Post-endoscopy checklist reduces length of stay for non-variceal upper gastrointestinal bleeding.
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OBJECTIVE: To examine the effect of improved gastroenterologist-to-admitting service communication on hospital stay for upper gastrointestinal bleeding. HYPOTHESIS: a detailed checklist addressing factors relevant to discharge planning would shorten hospital stay, when added to the procedure report. DESIGN: Pre-post intervention design, recording balance measures (potential confounders). SETTING: A Canadian university hospital. STUDY PARTICIPANTS: Intermittent 5- to 7-day batches of consecutive emergency patients presenting with non-variceal upper gastrointestinal bleeding as their primary problem. The durations of the background and intervention periods were 3 months (beginning 9 June 2003) and 4 weeks (beginning 8 September 2003), respectively. INTERVENTION: The gastrointestinal bleeding Quality Improvement and Health Information multidisciplinary team (quality improvement personnel; emergency physicians, hospitalists, gastroenterologists, in-patient and endoscopy nurses) developed a one-page checklist, outlining detailed recommendations (3-Ds-diet, drugs, discharge plan) to append to the procedure report. MAIN OUTCOME MEASURES: Difference in median length of hospital stay was the primary endpoint. As balance measures, demographics, bleeding severity, comorbidities, readmission rates, and various benchmark times were recorded prospectively. RESULTS: Thirty-nine patients met the criteria in the background period (4 months, intermittently sampled), and 22 in the intervention period (4 weeks, continuously sampled). There were no significant baseline differences. Median in-patient stay was 7.0 (95% interquartile range 2-24) versus 3.5 (95% interquartile range 1-12) days for the background and intervention periods, respectively (P = 0.003). This remained significant when outliers (stay > 10 days) were removed (P = 0.02). CONCLUSION: A checklist, with very specific recommendations to the admitting service, significantly reduced hospital stay for non-variceal gastrointestinal bleeding. (+info)
Idiopathic portal hypertension complicating systemic sclerosis: a case report.
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BACKGROUND: Patients with systemic sclerosis may develop mild abnormalities of liver function tests. More serious hepatic involvement has been well documented but is rare. Idiopathic portal hypertension had been reported only in a few female patients with systemic sclerosis. CASE PRESENTATION: An 82-year-old man with known systemic sclerosis presented with melaena. Urgent gastroscopy revealed oesophageal varices, which re-started bleeding during the procedure and were treated ensocopically, with Sengstaken tube and glypressin. Liver function tests and coagulation were normal. Non-invasive liver screen (including hepatitis viral serology and autoantibodies) was negative. Ultrasound scan of the abdomen revealed a small liver with coarse texture and no focal lesion. Hepato-portal flow was demonstrated in the portal vein. The spleen was enlarged. A moderate amount of free peritoneal fluid was present. A CT scan confirmed the absence of portal vein thrombosis. One month following discharge the patient had a liver biopsy. Histological examination showed essentially normal liver tissue; there was no evidence of any excess inflammation and no features to suggest cirrhosis or drug-induced liver disease. Taking into account the above evaluation we concluded that the patient had idiopathic portal hypertension. CONCLUSION: Both male and female patients with systemic sclerosis may -- rarely -- develop idiopathic portal hypertension. (+info)
Gastric epithelioid haemangioendothelioma: a rare cause of upper gastrointestinal bleeding.
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Vascular tumours of the stomach are rare, representing 0.9%-3.3% of all gastric neoplasms. A 58 year old man was admitted as an emergency with a one day history of haematemesis and melaena. He underwent an emergency laparotomy for a tumour in the lesser curve of the stomach. The tumour showed the characteristic histological and immunohistochemical features of epithelioid haemangioendothelioma. Surgery in the form of wide excision seems to be the treatment of choice for this rare neoplasm. This case highlights the difficulty in diagnosing this rare tumour preoperatively and emphasises the need for long term follow up in view of its uncertain metastatic potential. (+info)
Diffuse infiltrating T-cell lymphoma of the colon associated with polyclonal hypergammaglobulinemia and hepatocellular carcinoma: report of a case.
