Chronic radiation proctitis refractory to steroid enema was successfully treated by metformin and sodium butyrate: a case report.

BACKGROUND: Radiation proctitis (RP) is a significant complication of pelvic radiation. Effective treatments for chronic RP are currently lacking. We report a case where chronic RP was successfully managed by metformin and butyrate (M-B) enema and suppository therapy. CASE PRESENTATION: A 70-year-old Asian male was diagnosed with prostate cancer of bilateral lobes, underwent definitive radiotherapy to the prostate of 76 Gy in 38 fractions and six months of androgen deprivation therapy. Despite a stable PSA nadir of 0.2 ng/mL for 10 months post-radiotherapy, he developed intermittent rectal bleeding, and was diagnosed as chronic RP. Symptoms persisted despite two months of oral mesalamine, mesalamine enema and hydrocortisone enema treatment. Transition to daily 2% metformin and butyrate (M-B) enema for one week led to significant improvement, followed by maintenance therapy with daily 2.0% M-B suppository for three weeks, resulting in continued reduction of rectal bleeding. Endoscopic examination and biopsy demonstrated a good therapeutic effect. CONCLUSIONS: M-B enema and suppository may be an effective treatment for chronic RP.

Splenic artery pseudoaneurysm; a cause or consequence: a case report.

BACKGROUND: Splenic artery pseudoaneurysm is a rare complication of recurrent pancreatitis usually presenting as an incidental finding on abdominal computed tomography. CASE PRESENTATION: We present the case of a 66-year-old north African male with a known history of previous pancreatitis who presented with upper gastrointestinal bleeding along with recurrent epigastric pain for 3 days. Investigations did not reveal any particular pancreatitis etiology. Computed tomography of the abdomen with contrast showed splenic artery pseudoaneurysm along with findings suggestive of acute pancreatitis. Upper and lower endoscopies failed to identify gastrointestinal the bleed source. The patient underwent intervention radiology embolization of the aneurysm sac with multiple coils via right retrograde common femoral artery-celiac access. The patient was discharged with a plan for capsule endoscopy in outpatient setting. CONCLUSION: Splenic artery pseudoaneurysm is a life-threatening complication and carries a high mortality rate if left untreated. Prompt identification through various imaging modalities, followed by urgent intervention, is crucial to avoid adverse outcomes.

Preoperative Blood Transfusion Requirements for Hemorrhoidal Severe Anemia: A Retrospective Study of 128 Patients.

BACKGROUND Severe anemia caused by hemorrhoidal hematochezia is typically treated preoperatively with reference to severe anemia treatment strategies from other etiologies. This retrospective cohort study included 128 patients with hemorrhoidal severe anemia admitted to 3 hospitals from September 1, 2018, to August 1, 2023, and aimed to evaluate preoperative blood transfusion requirements. MATERIAL AND METHODS Of 5120 patients with hemorrhoids, 128 (2.25%; male/female: 72/56) experienced hemorrhoidal severe anemia, transfusion, and Milligan-Morgan surgery. Patients were categorized into 2 groups based on their preoperative hemoglobin (PHB) levels after transfusion: PHB ≥70 g/L as the liberal-transfusion group (LG), and PHB <70 as the restrictive-threshold group (RG). The general condition, bleeding duration, hemoglobin level on admission, transfusion volume, length of stay, immune transfusion reaction, surgical duration, and hospitalization cost were compared between the 2 groups. RESULTS Patients with severe anemia (age: 41.07±14.76) tended to be younger than those with common hemorrhoids (age: 49.431±15.59 years). The LG had a significantly higher transfusion volume (4.77±2.22 units), frequency of immune transfusion reactions (1.22±0.58), and hospitalization costs (16.69±3.31 thousand yuan) than the RG, which had a transfusion volume of 3.77±2.09 units, frequency of immune transfusion reactions of 0.44±0.51, and hospitalization costs of 15.00±3.06 thousand yuan. Surgical duration in the LG (25.69±14.71 min) was significantly lower than that of the RG (35.24±18.72 min). CONCLUSIONS Patients with hemorrhoids with severe anemia might require a lower preoperative transfusion threshold than the currently recognized threshold, with an undifferentiated treatment effect and additional benefits.

Proton pump inhibitor therapy after transcatheter angiography in refractory nonvariceal acute upper gastrointestinal bleeding patients: a cohort study.

