Severity and Outcomes of Upper Gastrointestinal Bleeding With Bloody Vs. Coffee-Grounds Hematemesis.

OBJECTIVES: Numerous reviews indicate bloody hematemesis signifies more severe bleeding than coffee-grounds hematemesis. We assessed severity and outcomes related to bleeding symptoms in a prospective study. METHODS: Consecutive patients presenting with hematemesis or melena were categorized as bloody emesis (N=1209), coffee-grounds emesis without bloody emesis (N=701), or melena without hematemesis (N=1069). We assessed bleeding severity (pulse, blood pressure) and predictors of outcome (hemoglobin, risk stratification scores) at presentation, and outcomes of bleeding episodes. The primary outcome was a composite of transfusion, intervention, or mortality. RESULTS: Bloody and coffee-grounds emesis were similar in pulse ≥100 beats/min (35 vs. 37%), systolic blood pressure ≤100 mm Hg (12 vs. 12%), and hemoglobin ≤100 g/l (25 vs. 27%). Risk stratification scores were lower with bloody emesis. The composite end point was 34.7 vs. 38.2% for bloody vs. coffee-grounds emesis; mortality was 6.6 vs. 9.3%. Hemostatic intervention was more common (19.4 vs. 14.4%) with bloody emesis (due to a higher frequency of varices necessitating endoscopic therapy), as was rebleeding (7.8 vs. 4.5%). Outcomes were worse with hematemesis plus melena vs. isolated hematemesis for bloody (composite: 62.4 vs. 25.6%; hemostatic intervention: 36.5 vs. 13.8%) and coffee-grounds emesis (composite: 59.1 vs. 27.1%; hemostatic intervention: 26.4 vs. 8.1%). CONCLUSIONS: Bloody emesis is not associated with more severe bleeding episodes at presentation or higher mortality than coffee-grounds emesis, but is associated with modestly higher rates of hemostatic intervention and rebleeding. Outcomes with hematemesis are worsened with concurrent melena. The presence of bloody emesis plus melena potentially could be considered in decisions regarding timing of endoscopy.

Terlipressin Induced Severe Hyponatremia.

Terlipressin is a vasopressin analogue used for its vasoconstrictor effect in the treatment of variceal bleeding. Despite its good safety profile compared to vasopressin, some adverse reactions may occur during its use - e.g. hyponatremia. We describe a case of a cirrhotic patient with active variceal bleeding treated during two separate hospitalizations with terlipressin. In both drug treatment periods, severe laboratory hyponatremia developed. After terlipressin discontinuation, mineral disbalance corrected rapidly. Positive dechallenge and rechallenge corresponding to the drug administration schedule confirms the causality between terlipressin administration and hyponatremia. Hyponatremia was preceded with substantial fluid retention in both episodes. In this case report we want to highlight the need for fluid balance monitoring immediately after first terlipressin dose, which may individually predict the patient risk for the development of hyponatremia as other risk factors have rather limited predictive value in real clinical settings.

Effect of acute upper gastrointestinal bleeding manifestations at admission on the in-hospital outcomes of liver cirrhosis: hematemesis versus melena without hematemesis.

OBJECTIVES: Patients with acute upper gastrointestinal bleeding (AUGIB) often manifest as hematemesis and melena. Theoretically, hematemesis will carry worse outcomes of AUGIB. However, there is little real-world evidence. We aimed to compare the outcomes of hematemesis versus no hematemesis as a clinical manifestation of AUGIB at admission in cirrhotic patients. METHODS: All cirrhotic patients with AUGIB who were consecutively admitted to our hospital from January 2010 to June 2014 were considered in this retrospective study. Patients were divided into hematemesis with or without melena and melena alone without hematemesis at admission. A 1:1 propensity score matching analysis was performed. Subgroup analyses were performed based on systemic hemodynamics (stable and unstable) and Child-Pugh class (A and B+C). Sensitivity analyses were conducted in patients with moderate and severe esophageal varices confirmed on endoscopy. Primary outcomes included five-day rebleeding and in-hospital death. RESULTS: Overall, 793 patients were included. Patients with hematemesis at admission had significantly higher five-day rebleeding rate (17.4 versus 10.1%, P = 0.004) and in-hospital mortality (7.9 versus 2.4%, P = 0.001) than those without hematemesis. In the propensity score matching analyses, 358 patients were included with similar Child-Pugh score (P = 0.227) and MELD score (P = 0.881) between the two groups; five-day rebleeding rate (19.0 versus 10.6%, P = 0.026) and in-hospital mortality (8.4 versus 2.8%, P = 0.021) remained significantly higher in patients with hematemesis. In the subgroup and sensitivity analyses, the statistical results were also similar. CONCLUSIONS: Hematemesis at admission indicates worse outcomes of cirrhotic patients with AUGIB, which is useful for the risk stratification of AUGIB.

