Rare Cause of Hematochezia in Children: Solitary Rectal Ulcer, Single Center Experience.

Background/Aims: Solitary rectal ulcer syndrome (SRUS) can be overlooked, diagnosed late, or misdiagnosed, particularly in childhood. This study reviewed the 13-year experience of the authors' institution to increase clinicians' awareness of SRUS in the presence of symptoms. This paper reports the endoscopic and histopathological findings in children presenting with hematochezia. Methods: The clinical and laboratory findings of 22 patients diagnosed with biopsy-proven SRUS in the authors' clinic between 2007 and 2020 were evaluated retrospectively. Results: The mean age at diagnosis was 12.5±2.6 years, and 59.1% of the patients were male. The median time of diagnosis was 24 months. A single ulcer lesion was found by colonoscopy in 18 patients (81.8%), two ulcers in two patients (9%), and more than two ulcers in two patients (9%). The pathology reports of all biopsies taken from the lesions were consistent with a solitary rectal ulcer. In the first stage, the treatment was started with toilet training, a high-fiber diet, and laxatives. In 11 patients (50%) who did not respond to the initial treatment, a 5-ASA enema was added. A glucocorticoid enema was added to treatment in five patients (22%) whose complaints did not regress despite this treatment. Clinical remission was achieved in five of the patients (18.1%). The time to diagnosis was significantly shorter in those in remission than those not in remission (p=0.04). Conclusions: This study is the first large series on Turkish children. An increased awareness of SRUS in children will increase the rate of early diagnosis and treatment, allowing remission in more patients.

Effects of Psychological Nursing Combined with Comprehensive Nursing on Gastrointestinal Bleeding and Nutritional Status in Cirrhosis.

Objective: Cirrhosis of the upper GIB is a surgical emergency, PN and CN can reduce the risk of gastrointestinal bleeding, but there is a lack of analysis on PN combined with CN in Cirrhotic patients. This work explored the effects of psychological nursing (PN) combined with comprehensive nursing (CN) on gastrointestinal bleeding (GIB) and nutritional status of patients with cirrhosis. Methods: Total 80 patients with GIB and cirrhosis who received emergency treatment in the Affiliated Hospital of Shaoxing University from October 2019 to October 2022 were randomly rolled into two groups. Patients in the control group (Ctrl group) received CN (n = 40 cases), and those in the experimental group (Exp group) received PN combined CN (n = 40 cases). The Model for end-stage liver disease (MELD) score, self-rating anxiety scale (SAS), self-rating depression scale (SDS), SCL-90, complication rate, and nursing satisfaction of patients from different groups were analyzed and compared. MELD score effectively predicts short - and medium-term mortality in end-stage liver disease. SAS consisted of 20 questions related to anxiety symptoms, four-level scoring method was adopted. The SCL-90 scale included four aspects: somatic symptoms, interpersonal relationships, psychological emotions, and psychological needs. Results: The results disclosed that after nursing intervention, SAS, SDS, and MELD scores in the Exp group were remarkably lower than those in the Ctrl group (P < .05). The scores of SCL-90 somatic symptoms, interpersonal relationships, psychological emotion, and psychological needs of participants in the Exp group were much lower than those in the Ctrl group (P < .05). The complication rate was significantly lower in the Exp (30.0%) than in the Ctrl groups (72.5%) (P < .05). The total nursing satisfaction was increased, and it is significan higher in the Exp group (97.5%) than control group (87.5% ) (P < .05). Conclusions: In conclusion, PN combined with CN could effectively reduce the incidence of complications in patients with GIB and cirrhosis and improve nursing satisfaction. Therefore, such a method was worth promoting, which provides a reference for the clinical diagnosis and treatment of patients with GIB and cirrhosis.

Recurrent intestinal ulcer with bloody stool for >10 years in an adolescent boy of 15 years: A case report.