BACKGROUND: Transcatheter angiography (TA) could help to diagnose and treat refractory nonvariceal upper gastrointestinal bleeding (NVUGIB). Proton pump inhibitors (PPIs) are the key medication for reducing the rebleeding rate and mortality and are usually continued after TA. It is unknown whether high-dose PPIs after TA are more effective than the standard regimen. METHODS: We retrospectively collected data from patients who received TA because of refractory NVUGIB from 2010 to 2020 at West China Hospital. 244 patients were included and divided into two groups based on the first 3 days of PPIs treatment. All baseline characteristics were balanced using the inverse probability of treatment weighting method. The 30-day all-cause mortality, rebleeding rate and other outcomes were compared. The propensity score matching method was also used to verify the results. RESULTS: There were 86 patients in the high-dose group and 158 in the standard group. The average daily doses of PPI were 192.1 ± 17.9 mg and 77.8 ± 32.0 mg, respectively. Cox regression analysis showed no difference in the 30-day all-cause mortality (aHR 1.464, 95% CI 0.829 to 2.584) or rebleeding rate (aHR 1.020, 95% CI 0.693 to 1.501). There were no differences found in red blood cell transfusion, hospital stay length and further interventions, including endoscopy, repeating TA, surgery and ICU admission. The results were consistent in the subgroup analysis of patients with transcatheter arterial embolization. CONCLUSION: In refractory NVUGIB patients who received TA, regardless of whether embolization was performed, high-dose PPI treatment did not provide additional benefits compared with the standard regimen.

Treatment of gastric varices with cyanoacrylate complicated by systemic embolization.

Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.

Risk factors and management of gastrointestinal bleeding in patients with or without antiplatelet and anticoagulation therapy: a multicenter real-world prospective study.

BACKGROUND: Antiplatelet and anticoagulation drugs complicate acute gastrointestinal bleeding (GIB) patients. Limited data about the risk factors and patient management has been presented. This study explored the association between previous antiplatelet or anticoagulant drug usage and clinical outcomes in GIB patients to improve awareness further and optimize treatment. METHODS: We conducted a multicenter, non-interventional, real-world prospective study in 106 hospitals in 23 provinces in China. GIB patients confirmed in the emergency department were included and were grouped according to previous drug histories. Univariate analysis, multivariate logistic regression, and multivariate stratification models were performed separately to investigate the associations. RESULTS: A total of 2299 patients (57.23 ± 17.21 years old, 68.3% male) were included, of whom 20.1% and 2.9% received antiplatelet and anticoagulation therapy, respectively. The all-cause 28-day mortality rates in patients without antiplatelet or anticoagulants, patients undergoing antiplatelet treatment, and patients with anticoagulation therapy were 2.8%, 4.6%, and 10.5%, respectively. After adjusting for confounding factors, both antiplatelet [odd ratio (OR), 2.92; 95% confidence interval (CI), 1.48-5.76; p = 0.002] and anticoagulation therapy (OR, 8.87; 95% CI, 3.02-26.02; p < 0.001) were associated with higher 28-day mortality. In the subgroup analysis, blood transfusion, especially red blood cell transfusion, in patients undergoing antiplatelet and anticoagulation therapy was associated with a decreased death risk. CONCLUSION: We confirmed an association between concurrent antiplatelet or anticoagulation therapy in GIB patients and elevated 28-day mortality. Blood transfusions could improve poor outcomes in such patients.

Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention. METHODS: A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data. RESULTS: On logistic regression analysis, A hemoglobin drop of > 20 g/L was the only variable that predicted endoscopic intervention (p = 0.030). Tachycardia, hypotension, or presence of anticoagulation were not significantly associated with endoscopic intervention (p > 0.05). CONCLUSIONS: A hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.

Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding.

Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.

Advancements in hemostatic strategies for managing upper gastrointestinal bleeding: A comprehensive review.

Upper gastrointestinal (GI) hemorrhage presents a substantial clinical challenge. Initial management typically involves resuscitation and endoscopy within 24 h, although the benefit of very early endoscopy (< 12 h) for high-risk patients is debated. Treatment goals include stopping acute bleeding, preventing rebleeding, and using a multimodal approach encompassing endoscopic, pharmacological, angiographic, and surgical methods. Pharmacological agents such as vasopressin, prostaglandins, and proton pump inhibitors are effective, but the increase in antithrombotic use has increased GI bleeding morbidity. Endoscopic hemostasis, particularly for nonvariceal bleeding, employs techniques such as electrocoagulation and heater probes, with concerns over tissue injury from monopolar electrocoagulation. Novel methods such as Hemospray and Endoclot show promise in creating mechanical tamponades but have limitations. Currently, the first-line therapy includes thermal probes and hemoclips, with over-the-scope clips emerging for larger ulcer bleeding. The gold probe, combining bipolar electrocoagulation and injection, offers targeted coagulation but has faced device-related issues. Future advancements involve combining techniques and improving endoscopic imaging, with studies exploring combined approaches showing promise. Ongoing research is crucial for developing standardized and effective hemorrhage management strategies.

Comparison of scoring systems for predicting clinical outcomes of acute lower gastrointestinal bleeding: A prospective cohort study.

