoscopy (Inject “Pillow” before burn; tattoo after) Lesion Probe Pressure Energy Time/ Site Ulcer 10 Fr Moderate 20 W 2 sec Stalk 10 Fr Moderate 20 W 2 sec Diverticuli 10 Fr Moderate 20 W 2 sec Cancer 10 Fr Moderate 20 W 2 sec Angiodys 7-10 Fr Light 15 W 1 sec plasia Common Causes of Lower Gastrointestinal Bleed Diverticular Bleed • Frequency: Occurs in 3‐15% of patients with diverticulosis • Causes 30‐50% of massive hematochezia. • Cause: Erosion of artery in dome of diverticulum. • Presentation: Painless maroon or red bleed • Location: Right colon 50‐90% (< 25% of tics are in this region) • Course: – Persistent bleed in 20% – Stops spontaneously in 75‐80% (90% of those needing < 4U PRBC); – 25% rebleed @ 4y • Treatment: – Endoscopic treatment (injection, BICAP, Heater Probe, banding, clip); if fails: – Arteriography + Intra‐arterial vasopressin is successful in 90%. Transcatheter embolization causes intestinal infarction in 20%. – Surgery: in 18% of those needing transfusion. Has 10% mortality. Blind segmental resection should not be done. Angiodysplasia of Colon • Prevalence in screening colonoscopy is 0.8%; – multiple in 40‐60%; – 20% have them in more than 1 portion of GI tract (eg: colon & SB). • Frequency of bleed: – Less than 10% of angioectasia patients bleed; – once they bleed, up to 50% rebleed. • Age: 2/3 are > 70 y old. • Presentation: – acute hemorrhage in 45%; – low grade blood loss in 55%. • Location: May have multiple lesions. – More frequent in Cecum (37%) & – Rt. Colon (17%), – Transverse and descending (7% each) – Sigmoid (18%) & – Rectum (14%) Angiodysplasia of Colon • Associations: – CKD (20‐30% of bleeds), – valvular heart dz., specially aortic stenosis (Heyde S.); • Ao valve replacement decreases bleeding risk. – von Willebrand, – latent acquired von Willebrand (eg: Aortic Stenosis or LVAD), – CREST, – HHT. • Diagnosis: – Endoscopy: Precautions; May “blanch” with narcotics, tense insufflation, or anemia. Can use Naloxone 0.4‐0.8 mg once in cecum, but has risk. Hemoclip is good choice if anticoagulation will be needed. – Angiography – CT angiography (yield 70‐100% as angiography) • Treatment: only if bleeding or in unexplained Fe deficiency. – Endoscopic; if fails, – Angio + intra‐arterial vasopressin (90% success). – Thalidomide 25 mg QID for refractory, transfusion dependent patients. – Octreotide 50 mcg SQ BID or Octreotide‐LAR monthly IM. Classification of Angiectasias LOCATION SIZE (S) NUMBER (N) Gastric (G) Minute (S1) = < 2 mm Unique (N1) = 1 Duodenal (D) Intermediate (S2) = 2 –5 Multiple (N2) = 2 ‐ 10 mm Jejunal (J) Large (S3) = > 5 mm Diffuse (N3) = > 10 Ileal (I) Colonic (C) Example: D‐ S3‐N3 Ischemic Colitis • Due to: – low flow state, – vasospasm, – small vessel dz., or – Occlusion (arterial or venous). • Types: – 85% non‐gangrenous; – 15% gangrenous. • Middle‐age or elderly patient. • Associations: Atherosclerosis, Ao surgery, DM, critical illness, hypotension, “pressors”, pseudoephedrine, IBS, COPD, constipation. • Symptoms: – abdominal cramps and tenderness over affected bowel (usually left side) followed with hematochezia. (Small bowel ischemia gives mid‐abdomen pain). – Usually bloody diarrhea dominates over pain, except in Isolated Right Colonic Ischemia (IRCI) where dominant symptom is pain. – Predictive factors: Age > 60, Hemodialysis, Hypertension, Hypoalbuminemia, Diabetes, Constipation induced medication. Spectrum and Pattern of Ischemic Colitis • Reversible • Right sided: 25.2% – Intramural hemorrhage, – More abdominal pain than colopathy. bloody diarrhea – Transient segmental colitis – More CAD, AF, ESRD – Stricture – Cause found in 22% • Irreversible – Males > females – Gangrenous infarction – Worse prognosis (LOS, – Persistent segmental colitis Surgery, and mortality) – Fulminant universal colitis – Consider CTA or MRA (acute • Other rare situations mesenteric ischemia). – Colitis simulating Cancer • Transverse: 10.2% – Colitis with distal obstruction • Left sided: 32.6% – Protein loosing enteropathy – Recurrent sepsis • Sigmoid/distal: 