RATIONALE: Infectious diseases, autoimmune diseases and vascular diseases can lead to intestinal ulcers, and inflammatory bowel disease is typically suspected as the underlying cause of ulcer and bleeding from the intestinal ulcers leading to bloody stool, and malnutrition. Here we report a rare case of successfully treated case of intestinal ulcer, bloody stool, and malnutrition by dietary modification and avoidance of long term barbecued spicy food and carbonated drinks. PATIENT CONCERNS: A 15-year-old male patient had repeated symptoms of blood in the stool for >10 years. Treatment for Chron's disease was not successful. An exhaustive investigation failed to confirm the diagnosis. DIAGNOSIS INTERVENTIONS: Through changing diet structure, avoiding spicy food, and supplementing enteral nutrition and recurrent glutamine. OUTCOMES: The patient's symptoms improved significantly, and the intestinal ulcer healed under endoscope. LESSONS: Pay attention to healthy diet in life and avoid long-term consumption of spicy food and carbonated drinks.

Prevalence and prognostic significance of vitamin C deficiency in patients with acute upper gastrointestinal bleeding: a prospective cohort study.

BACKGROUND: Vitamin C is an essential dietary nutrient important for collagen synthesis, including within the gastrointestinal tract. AIM: We aimed to document the prevalence of Vitamin C deficiency (VCD) in patients who present with upper gastrointestinal bleeding (UGIB) and its association with clinical outcomes. METHODS: We conducted a prospective cohort study of patients presenting with UGIB. Fasting Vitamin C levels were collected at admission. Primary outcomes were the prevalence of VCD (Vitamin C level <23 µmol/L, severe VCD < 12 µmol/L) and a composite outcome of adverse events, stratified by VCD status. Secondary outcomes were prolonged hospitalisation and the need for ICU admission. RESULTS: A total of 227 patients were included (mean age 64.5 years, males 63.9%). VCD was identified in 74 (32.6%) and severe deficiency in 32 (14.1%) patients. VCD was associated with a higher composite endpoint of AE (45.9% vs 24.8%, p < 0.01), higher in-hospital mortality (9.5% vs 1.3%, p < 0.01), increased prolonged admissions (62.2% versus 47.1%, p = 0.03) and increased rebleeding (17.6% vs 7.8%, p = 0.03), compared with patients with normal Vitamin C levels. Multivariate logistic regression models showed that VCD was independently associated with the composite endpoint of AE. CONCLUSION: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding and length of stay. Interventional studies are required to determine the impact of early Vitamin C supplementation on clinical outcomes.

Creating a Safety Net Process to Improve Colon Cancer Diagnosis in Patients With Rectal Bleeding.

Background Failure to follow up on patients with rectal bleeding is common and may result in a delay in diagnosis of colorectal cancer or in missing high-risk adenomas. The authors' purpose was to create an electronic patient safety net for those diagnosed with rectal bleeding but who did not have colonoscopy to ensure proper detection of colonic abnormalities, including colon cancer. Methods In an integrated health delivery system serving < 4.6 million patients in Southern California, from 2014 to 2019, the authors electronically identified patients with rectal bleeding aged 45 to 80 years but with no recently documented colonoscopy. These cases were reviewed by a gastroenterologist to determine if colonoscopy was appropriate. The physician looked for known documentation as to the cause of rectal bleeding and verified no contraindications to the procedure; if indicated, testing was offered. Results Using the authors' safety net program, 1430 patients with rectal bleeding who needed and completed a colonoscopy were identified. Of those patients, 7.5% had an advanced adenoma or cancer, with a total of 20 cancers, and 34% had findings that warranted more frequent colonoscopy. Conclusions The authors designed a safety net system that was able to capture information on patients with rectal bleeding who had not had a colonoscopy and detected in 34% colonic pathology that would have otherwise gone undetected. The program did not require many resources to implement and had the ability to potentially prevent harm from reaching patients whose rectal bleeding did not get prompt workup. Other health systems and practices should consider implementing a similar system.

