Esofagitis necrotizante aguda / Acute necrotizing esophagitis / Esofagite necrotizante aguda

La esofagitis necrotizante aguda es un trastorno poco común que puede ser causa de hemorragia digestiva alta. Predomina en el sexo masculino en la sexta década de la vida. El diagnóstico es endoscópico y muestra una mucosa esofágica de apariencia negra que afecta al esófago distal en toda su circunferencia y se detiene abruptamente en la unión gastroesofágica. Clínicamente suele presentarse con hematemesis y melenas, shock hipovolémico por sangrado masivo, siendo otras manifestaciones el dolor epigástrico, molestia retroesternal y disfagia. Se vincula a pacientes con antecedentes de enfermedad cardiovascular, alcoholismo, diabetes mellitus, desnutrición, hernia hiatal, estenosis gastroduodenal, cáncer, así como pacientes en shock, traumatizados, sometidos a cirugía mayor e inmunosuprimidos. El tratamiento se basa en fluidoterapia, inhibidores de la bomba de protones y suspensión de la vía oral, siendo controvertido el uso de antibioticoterapia. Su pronóstico es malo y dependerá de la gravedad de la enfermedad esofágica y del terreno del paciente, con una mortalidad de hasta el 36 %. Presentamos el caso clínico de un paciente de 81 años, hipertenso, que presenta hematemesis, confirmándose en la endoscopía una esofagitis necrotizante aguda, que evoluciona favorablemente con tratamiento médico.

Acute necrotizing esophagitis is a rare disorder that can cause upper gastrointestinal bleeding. It predominates in males in the sixth decade of life. The diagnosis is endoscopic and shows a black-appearing esophageal mucosa that affects the entire circumference of the distal esophagus and stops abruptly at the gastroesophageal junction. Usually, patients present with hematemesis and melena, with other manifestations such as epigastric pain, retrosternal discomfort, dysphagia, and hypovolemic shock. Almost all patients reported comorbidities: cardiovascular disease, alcoholism, diabetes mellitus, malnutrition, hiatal hernia, gastroduodenal stenosis, and malignant neoplasia; is related as well to patients with shock, trauma, undergoing major surgery, and immunosuppression. The treatment is based on fluid reposition, proton pump inhibitors and suspension of the oral route, the use of antibiotic therapy being controversial. Its prognosis is poor and will depend on the severity of the esophageal disease and the patient comorbidities, with a mortality rate up to 36 %. Case: A 81-year-old male patient with hypertension, who presented hematemesis, confirmed by endoscopy as acute necrotizing esophagitis, whose evolution was favorable with medical treatment.

A esofagite necrosante aguda é uma doença rara que pode causar hemorragia digestiva alta. Predomina no sexo masculino na sexta década de vida. O diagnóstico é endoscópico e mostra uma mucosa esofágica circunferencial difusa com aspecto preto que envolve quase universalmente o esôfago distal e para abruptamente na junção gastroesofágica. Clinicamente, geralmente se apresenta com hematêmese e melena, com outras manifestações sendo dor epigástrica, desconforto retroesternal, disfagia e choque hipovolêmico. Está relacionado a pacientes com histórico de doenças cardiovasculares, alcoolismo, diabetes mellitus, desnutrição, hérnia hiatal, estenose gastroduodenal e neoplasia maligna, bem como pacientes em choque, trauma, cirurgia de grande porte e imunossupressão. O tratamento é a medicação dietética higiênica baseada em fluidoterapia, inibidores da bomba de prótons e suspensão da via oral, sendo o uso de antibioticoterapia controverso. Seu prognóstico é ruim e dependerá da gravidade da doença esofágica e do terreno do paciente, com mortalidade de até 36 %. Apresentamos o caso clínico de um paciente hipertenso de 81 anos que apresentou hematêmese, confirmada por endoscopia como esofagite necrosante aguda, que evoluiu favoravelmente com tratamento higiênico-dietético e medicamentoso.

Coriocarcinoma gástrico primario: reporte de caso / Primary gastric choriocarcinoma: case report

El coriocarcinoma gástrico primario (CGP) es un tumor extremadamente raro, altamente invasivo y de rápida diseminación hematógena. Presentamos el caso de una paciente de 57 años que inicia con cuadro de hematemesis y, progresivamente, se le suman episodios de melena, baja de peso y epigastralgia. Es derivada al Instituto Nacional de Enfermedades Neoplásicas en donde se le realizan gastroscopía y biopsia. Así, el análisis histológico reportó patrón sugestivo para CGP; el cual se confirmó al realizarle a la paciente los estudios por imágenes necesarios y llevar a cabo el análisis inmunohistoquímico para gonadotrofina coriónica humana y alfa feto proteína. Posteriormente, a la paciente se le realiza una gastrectomía radical D2 con preservación esplénica y de cola de páncreas. Lamentablemente, su evolución no fue favorable y fallece por la progresión de la enfermedad.