24.6% • Pancolitis: 7.3% Ischemic Colitis • Diagnosis: Clinical features plus: – X‐Ray: “thumbprinting” on colon in 30%; pneumatosis in advanced severe disease. – CT Scan: segmental wall edema; Necrosis if pneumatosis or portal venous air – Flex‐Sigm or colonoscopy; found most frequently on splenic flexure, descending, and sigmoid. Ischemic mucosa +/‐ ulcers. May have pseudomembranes. • Treatment: – IV fluid resuscitation + bowel rest, and antibiotics. – NGT for ileus. – Improve oxygenation and cardiac output. – Surgery (unprep) for intestinal gangrene. – Anticoagulation + hypercoagulability work‐up for acute mesenteric vein thrombosis. • Prognosis: – most improve in 1‐2 days, and resolve in 1‐2 weeks. – 20% develop chronic ischemic colitis with strictures, recurrent bacteremia, protein loosing enteropathy, bloody diarrhea and/or weight loss. May need resection. Radiation Colitis • Timing: – Acute: within 6 weeks of radiation, – Chronic: > 6 weeks; often 9‐14 months post‐radiation, up to 30 years. • Presentation: – Diarrhea, tenesmus and/or rectal pain, bleeding. – Less often obstructive symptoms from stricture, or incontinence. – Fistulas are uncommon. • Endoscopy: – friable pale mucosa and telangiectasias. – Biopsy over prostate could cause fistula. • Treatment: – Acute: Butyrate enemas. – Chronic: • Endoscopic: APC, BICAP, H‐P, Laser (65‐90% success). • Formalin Instillation. • Sucralfate enemas 2 gm in 20 mL saline or water BID. • Hyperbaric oxygen. • Mesalamine+Betamethasone Enema + oral Flagyl 400 mg BID Infectious Colitis • Frequently related to shiga toxin: – Shigella, Enterohemorrhagic E. Coli, Salmonella. – Also C. difficile, Klebsiella oxytoca, and campylobacter jejuni. • Less often: – CMV, Ameba, Mycobacterium avium, Yersinia. • Dx: Stool culture • Endoscopy: spotty colitis; Bx c/w ischemia Inflammatory Bowel Disease • Diarrhea and bleeding. • Tenesmus is frequent. • DX: Colonoscopy/sigmoidoscopy with compatible Bx and negative stool studies. Rectal Varices • Massive bleed is infrequent. • Painless hematochezia in patient with portal hypertension. • Need exam after volume resuscitation. • Treatment: – Banding or sclerotherapy. – May need TIPSS or non‐selective surgical shunt. Obscure‐Overt Gastrointestinal Bleeding Initial Evaluation Obscure‐Overt LGI bleed • Repeat EGD and Colonoscopy after – volume resuscitation, – correction of anemia, – perfect colon preparation, – without use of narcotics, (or with Narcan given before endoscope withdrawal). • If work‐up is non‐diagnostic: – Push‐Enteroscopy – Capsule Endoscopy – Balloon assisted, or Intra‐operative Enteroscopy Etiology of Mid GI Bleeding (Ampulla of Vater to TI) • Younger than 40 – Tumors (lymphoma, carcinoid, adenocarcinoma, polyposis) – Meckel’s – Dieulafoy – Crohn – Celiac disease • Older than 40 – Angiectasia (latent acquired von Willebrand, HHT, blue rubber bleb S.): 40% – NSAID enteropathy – Celiac disease • Uncommon – Hemobilia – Hemosuccus pancreaticus – Aortoenteric fistula – Kaposi, Ehlers‐Danlos, neurifibromatosis, Klippel‐Trenaunay‐Weber 1: Push Enteroscopy • Ideally with “Dedicated Video‐Enteroscope”, using an overtube – Spiral Enteroscopy with pediatric colonoscope as second choice. • Yield is highest when lesion is seen in initial 10% of total SB length as determined by capsule enteroscopy [Tlesion‐pylorus / Tcecum‐pylorus] </= 0.1 • Yield: – 26‐80% with dedicated enteroscope; – 13‐38% with colonoscope without overtube. • Has therapeutic capabilities. 2: Capsule Endoscopy • Needs good Small Bowel Prep. • Reeding rate </= 15 frames/sec • Experimental Yield: Dedicated Enteroscope vs. Capsule Enteroscopy – Beads at reach of enteroscope: 94% vs 53% – Beads in all small bowel: 37% vs 64% • Clinical Yield of Capsule: – Ongoing obscure‐overt bleed within 2 weeks: 92% – Ongoing obscure‐overt bleed after 2 weeks: 34% – Obscure‐overt bleed in past year: 13% – Obscure‐occult bleed: 44% 2: Capsule Endoscopy • Predictors of (+) capsule finding: – Through Hb < 10 g, – more than 1 bleeding episode, or – bleeding persisting > 6 months • Capsule vs Intraop Endoscopy: – yield 74 vs 76.6%, – Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% • Management change: 37 to 66%; this led to resolution of bleeding in 65% 3: Intraoperative Enteroscopy (IOE) • Yield: 58‐88% of small bowel lesions. • IOE: Examination done “anterograde”, with dedicated enteroscope, with dimmed OR light. Lesions are marked when seen in the “way in”. • TI reached in > 90% •