Common Conditions II: Acute Appendicitis, Intussusception, and Gastrointestinal Bleeding.

Perforated appendicitis continues to be a significant cause of morbidity for children. In most centers, ultrasound has replaced computed tomography as the initial imaging modality for this condition. Controversies surrounding optimal medical and surgical management of appendicitis are discussed. Management of intussusception begins with clinical assessment and ultrasound, followed by image-guided air or saline reduction enema. When surgery is required, laparoscopy is typically utilized unless bowel resection is required. The differential diagnosis for pediatric gastrointestinal bleeding is broad but often made with age, history, and physical examination. Endoscopy or laparoscopy is sometimes needed to confirm a diagnosis or for treatment.

Video Capsule Endoscopy Has a Minor Long-term Therapeutic Impact on Patients with Iron Deficiency Anemia.

BACKGROUND: One of the main causes of iron deficiency anemia (IDA) is chronic gastrointestinal blood loss. The use of video capsule endoscopy (VCE) after negative bidirectional endoscopy in patients with IDA is controversial. OBJECTIVES: To evaluate the effect of VCE in the management and long-term outcomes of IDA patients. METHODS: A retrospective case-control study was performed on all patients with IDA undergoing VCE over a 5-year period. We compared those with positive findings on VCE to those with normal findings. All participants previously underwent a negative bidirectional endoscopy. RESULTS: We performed 199 VCE examinations; median follow-up time was 4 years (IQR 2-5). Positive findings were identified in 66 patients (diagnostic yield 33.2%). Double balloon enteroscopy or push enteroscopy was performed in eight patients (18.6%); only one was therapeutic. The main therapy in both groups was iron supplementation. There were no significant differences in iron treatment before and after VCE in each group and between groups. Anemia improved in both groups. There was no difference in the level of hemoglobin change between the groups during each year of follow-up compared to the baseline level prior to VCE. Anemia resolved in 15 patients (35%) in the positive VCE group and in 19 (45%) in the negative VCE group (P = 0.33). CONCLUSIONS: Positive findings on VCE led to subsequent endoscopic interventions only in a small percentage of patients with IDA. Anemia improved and resolved equally whether or not there were VCE findings. The main intervention that appears to help IDA is iron supplementation.

Long-term rebleeding rate and predictive factors of rebleeding after capsule endoscopy in patients with obscure GI bleeding.

BACKGROUND AND AIMS: The incidence of rebleeding in obscure GI bleeding (OGIB) remains unclear. This study used capsule endoscopy (CE) to determine the long-term rebleeding rate and predictive factors for rebleeding in patients with OGIB. METHODS: This single-center, observational study enrolled consecutive patients with OGIB who underwent CE as the first small intestinal examination between March 2004 and December 2015 and were followed up through medical records or letters. RESULTS: Three hundred eighty-nine patients were included in the analysis. Survival curve analysis showed that the overall cumulative rebleeding rate in OGIB during the 5 years was 41.7%. Multivariate analysis using the Cox proportional hazards model revealed that overt OGIB (hazard ratio [HR], 2.017; 95% confidence interval [CI], 1.299-3.131; P = .002), anticoagulants (HR, 1.930; 95% CI, 1.093-3.410; P = .023), positive balloon-assisted enteroscopy findings after CE (HR, 2.927; 95% CI, 1.791-4.783; P < .001), and iron supplements without therapeutic intervention (HR, 2.202; 95% CI, 1.386-3.498; P = .001) were associated with rebleeding, whereas a higher minimum hemoglobin level (HR, .902; 95% CI, .834-.975; P = .009) and therapeutic intervention (HR, .288; 95% CI, .145-.570; P < .001) significantly reduced the risk of rebleeding. Among the Charlson Comorbidity Index components, liver cirrhosis was an independent predictor associated with rebleeding in patients with OGIB (HR, 4.362; 95% CI, 2.622-7.259; P < .001) and in patients with negative CE findings (HR, 8.961; 95% CI, 4.424-18.150; P < .001). CONCLUSIONS: Rebleeding is common during the long-term follow-up of patients with OGIB. Careful follow-up is required for patients with liver cirrhosis or previous massive bleeding.