Hepatic and Gastric Involvement in a Case of Systemic Sarcoidosis Presenting with Rupture of Esophageal Varices.

A 46-year-old woman presented with massive hematemesis, caused by the rupture of esophageal varices. The laboratory investigations showed pancytopenia, and imaging tests revealed hepatosplenomegaly and ascites. A diagnosis of systemic sarcoidosis was made based on biopsies of the liver, stomach, lungs, heart, and skin. Although fat deposition was predominant, non-caseating granuloma and cirrhotic changes were found in the liver. Non-caseating granuloma was also identified in a biopsy specimen from minute depressions of the gastric folds. This case illustrates the rare involvement of the digestive system in a case of systemic sarcoidosis.

Traumatic pseudoaneurysm of the pharyngeal artery: An unusual cause of hematemesis and hematochezia after craniofacial trauma.

BACKGROUND: Traumatic aneurysms of the internal maxillary artery are extremely rare. We report a case of traumatic pseudoaneurysm of the pharyngeal artery, a branch of the internal maxillary artery, presenting with hematemesis and hematochezia. CASE DESCRIPTION: An 18-year-old man presented with deep drowsy consciousness after a motor vehicle accident, in which he had a severe craniofacial injury. Three days later, he had hematemesis and hematochezia with a marked decrease in circulating hemoglobin level. External carotid arteriography performed to rule out vascular injury revealed active leakage from a false aneurysm of the pharyngeal artery. The lesion was successfully obliterated by superselective endovascular embolization. CONCLUSIONS: In patients with craniofacial injury associated with multiple traumas, traumatic pseudoaneurysm of the pharyngeal artery should be suspected as one of the possible causes of hematemesis and hematochezia. Selective endovascular embolization with cerebral angiography is an effective modality for the treatment and diagnosis of this lesion.

Therapeutic Antibody-Induced Vascular Toxicity Due to Off-Target Activation of Nitric Oxide in Cynomolgus Monkeys.

PRO304186, a humanized monoclonal antibody targeting soluble interleukin-17 A and F, was developed for autoimmune and inflammatory disease indications. When administered to cynomolgus monkeys PRO304186 induced unexpected adverse effects characterized by clinical signs of hematemesis, hematochezia, and moribundity. Pathology findings included hemorrhage throughout the gastrointestinal tract without any evidence of vascular wall damage or inflammatory cellular infiltration. Mechanistic investigation of these effects revealed mild elevations of serum MCP-1 and IL-12/23 but without a classical proinflammatory profile in PRO304186-treated animals. In vitro studies demonstrated off-target effects on vascular endothelial cells including activation of nitric oxide synthase leading to production of nitric oxide (NO) accompanied by increased mitochondrial membrane depolarization, glutathione depletion, and increased paracellular permeability. Additionally, endothelial cell-PRO304186-conditioned medium reduced myosin light chain phosphorylation in vascular smooth muscle cells. Furthermore, an ex vivo study utilizing segments from cynomolgus aorta and femoral artery confirmed PRO304186-induced endothelium-dependent smooth muscle relaxation and vasodilation mediated via NO. Finally, a single dose of PRO304186 in cynomolgus monkeys induced a rapid and pronounced increase in NO in the portal circulation that preceded a milder elevation of NO in the systemic circulation and corresponded temporally with systemic hypotension; findings consistent with NO-mediated vasodilation leading to hypotension. These changes were associated with non-inflammatory, localized hemorrhage in the gastrointestinal tract consistent with hemodynamic vascular injury associated with intense local vasodilation. Together, these data demonstrate that PRO304186-associated toxicity in monkeys was due to an off-target effect on endothelium that involved regional NO release resulting in severe systemic vasodilation, hypotension, and hemorrhage.