Load more

Recommended publications
  • Chapter 156: Upper Gastrointestinal Bleeding
    8/23/2018 Principles and Practice of Hospital Medicine, 2e > Chapter 156: Upper Gastrointestinal Bleeding Stephen R. Rotman; John R. Saltzman INTRODUCTION Key Clinical Questions What is the timing and treatment of peptic ulcer disease? What are the factors in diagnosis and treatment of aortoenteric fistula? What treatments are available for each etiology of upper GI bleeding? What is the appropriate management and follow-up of variceal bleeding? How do you estimate the severity of bleeding so that you can triage appropriate patients to the ICU, medical floor, or observation unit? Which patients are more likely to rebleed and hence require continued observation in the hospital aer their bleeding has apparently stopped, and for how long? Upper gastrointestinal (GI) bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000 to 150,000 patients develop upper GI bleeding during hospitalizations. The annual cost of treating nonvariceal acute upper GI bleeding in the United States exceeds $7 billion. Upper GI bleeding is defined as a bleeding source in the GI tract proximal to the ligament of Treitz. The presentation varies depending on the nature and severity of bleeding and includes hematemesis, melena, hematochezia (in rapid upper GI bleeding), and anemia with heme-positive stools. Bleeding can be associated with changes in vital signs, including tachycardia and hypotension including orthostatic hypotension. Given the range of presentations, pinpointing the nature and severity of GI bleeding may be a challenging task. The natural history of nonvariceal upper GI bleeding is that 80% of patients will stop bleeding spontaneously and no further urgent intervention will be needed.
    [Show full text]
  • General Anesthesia for GI Endoscopy MP9519
    Coverage of any medical intervention discussed in a WellFirst Health medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. General Anesthesia for GI Endoscopy MP9519 Covered Service: Yes Prior Authorization Required: No Additional An appropriate diagnosis code must appear on the claim. Information: Claims will deny in the absence of an appropriate diagnosis code. WellFirst Health Medical Policy: 1.0 Use of general anesthesia may be considered medically necessary for upper or lower gastrointestinal endoscopic procedures when there is documentation by the endoscopist or anesthesiology provider that ANY of these specific risk factors or significant medical conditions are present: 1.1 Prolonged or therapeutic endoscopy procedure is planned and requires deep sedation (e.g. endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), upper gastrointestinal stenting, emergency therapeutic procedures; OR 1.2 Anesthesia Risk Category III or greater based on ASA Physical Status Classification System* when there is increased risk for complication because of severe comorbidity; OR 1.3 Morbid obesity (BMI >40, or BMI >35) with comorbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes); OR 1.4 Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment); OR 1.5 Spasticity or movement disorder complicating procedure (e.g. epilepsy, seizure disorder); OR 1.6 Persons with anticipated intolerance of standard sedative (e.g. previous problems with anesthesia or sedation, dependence on opiates, sedatives or hypnotics; or drug or alcohol abuse); OR 1.7 Patients who are pregnant; OR All WellFirst Health products and services are provided by subsidiaries of SSM Health Care Corporation, including, but not limited to, SSM Health Insurance Company and SSM Health Plan.