Primary gastric choriocarcinoma (PGC) is an extremely rare and highly invasive tumor with rapid hematogenous spread. We present the case of a 57-year-old female patient who started with hematemesis and progressive episodes of melena, weight loss and epigastralgia. It is derived from the National Institute of Neoplastic Diseases where gastroscopy and biopsy are performed. Histological analysis reported pattern suggestive of PGC; that was confirmed by immunohistochemical analysis for human chorionic gonadotrophin and fetal alpha protein. Subsequently, the patient underwent a radical D2 gastrectomy with splenic preservation and tail of the pancreas preservation. Unfortunately, her evolution was not favorable and died due to the progression of the disease.

Extramedullary relapse of multiple myeloma presenting as massive upper gastrointestinal bleeding: a rare complication

No abstract available.

Hemorrhagic shock secondary to button battery ingestion / Choque hemorrágico secundário à ingestão de bateria em disco

CONTEXT: Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications. CASE REPORT: A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration. CONCLUSION: This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals. .

CONTEXTO: A ingestão de bateria em disco é queixa frequente em pediatria. As complicações graves decorrentes de ingestão acidental têm aumentado significativamente nas últimas duas décadas, devido ao fácil acesso aos aparelhos e brinquedos eletrônicos. Nos últimos anos, o aumento do uso de baterias de lítio com diâmetro de 20 mm trouxe novos desafios, por serem mais prejudiciais para a mucosa em comparação com outros tipos, com elevada morbidade e mortalidade. As queixas clínicas, muitas vezes inespecíficas, podem levar ao atraso no diagnóstico, aumentando o risco de complicação grave. RELATO DE CASO: Menino de cinco anos, com queixa de dor abdominal há 10 dias, é trazido ao serviço de emergência com quadro clínico de hematêmese há duas horas. Na admissão, apresentava palidez, taquicardia e hipotensão. Imagem sugestiva de bateria em disco foi visualizada na radiografia simples de abdome. A endoscopia digestiva demonstrou lesão ulcerada profunda no esôfago sem sangramento ativo. Após o procedimento, o paciente apresentou hematêmese profusa e hipotensão grave, seguidos de parada cardiorrespiratória (PCR), revertida. Submetido a laparotomia exploradora de urgência, apresentou novo episódio de PCR, sem reversão. A bateria foi removida por exploração retal. CONCLUSÃO: Este caso descreve a evolução fatal de ingestão da bateria em disco com diagnóstico tardio e associação com lesão grave de mucosa digestiva. Alto nível de suspeita clínica é obrigatório para evitar tal evolução. As estratégias de prevenção são necessárias, bem como a educação em saúde, com alerta aos pais, cuidadores e profissionais de saúde. .

Hematoma intramural esofágico / Esophageal intramural hematoma

The most common presentation of esophageal hematoma is pain, dysphagia and hematemesis. We report two patients with the condition. A 77 years old female presenting with retrosternal pain and odynophagia after ingesting a pig bone. An upper gastrointestinal endoscopy showed a lineal hematoma, protruding to the lumen in the upper portion of the esophagus. The patient was managed with nil per os (NPO) and parenteral hydration and discharged 72 hours later. An 87 years old male presenting with two episodes of hematemesis and weight loss, an upper gastrointestinal endoscopy showed a dissecting hematoma involving the entire esophageal wall. The patient was managed with NPO and hydration and discharged in good conditions 11 days after admission.

El hematoma intramural esofágico es infrecuente, existiendo pocos casos registrados en la literatura. Generalmente se presenta posterior a un trauma, por ejemplo asociado a procedimientos endoscópicos (escleroterapia), o en forma espontánea. La presentación clínica más frecuente es la tríada de dolor torácico, odinofagia/disfagia y/o hematemesis. Generalmente el tratamiento consiste en un manejo expectante con medidas de soporte habitual. Se exponen 2 casos clínicos presentados en nuestro centro durante el año 2009 y se realiza una revisión de la literatura.

Upper gastrointestinal bleeding in children in southern Iran.