Clinical Presentation of Cases with Upper Gastro - Intestinal Bleeding.

Acute upper gastrointestinal bleeding (UGIB) is a common emergency and can be a serious condition that requires hospitalization, rapid evaluation and management. The usual presentation is hematemesis (vomiting of blood or coffee ground-like material) and/or melena (black, tarry stools) 1. UGIB occurs more commonly in men and older subjects. PUD is the most common cause of UGIB in the US accounting for about 50% of the cases, whereas in tropical country like India, esophageal varices attribute to half the cases. Esophago-Gastro-Duodenoscopy [EGD] is a primary diagnostic and therapeutic modality in the setting of UGIB. MATERIAL: Prospective study. Forty patients who have presented with frank blood or coffee ground color vomitus and/or melena were considered for this study. All patients greater than 18 years of age were included. Their clinical presentation, hemogram and endoscopic findings were analyzed. Descriptive statistical analysis has been applied. OBSERVATION: In our study, the age distribution was between 23 and 87 years. There is a male preponderance with 65 % males and 35%females. Among 40 patients,42.5%had varices, 17.5% had Peptic Ulcer Disease and12.5% had Erosive Gastritis. The other causes of UGIB include Pangastritis(10%), Mallory Weiss Tear(7.5%), Polyp(5%), Esophagitis(2.5%), Coagulopathy induced bleed(2.5%) and Carcinoma stomach(2.5%). Of the 40 cases admitted, only 3 patients (7.5%) had massive Upper GI Bleed.10 patients (25%) had moderate bleed and 27 patients (67.5%) had mild bleed. Amongst the patients with massive bleed, an important cause is esophageal varices(66.7%). A total of 21 (52.5%) patients have recovered. There was one death(2.5%) amongst the cases which was not attributed to UGIB. 14 patients(45%) has residual disease of which 42.5% were of variceal bleed. Patients with variceal bleed have undergone banding and have been asked to regularly follow up for check endoscopy and banding till their eradication. There was 1 patient of residual disease with Carcinoma stomach(2.5%) who has been initiated on chemotherapy. CONCLUSION: Hematemesis is much commoner than melena in the presentation of upper GI bleed. EGD has a diagnostic as well as therapeutic role in UGIB .In this study endoscopy provided diagnosis in 97.5% of patients. In this cross sectional study, the most common cause of upper GI bleed was esophageal varices, with alcoholic cirrhosis being the main cause of portal hypertension. Varices remain to be the most common cause of UGIB in both males and females, however, the percentage is more in males as compared to females. Varices are an important cause of massive variceal bleed.

Gastrointestinal Bleeding in Congenital Bleeding Disorders.

Gastrointestinal bleeding (GIB) is serious, intractable, and potentially life-threatening condition. There is considerable heterogeneity in GIB phenotypes among congenital bleeding disorders (CBDs), making GIB difficult to manage. Although GIB is rarely encountered in CBDs, its severity in some patients makes the need for a comprehensive and precise assessment of underlying factors and management approaches imperative. Initial evaluation of GIB begins with assessment of hematological status; GIB should be ruled out in patients with chronic anemia, and in presentations that include hematemesis, hematochezia, or melena. High-risk patients with recurrent GIB require urgent interventions such as replacement therapy for treatment of coagulation factor deficiency (CFD). However, the best management strategy for CFD-related bleeding remains controversial. While several investigations have identified CBDs as potential risk factors for GIB, research has focused on assessing the risks for individual factor deficiencies and other CBDs. This review highlights recent findings on the prevalence, management strategies, and alternative therapies of GIB related to CFDs, and platelet disorders.