    [Show full text]
  • Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations
    Open Access Original Article DOI: 10.7759/cureus.14353 Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations Takumi Notsu 1 , Kyoichi Adachi 1 , Tomoko Mishiro 1 , Kanako Kishi 1 , Norihisa Ishimura 2 , Shunji Ishihara 3 1. Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN 2. Second Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, JPN 3. Gastroenterology, Shimane University Hospital, Izumo, JPN Corresponding author: Kyoichi Adachi, [email protected] Abstract Background This study was performed to examine the prevalence of asymptomatic angiodysplasia detected in upper gastrointestinal endoscopic examinations and of hereditary hemorrhagic telangiectasia (HHT) suspected cases. Methodology The study participants were 5,034 individuals (3,206 males, 1,828 females; mean age 53.5 ± 9.8 years) who underwent an upper gastrointestinal endoscopic examination as part of a medical check-up. The presence of angiodysplasia was examined endoscopically from the pharynx to duodenal second portion. HHT suspected cases were diagnosed based on the presence of both upper gastrointestinal angiodysplasia and recurrent nasal bleeding episodes occurring in the subject as well as a first-degree relative. Results Angiodysplasia was endoscopically detected in 494 (9.8%) of the 5,061 subjects. Those with angiodysplasia lesions in the pharynx, larynx, esophagus, stomach, and duodenum numbered 44, 4, 155, 322, and 12, respectively. None had symptoms of upper gastrointestinal bleeding or severe anemia. Subjects with angiodysplasia showed significant male predominance and were significantly older than those without. A total of 11 (0.2%) were diagnosed as HHT suspected cases by the presence of upper gastrointestinal angiodysplasia and recurrent epistaxis episodes from childhood in the subject as well as a first-degree relative.
    [Show full text]
  • Challenges in the Management of Acute Peptic Ulcer Bleeding
    Review Challenges in the management of acute peptic ulcer bleeding James Y W Lau, Alan Barkun, Dai-ming Fan, Ernst J Kuipers, Yun-sheng Yang, Francis K L Chan Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding Lancet 2013; 381: 2033–43 peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the Institute of Digestive Diseases, management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery The Chinese University of Hong continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and Kong, Hong Kong, China (Prof J Y W Lau MD, recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder Prof F K L Chan MD); Division of has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use Gastroenterology, McGill antiplatelet agents, non-steroidal anti-infl ammatory drugs, and anticoagulants. The management of such patients, University and the McGill especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise University Health Centre, Quebec, Canada the published scientifi c literature about the management of patients with bleeding peptic ulcers, identify directions for (Prof A Barkun MD); Institute of future clinical research, and suggest how mortality can be reduced. Digestive Diseases, Xijing Hospital, Fourth Military Introduction by how participants were sampled, their inclusion Medical University, Xian, China (Prof D Fan MD); Department of Acute upper gastrointestinal bleeding is characterised by criteria, and defi nitions of case ascertainment.
    [Show full text]
  • Obscure Gastrointestinal Bleeding in Cirrhosis: Work-Up and Management
    Current Hepatology Reports (2019) 18:81–86 https://doi.org/10.1007/s11901-019-00452-6 MANAGEMENT OF CIRRHOTIC PATIENT (A CARDENAS AND P TANDON, SECTION EDITORS) Obscure Gastrointestinal Bleeding in Cirrhosis: Work-up and Management Sergio Zepeda-Gómez1 & Brendan Halloran1 Published online: 12 February 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Obscure gastrointestinal bleeding (OGIB) in patients with cirrhosis can be a diagnostic and therapeutic challenge. Recent advances in the approach and management of this group of patients can help to identify the source of bleeding. While the work-up of patients with cirrhosis and OGIB is the same as with patients without cirrhosis, clinicians must be aware that there are conditions exclusive for patients with portal hypertension that can potentially cause OGIB. Recent Findings New endoscopic and imaging techniques are capable to identify sources of OGIB. Balloon-assisted enteroscopy (BAE) allows direct examination of the small-bowel mucosa and deliver specific endoscopic therapy. Conditions such as ectopic varices and portal hypertensive enteropathy are better characterized with the improvement in visualization by these techniques. New algorithms in the approach and management of these patients have been proposed. Summary There are new strategies for the approach and management of patients with cirrhosis and OGIB due to new develop- ments in endoscopic techniques for direct visualization of the small bowel along with the capability of endoscopic treatment for different types of lesions. Patients with cirrhosis may present with OGIB secondary to conditions associated with portal hypertension. Keywords Obscure gastrointestinal bleeding . Cirrhosis . Portal hypertension .