Objective. To find out whether the causes of upper GI bleeding in our center in a developing country differed from developed countries. Methods. Children presenting to our center with upper GI bleeding from March 2002 to March 2007, were retrospectively evaluated. Informations were retrieved from patient’s history and physical examination and results of upper GI endoscopy regarding etiology of bleeding, managements, use of medications which might predispose patient to bleeding, and the mortality rate. Results. From 118 children (67 boys; with age of 7.7±4.7 yrs) who underwent upper GI endoscopies, 50% presented with hematemesis, 14% had melena and 36% had both. The most common causes of upper GI bleeding among all patients were gastric erosions (28%), esophageal varices (16%), duodenal erosions (10%), gastric ulcer (8.5%), Mallory Weiss syndrome tear (7.8%), duodenal ulcer (6.8%), esophagitis (1.7%) and duodenal ulcer with gastric ulcer (0.8%). The causes of bleeding could not be ascertained in 20.5% of cases. No significant pre-medication or procedure related complications were observed. Endoscopic therapy was performed in 13.5% of patients. In 14.4% of patients, there was a history of consumption of medications predisposing them to upper GI bleeding. Two deaths occurred (1.7%) too. Conclusion. The findings in the present study showed that half of upper GI bleedings in pediatric patients from south of Iran, were due to gastric and duodenal erosions and ulcers. This study concludes that the causes of upper GI bleeding in children in our center of a developing country, are not different from those in developed ones.

External hemorrhoids in children

Hemorrhoids in children are not common. The most common cause of hemorrhoids in the young children is portal hypertension. A 3 year old boy with history of hematemsis and external hemorrhoids is being reported. Patient had associated varices for which he was put on proparnolol

Jejunogastric intussusception--a rare cause of recurrent upper gastrointestinal bleeding: case report and review of literature.

Jejunogastric intussusception is a known complication following gastrojejunostomy. However, only occasionally have they presented with haematemesis and we are unaware of any case where it led to recurrent haematemesis. We describe a case where the patient developed recurrent upper gastrointestinal bleeding due to recurrent episodes of jejunogastric intussusception following gastrojejunostomy performed 12 years earlier for duodenal ulcer disease.

Lieno-adrenal shunt.

Portal hypertension with variceal bleed and a well functioning liver is an indication for shunt surgery. The commonly performed procedure is the lieno-renal shunt. When the left adrenal vein is long enough, and of healthy diameter a spleno-adrenal shunt is possible. Most of the reported cases are of distal spleno-adrenal type. A case of proximal spleno-adrenal patent shunt with a follow-up two years is presented along with review of literature.

Fatal gastro-intestinal bleeding: A complication following spinal injury.

On 30.08.2003, a 20-year-old boy met with a vehicular accident and sustained spinal injury and left upper limb fracture. He was immediately hospitalized and seemed to recover well after treatment for a period of 15 days, when just before discharge he suddenly had hematemesis and bleeding per rectum and succumbed within another 24 hours. The case is discussed in detail.

Clinical profile of dengue hemorrhagic fever cases in Mexico

OBJETIVO: El dengue hemorrágico en México es una enfermedad emergente desde 1994. La circulación de los cuatro serotipos incrementa el riesgo de epidemias de dengue hemorrágico. MATERIAL Y MÉTODOS: Se reportan los datos clínicos y epidemiológicos de los casos de dengue hemorrágico confirmados y notificados por el IMSS de 1995 a 2003. Se analizaron las características clínicas y epidemiológicas entre grupos. Para el control y la evaluación final de las variables se utilizó un modelo multivariado. RESULTADOS: Los casos fueron asignados en dos grupos: 438 con dengue clásico, que incluye 109 casos con manifestaciones hemorrágicas sin trombocitopenia, y 977 casos de dengue hemorrágico con 79 defunciones. Los factores de riesgo asociados a las defunciones fueron: hematemesis (RR 2.6; IC 95 por ciento 1.4-4.6) y melena (RR 2.2; IC 95 por ciento 1.2-3.7). CONCLUSIONES: El cuadro clínico descrito para la población del Instituto Mexicano del Seguro Social permite identificar factores pronósticos que ayuden al clínico a prevenir y manejar adecuadamente los casos severos de dengue hemorrágico.