Proton Pump Inhibitor Co-Therapy in Patients with Atrial Fibrillation Treated with Oral Anticoagulants and a Prior History of Upper Gastrointestinal Tract Bleeding.

PURPOSE: The risk of gastrointestinal bleeding (GIB) can be mitigated by proton pump inhibitor (PPI) co-therapy in patients with atrial fibrillation (AF) treated with anticoagulants. We aimed to evaluate the effect of PPIs on the risk of GIB in Asian patients with AF, treated with oral anticoagulants (OACs), and with a prior history of upper GIB. METHODS: Using a nationwide claims database, OAC-naïve patients with AF and a history of upper GIB before initiating OAC treatment between January 2010 and April 2018 were included. Patients were categorized into 10 groups according to the index OAC (warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban) and whether or not they received PPI co-therapy, and were followed up for incidence of major GIB. RESULTS: Among a total of 42,048 patients, 40% were prescribed PPIs as co-therapy with OACs. Over a median 0.6 years (interquartile ranges 0.2-1.7 years) of follow-up, rivaroxaban use without PPIs showed the highest crude incidence of major GIB (2.62 per 100 person-years), followed by the use of warfarin without a PPI (2.20 per 100 person-years). Compared to the patients without PPI use, PPI co-therapy was associated with a significantly lower risk of major GIB, by 40% and 36%, in the rivaroxaban and warfarin groups, respectively. In dabigatran, apixaban, and edoxaban users, PPI co-therapy did not show a significant reduction in the risk of major GIB. CONCLUSION: Among patients with AF receiving anticoagulant treatment and with a prior history of upper GIB, PPI co-therapy was associated with a significant reduction in the risk of major GIB in patients treated with rivaroxaban and warfarin.

Iron Deficiency and the Small bowel​.

PURPOSE OF REVIEW: This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. RECENT FINDINGS: Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021.

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Obscure gastrointestinal bleeding caused by congenital enteropathy in a Chinese young child-a case report.

BACKGROUND: SLCO2A1 was recently reported to cause nonspecific ulcers at small bowel, it was named as chronic enteropathy associated with SLCO2A1 (CEAS). It was rarely reported beyond the Japanese population. CASE PRESENTATION: A 4-year-5-month old girl presented with intractable anemia since 1-year-3-month. Her stool occult blood test was positive and the result of esophagogastroduodenoscopy and colonoscopy were normal. She was considered as obscure gastrointestinal bleeding. The magnetic resonance enterography and ultrasound of small intestinal revealed segmental thickening of small bowel. The capsule endoscopy detected ulcers, erosion and slightly stenosis near the site of junction of jejunum and ileum. She was considered chronic non-specific multiple ulcers of the small intestine and was advised to have whole exon sequencing. She was treated with exclusive enteral nutrition and iron supplement for two months. However, she was not responsive to this treatment, then she had three doses of infliximab. At the same time, the next-generation sequencing of this patient revealed two novel compound heterozygous mutations in SLCO2A1. She was diagnosed with CEAS and was treated with oral mercaptopurine. Her hemoglobin level was stable and the serum albumin level was slightly decreased during the follow up. CONCLUSION: CEAS may present as nonspecific small bowel ulcers, and misinterpret as small bowel Crohn's disease. Genetic tests may help with the precise diagnosis of small bowel ulcers.

A 55-Year-Old Man With Cough and Hematochezia.

CASE PRESENTATION: A 55-year-old man presented to the ED with a 3-week history of worsening cough and shortness of breath. He had blood-tinged sputum, fever, night sweats, and a 2.7 kg weight loss within the same period. For the past few days, he had taken amoxicillin-clavulanate for presumed sinusitis. Despite this, his symptoms persisted, prompting him to seek further evaluation. His medical history was significant for ulcerative colitis and he had some bloody diarrhea for the past few weeks. Medications included aspirin, mesalamine, multivitamins, folic acid, and herbal supplements including gingko biloba, ginseng, and turmeric-ginger. He never smoked and drank alcohol occasionally. Family history was notable for stroke and myocardial infarction.