Comparison of Direct and Indirect Laryngoscopes in Vomitus and Hematemesis Settings: A Randomized Simulation Trial.

BACKGROUND: Videolaryngoscopes may not be useful in the presence of hematemesis or vomitus. We compared the utility of the Macintosh laryngoscope (McL), which is a direct laryngoscope, with that of the Pentax-AWS Airwayscope (AWS) and McGRATH MAC (McGRATH), which are videolaryngoscopes, in simulated hematemesis and vomitus settings. METHODS: Seventeen anesthesiologists with more than 1 year of experience performed tracheal intubation on an adult manikin using McL, AWS, and McGRATH under normal, hematemesis, and vomitus simulations. RESULTS: In the normal setting, the intubation success rate was 100% for all three laryngoscopes. In the hematemesis settings, the intubation success rate differed significantly among the three laryngoscopes (P = 0.021). In the vomitus settings, all participants succeeded in tracheal intubation with McL or McGRATH, while five failed in the AWS trial with significant difference (P = 0.003). The intubation time did not significantly differ in normal settings, while it was significantly longer in the AWS trial compared to McL or McGRATH trial in the hematemesis or vomitus settings (P < 0.001, compared to McL or McGRATH in both settings). CONCLUSION: The performance of McGRATH and McL can be superior to that of AWS for tracheal intubation in vomitus and hematemesis settings in adults.

Downhill oesophageal variceal bleeding: A rare complication in Behçet's disease-related superior vena cava syndrome.

Behçet's disease (BD) is a multisystemic disorder that involves vessels of all sizes. Superior vena cava (SVC) thrombosis is a rare complication that can lead to the development of various collateral pathways. A 31-year-old man presented with SVC syndrome. He had a history of recurrent genital aphthosis. Computed tomography revealed extensive thrombosis of the right internal jugular, axillary, and subclavian veins with collateral circulation. The patient was diagnosed with BD, and he was started on anticoagulation and immunosuppressive therapy. One week later, he presented with haematemesis. Upper gastrointestinal endoscopy disclosed varices in the upper third of the oesophagus with stigmata of recent bleeding. Portal hypertension was ruled out. Anticoagulation therapy was discontinued. He was discharged on immunosuppressive therapy. Bleeding from downhill oesophageal varices should be suspected in any patient presenting with upper gastrointestinal bleeding and a history of SVC syndrome due to BD.

Hyperfibrinolysis in hepatosplenic schistosomiasis.

AIM: To evaluate the nature of accelerated fibrinolysis in hepatosplenic schistosomiasis. METHODS: The biological activity of plasminogen (Plg), plasminogen activators (PA), alpha 2-antiplasmin (alpha 2-AP) and plasminogen activator inhibitor-1 (PAI-1) was determined by photometric analysis in 15 compensated and 35 decompensated patients with endemic Egyptian hepatosplenomegaly. Quantitative measurement of plasma concentrations of tissue t-PA, t-PA-PAI-1 complex, alpha 2-antiplasmin-plasmin complex (alpha 2-APP), fibrinogen degradation products (FbDP), D-dimers (D-D), thrombin-antithrombin complex (TAT) and prothrombin fragment (F 1 + 2) complexes, using double antibody sandwich enzyme linked immunosorbent assays and grading of the degree of hepatic insufficiency according to the Child-Pugh classification, were also carried out. RESULTS: The progressive deterioration of liver function in schistosomal patients, which matched the severity of the disease, led to simultaneous defects in profibrinolytic (decreased Plg and increased PA and t-PA) and antifibrinolytic (decreased alpha 2-AP and PAI-1) factors-the latter defects being the most prominent-resulting in significant generation of plasmin (increased APP complexes) and therefore enhanced fibrinolysis (increased FbDP and D-dimer). The raised concentrations of FbDP, D-D, TAT and F 1 + 2 established its secondary nature. CONCLUSION: These findings suggest that the amount of PAI-1 available to bind and neutralise circulating t-PA may be a critical factor in the progress of hyperfibrinolysis observed in hepatosplenic schistosomiasis, and that the pronounced reduction in its plasma concentration may be regarded as a potential warning indicator of haemostatic imbalance in decompensated schistosomal patients at high risk of variceal bleeding.