Spontaneous endobroncheal erosion of a bullet - an uncommon presentation of gunshot trauma in remote past

A case of unknown bullet trauma to the lung, in remote past, presented with hemoptysis which was mislabeled as hematemesis. Once labeled, a number of physicians, one after the other, kept on treating her for that symptom. She also consulted a number of specialties and was treated for reflux esophagitis, tuberculosis etc. Meanwhile her x-ray chest revealed a foreign body which was treated as an artifact first, and proved to be a bullet on CT scan. Thoracotomy had to be performed to remove the pathologic right lower lobe of lung

Leech infestation causing upper gastrointestinal bleeding

This article present a case of hematemesis caused by a leech infesting the floor of the mouth, which was managed in Princess Haya Hospital in Aqaba/Jordan in October-2003. This pathological condition is extremely rare in urban areas but is frequent in endemic rural areas. We also highlighted some very interesting features of Leech due to chemicals they possess and their medicinal use

Testicular choriocarcinoma with gastric metastasis presenting as hematemesis.

We report a 28-year-old man who presented with hematemesis due to choricarcinoma of testis metastatic to the stomach. Gastroscopy showed a polypoidal lesion. Testicular wedge biopsy confirmed mixed germ cell tumor, the choriocarcinomatous portion alone getting metastasized to the stomach. He was initiated on chemotherapy with actinomycin-D, etoposide and methotrexate, but died due to multiple metastases to the lung and brain.

Gastric zygomycosis--an unusual cause of massive upper gastrointestinal bleed.

We report a 62-year-old man with cardiac failure and acute renal failure, who had massive hematemesis. Upper GI endoscopy showed a large gastric lesser curvature ulcer. Billroth II gastrectomy specimen showed fungal invasion. He received amphotericin B postoperatively, and recovered uneventfully.

Hematemesis in infants induced by cow milk allergy.

This study was conducted in order to analyze the clinical manifestations, the endoscopic findings, the histology of the gastrointestinal mucosa, the treatments and the clinical course in infants who had hematemesis induced by cow milk allergy. The medical records were reviewed retrospectively. The criteria for the diagnosis of CMA included elimination of cow milk formula resulting in improvement of symptoms, specific endoscopic and histologic findings as well as the exclusion of other causes. Twenty-three infants with a diagnosis of hematemesis were analyzed, which included 20 infants with CMA and 3 infants with gastroesophageal reflux disease (GERD). In the CMA group were 12 girls and 8 boys whose ages were 4.3 +/- 1.4 months. The onset of vomiting after starting cow milk formulas was 70.6 +/- 48.9 days. Gastroduodenoscopy was performed on 15 patients showing erythema, erosion and friability of the gastric mucosa in all patients and lymphoid hyperplasia in the duodenal bulb in 7 patients. Eight patients had mild to moderate eosinophilic infiltration and 5 patients had eosinophilia. Cow milk formulas were changed to other formulas: two children were initially given extensively hydrolyzed casein formulas and later followed by a soy formula, 14 were given a soy formula and 4 were given partially whey hydrolyzed formulas. All patients showed clinical signs of improvement a few days later. Patients that were able to tolerate cow milk were 1.5 +/- 0.9 years old. During the follow-up period (2.6 +/- 1.8 years after treatment) 4 patients were diagnosed with asthma, 4 patients with chronic respiratory symptoms, 4 patients with constipation and 2 others with food allergies. CMA induced gastritis in infancy may not be classified as eosinophilic gastritis because of the low level of eosinophilic infiltration. The elimination of cow milk and subsequent substitution with a soy formula is the proper management.

Aortoesophageal Fistula Associated with Tuberculous Mediastinitis, Mimicking Esophageal Dieulafoy's Disease

Aortoesophageal fistula is a rare and lethal disorder that may result from primary diseases of aorta or esophagus, aortic bypass graft, ingestion of foreign body, trauma, surgical procedure or instrumentation. Tuberculous fistula is extremely rare. We present a 27-yr-old female patient with aortoesophageal fistula associated with tuberculous mediastinitis. The patient experienced massive hematemesis and esophagoscopy revealed a small mucosal defect with exudate-coated blood vessel like Dieulafoy 's lesion on about 25 cm from the incisor teeth. Despite two sessions of endoscopic hemostatic procedures, active massive hemorrhage recurred and was controlled effectively with a prompt insertion of Sengstaken-Blakemore tube. The patient underwent open thoracotomy, which revealed aortoesophageal fistula. Numerous white-yellowish, millet seed-like tubercles were scattered in pleural and abdominal cavity. Division of fistular tract and esophageal resection with Ivor-Lewis anastomosis were performed. Histopathologic study confirmed tuberculous pleuritis and peritonitis. The patient died of postoperative pulmonary complication.