    [Show full text]
  • Endoscopic Diagnosis and Management of Nonvariceal Upper
    Guidelines Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021 Authors Ian M. Gralnek1, 2,AdrianJ.Stanley3, A. John Morris3, Marine Camus4,JamesLau5,AngelLanas6,StigB.Laursen7 , Franco Radaelli8, Ioannis S. Papanikolaou9, Tiago Cúrdia Gonçalves10,11,12,MarioDinis-Ribeiro13,14,HalimAwadie1 , Georg Braun15, Nicolette de Groot16, Marianne Udd17, Andres Sanchez-Yague18, 19,ZivNeeman2,20,JeaninE.van Hooft21 Institutions 17 Gastroenterological Surgery, University of Helsinki and 1 Institute of Gastroenterology and Hepatology, Emek Helsinki University Hospital, Helsinki, Finland Medical Center, Afula, Israel 18 Gastroenterology Unit, Hospital Costa del Sol, 2 Rappaport Faculty of Medicine, Technion-Israel Marbella, Spain Institute of Technology, Haifa, Israel 19 Gastroenterology Department, Vithas Xanit 3 Department of Gastroenterology, Glasgow Royal International Hospital, Benalmadena, Spain Infirmary, Glasgow, UK 20 Diagnostic Imaging and Nuclear Medicine Institute, 4 Sorbonne University, Endoscopic Unit, Saint Antoine Emek Medical Center, Afula, Israel Hospital Assistance Publique Hopitaux de Paris, Paris, 21 Department of Gastroenterology and Hepatology, France Leiden University Medical Center, Leiden, The 5 Department of Surgery, Prince of Wales Hospital, The Netherlands Chinese University of Hong Kong, Hong Kong SAR, China published online 10.2.2021 6 Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain Bibliography 7 Department of Gastroenterology, Odense University Endoscopy 2021; 53: 300–332 Hospital, Odense, Denmark DOI 10.1055/a-1369-5274 8 Department of Gastroenterology, Valduce Hospital, ISSN 0013-726X Como, Italy © 2021. European Society of Gastrointestinal Endoscopy 9 Hepatogastroenterology Unit, Second Department of All rights reserved. Internal Medicine – Propaedeutic, Medical School, This article ist published by Thieme.
    [Show full text]
  • Defining and Measuring Quality in Endoscopy
    Communication from the ASGE QUALITY INDICATORS FOR Quality Assurance in Endoscopy Committee GI ENDOSCOPIC PROCEDURES Defining and measuring quality in endoscopy Quality has been a key focus for gastroenterology, The expert panels that were convened in 2005 compiled a driven by a common desire to promote best practices list of quality indicators that were deemed, at the time, to be among gastroenterologists and to foster evidence-based both feasible to measure and associated with improved pa- care for our patients. The movement to define and then tient outcomes. Feasibility concerns precluded measures measure aspects of quality for endoscopy was sparked by that required data collection after the date of endoscopy ser- public demand arising from alarming reports about medi- vice. Accordingly, the majority of the initial indicators con- cal errors. Two landmark articles published in 2000 and sisted of process measures, often related to documentation 2001 led to a national imperative to address perceived of important parameters in the endoscopy note. The evi- areas of underperformance and variations in care across dence demonstrating a link between these indicators to many fields of medicine.1,2 Initial efforts to designate and improved outcomes was limited. In many instances, the require reporting a small number of basic outcome mea- 2005 task force relied on expert opinion. Setting perfor- sures were mandated by the Centers for Medicare & mance targets based on community benchmarks was intro- Medicaid Services, and the process to develop perfor- duced, yet there was significant uncertainty about standard mance measures for government reporting and “pay for levels of performance. Reports citing performance data often performance” programs was initiated.