Sending in the ViCE Squad: Evaluation and Management of Patients with Small Intestinal Bleeding.

Bleeding from the small intestine remains a clinically challenging diagnostic and therapeutic problem. It may be minor, requiring only supplemental iron treatment, to patients who have severe overt bleeding that requires multimodal intervention. This article provides an up-to-date review of the state-of-the-art of diagnosis and treatment of small intestinal bleeding.

Is coffee ground vomiting important? Findings from a large bleeding unit database and outcomes at 30 days.

OBJECTIVES: 'Coffee ground' vomiting (CGV) has classically been considered a sign of upper gastrointestinal bleeding. There is a paucity of data concerning endoscopic findings and outcomes in patients presenting with CGV. The aim of this study was to analyze endoscopic yield and 30-day outcomes in CGV patients. METHODS: Analysis was performed over the period 1992-2005 and four groups were identified: CGV alone, hematemesis alone, melena alone, and hematemesis and melena. Endoscopic yield, requirement for blood transfusion, rebleeding, and mortality rate at 30 days were calculated and compared using logistic regression analysis. RESULTS: 6054 patients (mean age 61.3 years, 3538 male) were included in the study. The hematemesis group was younger compared with the other groups. Therefore, endoscopic yield was adjusted for age and sex. CGV was associated with a significantly lower risk of gastric ulcer, duodenal ulcer, varices, gastric cancer, esophageal cancer, and Mallory-Weiss tears compared with some or all of the other groups. CGV was associated with an increased risk of esophagitis and no source was found. CGV was associated with a lower rate of blood transfusion and rebleeding (all P < 0.0001) but 30-day mortality rates were similar. CGV was less likely to require endoscopic intervention compared with the other groups (all P < 0.001). CONCLUSIONS: CGV is associated with a lower endoscopic yield, requirement for blood transfusion, rebleeding rate, and potential for intervention compared to those with hematemesis, melena or both. Mortality rates are similar suggesting a nonbleeding cause and therefore questions the role of endoscopy in CGV.

Solitary Rectal Ulcer Syndrome in Children: A Report of 140 Cases.

OBJECTIVES: Solitary rectal ulcer syndrome (SRUS) is said to be rare in children (largest series so far; 55 in children, 116 in adults). We analyzed our experience to look at its clinical presentations, endoscopic appearance, and treatment outcome in a large cohort of children. METHODS: Clinical and endoscopic data were collected between 2000 and 2018. Children (18 years or younger) diagnosed to have SRUS on colonoscopy and confirmed by histopathology were included. All children with SRUS were treated with behavioral modification, bulk laxative. Most with ulcer received steroid enema and some sulfasalazine or sucralfate enema. RESULTS: The median age of 140 children was 12 (interquartile range [IQR]: 10-14) years, 79% were boys. The median symptom duration was 21 (IQR: 9-36) months. Rectal bleeding was the presenting feature in 131 (93.6%); constipation in 38 (27%); and small, frequent stools in 79 (56%). Most children had features of dyssynergic defecation such as prolonged sitting in the toilet (131, 93.6%), excessive straining (138, 98.6%), a feeling of incomplete evacuation (130, 92.8%), and rectal digitation (71, 50.7%). Rectal prolapse was noted in 24 (17%) cases. Colonoscopy documented rectal ulcer in 101 (72%) [Single: 84]. Over a median follow-up of 6 (IQR: 4-18) months, 27 patients were lost to follow-up and of the remaining 113 cases, 71 (62.8%) showed clinical improvement (healing of ulcer documented in 36/82, 44%). CONCLUSIONS: The majority of cases of SRUS presented in second decade with rectal bleeding and features of dyssynergic defecation. Ulcer was noted in three fourths of cases. The outcome of medical treatment with behavioral modification and local therapy was modest.