Hepatitis and hematemesis complicating nicotinic acid use.

Nicotinic acid has a proven efficacy in the treatment of hypercholesterolemia. Therapeutic use of this water-soluble B vitamin has resulted in a survival benefit among patients enrolled in the Coronary Drug Project. Conversely, nicotinic acid has been associated with a high side-effect profile when used at therapeutic doses. Nevertheless, there are no previously reported cases of hematemesis temporally associated with nicotinic acid use. The authors report the case of a previously healthy 20-year-old man who developed hematemesis and hepatitis 1 week after self-initiating the daily consumption of 6 g of nicotinic acid. Supportive therapy and discontinuing nicotinic acid resulted in rapid clinical improvement in this patient. The clinical circumstances suggest a possible causal relationship between nicotinic acid consumption and his presenting problems. The use of large doses of nicotinic acid may be rapidly complicated by hematemesis and hepatitis.

Esophagitis in infants with hypertrophic pyloric stenosis: a source of hematemesis.

This study was undertaken to clarify the source of blood in the vomitus of patients with hypertrophic pyloric stenosis (HPS). Twenty-one infants with HPS were examined. Hematemesis was noted in 14 infants. Esophagogastric endoscopy showed a 100% incidence of esophagitis and in one patient gastric erosion was also observed. Histological study of the esophageal mucosa showed evidence of esophagitis in 18 patients (85.7%). Preoperative pH monitoring showed gastroesophageal reflux (GER) in all infants. Excessive acid exposure (> or = 7%) was significantly correlated with the grade of esophagitis and the incidence of hematemesis, whereas acid exposure time was shorter in the cases without histological esophagitis. These results suggested that the source of bleeding in HPS is the esophageal mucosa affected by esophagitis secondary to excessive acid reflux. Although there is obvious massive gastroesophageal reflux in HPS, it is too difficult to evaluate the lower esophageal sphincter function in HPS.

[Bleeding of gastric ulcers. Epidemiologic, clinical and functional characteristics]. / Il sanguinamento da ulcera gastrica. Caratteristiche epidemiologiche, cliniche e funzionali.

The frequency of gastrointestinal haemorrhage due to gastric ulcer has been assessed in 254 personally observed patients suffering from this endoscopically verified pathology. 56 patients, namely 22% of the cases, presented haematemesis and/or melena of the ulcerative lesion. This subgroup was compared with 65 patients with endoscopically verified gastric ulcer without previous bleeding episodes from the lesion in their clinical history, in respect of certain epidemiological, clinical and biohumoral features. The purpose of the study was to check the possible existence of clinical and/or physiopathological differences between subjects with bleeding gastric ulcer and the population of non-bleeding ulcer patients. In 80% of patients studied, the gastric ulcerous disease started with digestive haemorrhage and it was not accompanied by dyspeptic-painful symptomatology in 20% of cases. The pain symptomatology does not appear to be influenced by the intake of non-steroid anti-phlogistic drugs. No significant difference emerges between the two groups considered as regards epidemiological features and biohumoral data (PG I, gastrin, B.A.O. and M.A.O.).

Neonatal hypertrophic pyloric stenosis: congenital or infantile?

Hypertrophic pyloric stenosis (HPS) is very rare during the newborn period. Here we present a fullterm male neonate with abundant hematemesis 12 hours after birth which interrupted oral feeding. Bleeding subsided within three days after conservative measures, and oral feeding was restarted but not tolerated. The vomiting was effortless and nonbilious. An upper gastrointestinal series revealed gastric dilatation and partial obstruction of the gastric outlet. HPS was found by laparotomy on the fourth day and Fredet-Ramstedt pyloromyotomy relieved the gastric emptying. This is one of the few cases of HPS present at birth, which was diagnosed and surgically treated early, and we suggest a congenital etiology in previously reported cases of HPS. Hypertrophic pyloric stenosis (HPS) is a common cause of pediatric surgery. Usually young infants are involved; HPS is extremely rare in neonates and infants older than 6 months. Vomiting typically begins between the 3rd and 6th week of life, although some infants may have mild symptoms like regurgitation from birth.

The utility of upper endoscopy in patients with concomitant upper gastrointestinal bleeding and acute myocardial infarction.

Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996-December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%-4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.