    [Show full text]
  • Angiodysplasia of Colon Or GI Tract
    Angiodysplasia of Colon or GI Tract Background Phillips first described a vascular (blood vessel) abnormality that caused bleeding from the large bowel in a letter to the London Medical Gazette in 1839. During the 1920s, cancers were considered the major source of GI bleeding/hemorrhage. However, in the 1940s and 1950s, diverticular disease was recognized as an important source of bleeding. In 1951, Smith described active bleeding from a diverticulum visualized through a sigmoidoscope. Galdabini first used the name angiodysplasia in 1974; however, confusion about the exact nature of these lesions resulted in a multitude of terms that included AVM = arteriovenous malformation, hemangioma, telangiectasia, and vascular ectasia. These terms have varying pathophysiologies, with a common presentation of GI bleeding and may be used interchangeably by many physicians. Angiodysplasia is a degenerative lesion of previously healthy blood vessels found most commonly in the right-side of colon. 77% of angiodysplasias are located in the cecum and ascending colon, 15% are located in the jejunum and ileum (small intestine), and the remainder are distributed throughout the GI tract. These lesions typically are nonpalpable and small (<5 mm). Angiodysplasia is the most common vascular abnormality of the GI tract. After diverticulosis, it is the second leading cause of lower GI bleeding in patients older than 60 years. Angiodysplasia may account for approximately 6% of cases of lower GI bleeding. It may be observed incidentally at colonoscopy in as many as 0.8% of patients older than 50 years. The prevalence for upper GI lesions is approximately 1-2%. Small bowel angiodysplasia may account for 30-40% of cases of GI bleeding of obscure origin.
    [Show full text]
  • Crohn's Disease
    Harvard-MIT Division of Health Sciences and Technology HST.121: Gastroenterology, Fall 2005 Instructors: Dr. Jonathan Glickman Vascular and Inflammatory Diseases of the Intestines Overview • Vascular disorders – Vascular “malformations” – Vasculitis – Ischemic disease • Inflammatory disorders of specific etiology – Infetious enterocolitis – “Immune-mediated” enteropathy – Diverticular disease • Idiopathic inflammatory bowel disease – Crohn’s disease – Ulcerative colitis Sporadic Vascular Ectasia (Telangiectasia) • Clusters of tortuous thin-walled small vessels lacking muscle or adventitia located in the mucosa and the submucosa • The most common type occurs in cecum or ascending colon of individuals over the age of 50 and is commonly known as “angiodysplasia” • Angiodysplasias account for 40% of all colonic vascular lesions and are the most common cause of lower GI bleeding in individuals over the age of 60 Angiodysplasia Hereditary Vascular Ectasia • Hereditary Hemorrhagic Telangiectasia (HHT) or Osler- Webber-Rendu disease • Systematic disease primarily involving skin and mucous membranes, and often the GI tract • Autosomal dominant disease with positive family history in 80% of cases • After epistaxis which occurs in 80% of individuals, GI bleed is the most frequent presentation and occurs in 10-40% of cases Arteriovenous Malformations (AVM’s) • Irregular meshwork of structurally abnormal medium to large ectatic vessels • Unlike small vessel ectasias, AVM’s can be distributed in all layers of the bowel wall • AVM’s may present anywhere
    [Show full text]
  • Endoscopic Variceal Ligation: a to Z
    Endoscopic Variceal Ligation: A to Z Division of Gastroenterology and Hepatology, Liver Clinic Department of Internal Medicine Soon Chun Hyang University School of Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea 김 상 균 Agenda 1. Endoscopic classification of esophageal varices 2. Endoscopic ultrasound for the management of esophageal varices 3. Endoscopic treatment of esophageal varices 1) Endoscopic injection sclerotherapy (EIS) vs. Endoscopic variceal ligation (EVL) 2) Primary prophylaxis for esophageal varices 3) Acute esophageal bleeding 4) Secondary prophylaxis after variceal bleeding 4. Procedure of endoscopic band ligation 5. Recurrence of esophageal varices after band ligation 6. Conclusions Case • 52/M, Chronic alcoholism • C/C : Abdominal distension, 1 month ago • MELD score:22, Child-Pugh class C with ascites • endoscopy What should be recorded? 1. F2, Lm, Cb, red wale marking, hematocystic spots 2. F3, Lm, Cb, RC (++), 3. F2, Lm, RC (++) 4. F3, RC (++) 5. F1, RC Endoscopic Classification According to Form F0: No varicose appearance F1: Straight, small-caliber varices F2: Moderately enlarged, beady varices F3: Markedly enlarged, nodular or tumor-shaped varices The Japanese Research Society for Portal Hypertension. Dig Endosc 2010;22:1-229 Endoscopic Classification According to Color • Cw: White varices Cb: Blue varices • Cw-Th: Thrombosed white varices • Cb-Th: Thrombosed blue varices Endoscopic Classification According to Location • Ls: Locus superior • Lm: Locus medialis • Li: Locus inferior • Lg-c: Adjacent to the cardiac orifice • Lg-cf: Extension from the cardiac orifice to the fornix • Lg-f: Isolated in the fornix • Lg-b: Located in the gastric body • Lg-a: Located in the gastric antrum Modified from Sohendra N, et al.
