Nebulized Vasopressin for the Control of Hematemesis and Hemoptysis in a Child With Recurrent, Refractory Stage III Burkitt Lymphoma.

BACKGROUND: Bleeding occurs with some regularity at the end of life. Patients often endure fatigue, weakness, pain, dyspnea and anxiety. These symptoms are magnified in visually apparent bleeds. Management can be particularly challenging as we attempt to balance therapies with goals of care. Children are at risk for such complications and symptoms; providers must ensure comfort for both the patient and family. CASE DESCRIPTION: A 7-year-old male with recurrent, refractory Burkitt lymphoma was frequently hospitalized for palliative chemotherapy and disease complications. On his final admission, he experienced gross hemoptysis and hematemesis: he was short of breath, fatigued and anxious due to his blood loss. His and his family's angst were heightened by "seeing" his bleed. Potential, especially invasive, treatments were limited by our goals to promote comfort, limit interventions, maintain alertness, poor intravenous access and a small bowel obstruction. Nebulized vasopressin, 10 units in 4ml of normal saline given over 10 minutes provided JC with needed relief. His bleeding remitted and he tolerated its administration. CONCLUSION: There are many treatments for hemorrhage; however, given the challenges of goals of care, administration, side-effects and tolerability, further investigation into nebulized vasopressin as a potential therapy for hemoptysis and hematemesis at the end-of-life is warranted.

Severe gastrointestinal hemorrhage related to everolimus: a case report.

Everolimus is an mTOR (the mammalian target of rapamycin) inhibitor, which is used for the treatment of advanced renal cell carcinoma. Life-threatening hemorrhages are extremely rare adverse effect of everolimus. We herein report a successfully treated case of severe everolimus-related gastrointestinal hemorrhage by emergency surgical resection for patient with advanced renal cell carcinoma. A 72-year-old male was diagnosed with renal cell carcinoma, for which everolimus was administered after unsuccessful treatment with sunitinib and sorafenib. The patient suddenly developed hematemesis 4 weeks after administration. Upper gastrointestinal endoscopy showed gastric antral vascular ectasia. Once the hemorrhage was successfully cauterized by argon plasma coagulation, everolimus was discontinued. However, the patient after re-administration of everolimus developed hematemesis again and exhibited hemorrhage shock. Since therapeutic endoscopy could not achieve hemostasis, the patient underwent emergency distal gastrectomy with Billroth I reconstruction. The patient's vital signs and hemoglobin level stabilized after the surgery. Thereafter, the patient made a satisfactory recovery, and was discharged on postoperative day 10.

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study.

BACKGROUND: Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD. METHODS: In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl. RESULTS: Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment. CONCLUSIONS: Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.

An odd lump in the oesophagus - diagnostic and therapeutic approach?

A 60-year-old woman initially presented with a history of mild haematemesis. The patient denied any dysphagia, weight loss, or fever, intake of non-steroidal anti-inflammatory drugs or excessive alcohol consumption. She did not have abdominal pain and had not observed blood in her stools or melaena. At upper endoscopy, a potential source of bleeding could not be detected, but a subepithelial mass in the mid-oesophagus was revealed. The diagnostic and therapeutic approach to subepithelial oesophageal lesions is discussed.

Arterioportal fistula causing jejunal variceal hemorrhage.

Hepatoportal arteriovenous fistulas are an uncommon cause of portal hypertension and may lead to severe gastrointestinal bleeding. Esophageal varices are the main source of hemorrhage in patients with portal hypertension. We report a 40-year-old man with a hepatic arterioportal fistula, who had gastrointestinal bleeding from jejunal varices. He had had hematemesis four years previously and was diagnosed as esophageal variceal bleeding secondary to hepatic arterioportal fistula-complicated portal hypertension. The fistula had been successfully closed with a detachable balloon but it was found to have reformed during his recent hospitalization for jejunal variceal bleeding. Alcoholism and development of portal vein thrombosis afterwards were the other contributing factors for jejunal variceal formation. Hemorrhage was controlled with medical treatment. Since he refused any surgical intervention he was discharged and advised to continue follow-up.