BACKGROUND: This study aimed to determine the performance of the Oakland, Glasgow-Blatchford, and AIMS65 scores in predicting the clinical outcomes of acute lower gastrointestinal bleeding (LGIB). METHODS: This prospective cohort study was conducted from July 2020 to July 2021. Patients admitted with acute lower gastrointestinal bleeding were enrolled. The Oakland, Glasgow-Blatchford, and AIMS65 scores were calculated. The primary outcome was validating the performance of the scores in predicting severe LGIB; secondary outcomes were comparing the performance of the scores in predicting the need for blood transfusion, hemostatic interventions, in-hospital rebleeding, and mortality. Receiver operating characteristic curves were calculated for all outcomes. The associations between all three scores and the primary outcomes were calculated using multivariate logistic regression analysis. RESULTS: Patients with acute LGIB (n = 150) were enrolled (88 [58.7%] men and mean age: 63.6 ± 17.3 years). The rates of severe LGIB, need for blood transfusion, hemostatic intervention, in-hospital rebleeding, and in-hospital mortality were 54.7%, 79.3%, 10.7%, and 3.3%, respectively. The Oakland and Glasgow-Blatchford scores had comparable performance in predicting severe LGIB, need for blood transfusion, and mortality, outperforming the AIMS65 score. All scores were suboptimal for predicting hemostatic interventions and rebleeding. CONCLUSIONS: Our results demonstrate the predictive performances of the Oakland score and the GBS are excellent and comparable for severe LGIB, the need for blood transfusion, and in-hospital mortality in patients with acute LGIB. Thus, GBS could be considered as an alternative predictive score for stratification of the patients with acute LGIB.

Digestive bleeding due to jejunal diverticula: diagnosis and management.

A jejunal diverticular haemorrhage is the second most common complication of jejunum diverticula. It can manifest clinically as acute upper gastrointestinal bleeding and is common to imitate acute rectal bleeding. Bleeding is usually associated with or without haemodynamic stability. Its diagnosis is challenging, requiring imaging examinations. Treatment is conservative management or surgery.

Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports.

BACKGROUND: Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY: We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION: We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.

Efficacy of transcatheter arterial embolization in treating nonvariceal gastric remnant bleeding: a retrospective 5-year study.

BACKGROUND: Gastric remnant bleeding is a special case of upper gastrointestinal bleeding with certain specific disease characteristics, and some matters of transcatheter arterial embolization (TAE) for hemostasis need attention. In this study, we aimed to explore the clinical use of TAE in patients with nonvariceal gastric remnant bleeding and identify the factors influencing the clinical efficacy of these interventions. METHODS: Data were retrospectively analyzed from 42 patients for whom angiography and embolization were performed but could not be treated endoscopically or had failed endoscopic management in our department between January 2018 and January 2023 due to nonvariceal gastric remnant bleeding. We investigated the relationship between the incidence of re-bleeding and the following variables: sex, age, pre-embolization gastroscopy/contrast-enhanced computer tomography, embolization method, aortography performance, use of endoscopic titanium clips, and the presence of collateral gastric-supplying arteries. RESULTS: Forty-two patients underwent 47 interventional embolizations. Of these, 16 were positive for angiographic findings, and 26 were negative. Based on arteriography results, different embolic agents were selected, and the technical success rate was 100%. The incidence of postoperative re-bleeding was 19.1% (9/47), and the overall clinical success rate was 81.0% (34/42). Logistic regression analysis of the relationship between the incidence of early re-bleeding following embolization and the proportion of collateral gastric supply arteries revealed an odds ratio of 10.000 (p = 0.014). CONCLUSIONS: Utilizing TAE for nonvariceal gastric remnant bleeding is safe and effective. The omission of collateral gastric-supplying arteries can lead to early re-bleeding following an intervention.

A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS: This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS: The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION: Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.

A novel prediction tool for mortality in patients with acute lower gastrointestinal bleeding requiring emergency hospitalization: a large multicenter study.

The study aimed to identify prognostic factors for patients with acute lower gastrointestinal bleeding and to develop a high-accuracy prediction tool. The analysis included 8254 cases of acute hematochezia patients who were admitted urgently based on the judgment of emergency physicians or gastroenterology consultants (from the CODE BLUE J-study). Patients were randomly assigned to a derivation cohort and a validation cohort in a 2:1 ratio using a random number table. Assuming that factors present at the time of admission are involved in mortality within 30 days of admission, and adding management factors during hospitalization to the factors at the time of admission for mortality within 1 year, prognostic factors were established. Multivariate analysis was conducted, and scores were assigned to each factor using regression coefficients, summing these to measure the score. The newly created score (CACHEXIA score) became a tool capable of measuring both mortality within 30 days (ROC-AUC 0.93) and within 1 year (C-index, 0.88). The 1-year mortality rates for patients classified as low, medium, and high risk by the CACHEXIA score were 1.0%, 13.4%, and 54.3% respectively (all P < 0.001). After discharge, patients identified as high risk using our unique predictive score require ongoing observation.