    [Show full text]
  • Heyde's Syndrome
    Cease Report Adv Res Gastroentero Hepatol Volume 2 Issue 4 - January 2017 DOI: 10.19080/ARGH.2017.04.555592 Copyright © All rights are reserved by Deepankar Kumar Basak Heyde’s syndrome: Rarely heard and often missed Deepankar Kumar Basak1*, Richmond Ronald Gomes2 and Md Samsul Arfin3 1Specialist-Gastroenterology, Square Hospitals Ltd., Bhangladesh 2Assistant Professor, Internal Medicine, Ad-din Sakina Medical College & Hospital, Bhangladesh 3Gasroenterology, Square Hospitals Limited., Bhangladesh Submission: November 11, 2016; Published: January 19, 2017 *Corresponding author: Deepankar Kumar Basak, MBBS, FCPS (Medicine), Specialist-Gastroenterology, Square Hospital Ltd., Dhaka, Bangladesh, Tel: Email: Abstract Bleeding from the gastrointestinal tract is very common and important problem in clinical practice. There are lots of causes of GI bleeding, gastrointestinal bleeding in an elderly female patient who is also suffering from HCV related decompensated CLD with multiple myeloma. Heyde’sbut sometimes syndrome it is is very now difficult known to belocate gastrointestinal and treat gastrointestinal bleeding from bleeding. angiodysplasic Here we lesions discuss due Heyde’s to acquired syndrome, vWD-2A an secondaryimportant tocause aortic of stenosis, and the diagnosis is made by confirming the presence of those three things. For this, a wide range of investigations and treatment showingmodalities gastrointestinal are now available. bleeding One aftershould aortic therefore valve makereplacement. an aggressive Old age attempt and co-morbidities to localize the may bleeding create site.a hindrance Newer endoscopic in valve replacement technologies or resectionmay prove surgery. beneficial. Some Aortic newer valve treatment replacement options is claimed like hormonal to minimize and orthalidomide even stop thetherapy bleeding look in promising such patients.
    [Show full text]
  • Therapeutic Endoscopy Fantastic Voyage Now a Reality Robert Luís Pompa, MD Gastroenterology History of Endoscopy
    Therapeutic Endoscopy Fantastic Voyage Now a Reality Robert Luís Pompa, MD Gastroenterology History of Endoscopy • Two major obstacles: • The gut is not straight • It’s dark in there! • Dr. Kussmaul 1868 first gastroscopy • Thomas Edison 1878: first practical/commercial incandescent light bulb • Hoffmann 1911: first proposed flexible endoscope • Hopkins 1954: First model of a flexible fiber imaging device History of Therapeutic Endoscopy Gut 2006 Aug; 55(8): 10-6110-64 The Golden Era of Endoscopy • Major advancements in flexibility and imaging in the GI tract • Reduction in size of endoscopic instruments • Disinfection of instruments • Disposable equipment • Development of Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) • Management of clinical issues steered away from surgical approaches • Surgical discipline free to advance techniques in more complicated clinical issues Times Have Changed Rigid Sigmoidoscopy Google images Times Have Changed Modern Day HD Endoscope Capsule Endoscope Optical Endoscope Google images Cholangioscopy Advancements and Impacts in Biliary Endoscopy Applications and Indications for Biliary Endoscopy • Indications include: • Bile duct stones • Gallbladder stones • Biliary obstruction • Malignancy of the pancreas and biliary tree • Scope and Scale: • 20+ million with gallbladder/bile duct disease • ~37,000 cases of pancreatic cancer Google image • ~10,000 cases of gallbladder/bile duct cancer • 10-15% of those undergoing cholecystectomy have bile duct stones Applications and
    [Show full text]