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A 55-year-old man with a chief complaint of melena had diffusely infiltrated lymphoma from the rectum to the sigmoid colon and polyclonal hypergammaglobulinemia. Biopsy specimen obtained from the rectum revealed diffuse medium-sized lymphoma cell with plasmocytosis. Histochemical analysis with monoclonal antibodies indicated that the origin of the tumor cell to be T-lymphocyte. Chemotherapy with cyclophosphamide, vincristine and prednisolone (VEP regimen) was effective for mucosal bleeding of the colonic lesion and reduction of polyclonal hypergammaglobulinemia. Five yrs later he showed recurrence of the disease and elevation of serum alphafetoprotein, and died of pulmonary infections. Autopsy finding confirmed the diagnosis of malignant lymphoma of the colon and disclosed the association of hepatocellular carcinoma. (+info)
Melaena as the presenting symptom of gastric mucosal injury due to blunt abdominal trauma.
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Blunt abdominal trauma is a common cause of admission to the typical trauma centre. Hollow viscus injury from blunt trauma, however, is unusual and rarely involves the stomach. A 15 year old boy sustained a bicycle handle bar injury to the abdomen and presented to the casualty department four days later with melaena. A computed tomography (CT) scan of the abdomen showed normal findings but endoscopy revealed two "kissing" areas of mucosal ulceration on the anterior and posterior wall of the gastric antrum. The patient received a blood transfusion for anaemia but was otherwise treated conservatively and made a full recovery. The authors believe this to be the first reported case of melaena as the primary presenting symptom of gastric ulceration secondary to blunt abdominal trauma. Diagnosis of hollow viscus injuries due to blunt abdominal trauma requires a high index of suspicion and thorough investigation, particularly if the presentation is delayed. (+info)
A case of Glanzmann's thrombasthenia successfully treated with recombinant factor viia during a surgical procedure: observations on the monitoring and the mechanism of action of this drug.
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Recombinant factor VIIa (rFVIIa) has been shown to be efficient for the treatment of haemorrhages in patients with Glanzmann's thrombasthenia presenting anti-glycoprotein IIb-IIIa antibodies, but the mechanism of action is not well established and there is no routine laboratory test for the monitoring of rFVIIa. In this study, thrombin generation (TG) test was used to assess the efficacy of rFVIIa ex vivo in a Glanzmann patient with inhibitor, who had a surgery for cholesteatoma. The day before surgery, TG capacity in platelet rich plasma was significantly diminished (Endogenous thrombin potential = 637nM x min) in comparison with the normal control group (1338+/-353 nM x min). Thirty minutes after the first infusion of 90 microg/kg of rFVIIa, TG was increased by 59% (1010 nM x min). rFVIIa was administered as intravenous bolus injection of 90 microg/kg q x 2h during the first 24h, than 66microg/kg q x 2h during 24h and 53 microg/kg q x 2h on the post-operative day 3. Residual TG capacity measured before rFVIIa administration mostly remained above 1000nM x min and the coagulation capacity was not significantly modified after a new injection of rFVIIa. The fibrin network was studied with 3D confocal microscopy using clots obtained with TG test. After rFVIIa infusion, the fibrin network was tighter in comparison with the sample before rFVIIa injection. These results provide further ex vivo evidence on haemostatic efficacy of rFVIIa in Glanzmann's patients. (+info)
Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: Report of a case.
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We present a female patient with continuous melena, diagnosed with rectal variceal bleeding. She had a history of esophageal varices, which were treated with endoscopic therapy. Five years after the treatment of esophageal varices, continuous melena occurred. Since colonoscopy showed that the melena was caused by giant rectal varices, we thought that they were not suitable to receive endoscopic treatment. We chose the modified percutaneous transhepatic obliteration with sclerosant, which is one of the interventional radiology techniques but a new clinical procedure for rectal varices. After the patient received this therapy, her condition of rectal varices was markedly improved. (+info)
Thalidomide as treatment for digestive tract angiodysplasias.
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An 80-year-old man with von Willebrand's disease was admitted with severe melaena. Despite suppletion with von Willebrand concentrate he continued to be dependent on blood transfusions. Endoscopic examination did not show a bleeding focus. Video capsule endoscopy showed active bleeding from angiodysplasias in the proximal section of the small intestine. Ultimately, treatment with thalidomide was initiated at a dose of 100 mg/day. Soon after starting treatment his stools became normal and his haemoglobin level stabilised. No bleeding problems occurred for 11 months, after which the thalidomide treatment was stopped because of the potential side effects. Two months later he again developed melaena and treatment with thalidomide was restarted with a successful outcome. Trying to lower the dose to 50 mg resulted in rebleeding after three months with stabilisation after increasing the dose to 100 mg again. Monotherapy with thalidomide improves the clinical picture but may not be sufficient in the long term. Additional therapy, such as argon plasma coagulation or the use of the novel drug lenalidomide, might be necessary. (+info)