Active gastrointestinal bleeding: use of hemostatic forceps beyond endoscopic submucosal dissection.

To the best of our knowledge, this is the first report of the application of hemostatic forceps in active gastrointestinal (GI) bleeding that is not related to endoscopic submucosal dissection. An 86-year-old woman with chronic intake of low-dose aspirin had a Dieulafoy's lesion of the third duodenal portion. Bleeding control with epinephrine injection was unsuccessful. A 60-year-old man presented with a bleeding ulcer in the duodenal bulb. Ten days after combined endotherapy, he had recurrent bleeding from two minimal lesions in the same location. A 66-year-old woman under combined antithrombotic treatment was referred to us for chronic GI bleeding of unexplained origin. Endoscopy revealed active diverticular bleeding in the second duodenal portion. A 61-year-old woman underwent endoscopic mucosal resection of superficial gastric adenocarcinoma, which was complicated with immediate bleeding. In all cases, the blood was washed out using a water-jet-equipped, single-channel gastroscope with a large working channel. The bleeding points were pinched and retracted with hemostatic forceps. Monopolar electrocoagulation was performed using an electrosurgical current generator. Hemostasis was achieved. No complications occurred. In conclusion, hemostatic forceps may be an effective as well as safe alternative approach for active GI bleeding of various origins.

Endoscopic management of a tubular esophageal duplication diagnosed in adolescence (with videos).

BACKGROUND: Esophageal duplication is a rare congenital lesion. Surgery is the standard treatment. Tubular duplication is extremely rare, with esophageal communication in very few cases. OBJECTIVE: The aim of this study was to document the feasibility of the endoscopic management of tubular esophageal duplication. DESIGN: Case report. INTERVENTION: A 14-year-old boy presented with acute dysphagia and acute retrosternal pain. Based on his radiographic and endoscopic findings, a cystic esophageal duplication with an upper esophageal stricture was initially suspected. A laparoscopic gastrostomy was performed. A cyst resection through right thoracoscopy assisted by flexible endoscopy was decided upon. When no extraluminal cystic duplication was found, a tubular duplication was considered and the procedure was abandoned. An endoscopic treatment was performed. A standard endoscope was inserted through an upper esophageal stricture. Two lumens were identified 25 cm from the incisors. A pediatric endoscope was passed through the main one, revealing a thick intraluminal bridge. By using a guidewire, the endoscope's passage into the narrow lumen revealed a distal communication with the esophagus. With the guidewire left in place, the endoscope was reintroduced into the main lumen. A lengthwise incision of the bridge was performed by using a needle knife. At the end of the procedure, an esophageal dilation was performed. Histology confirmed the diagnosis of duplication. RESULTS: The endoscopic incision of the duplication was completed uneventfully. For 11 months, the patient followed a normal diet and experienced no symptoms. LIMITATIONS: Single case. CONCLUSION: To our knowledge, this is the first report of successful endoscopic incision of a total tubular esophageal duplication.

Trend in incidence of cardiovascular risk factors in elderly and over-aged stroke patients between 2003 and 2007 in Greece.

The aim of this study is to identify the main cardiovascular risk factors (CRFs) in patients over 65 years with ischemic stroke. This is a retrospective study in 175 patients that were hospitalized in our department due to ischemic stroke in the period 2006-2007. The patients were divided in two groups: Group I--elderly (65-80 years) and Group II--over-aged (>or=81 years). The results were compared with a similar study performed in our department in the period 2002-2003 in 160 ischemic stroke patients. Statistical analysis was made by the chi2-test. Hypertension, either alone or in combination with other CRFs, constitutes the main CRF. Diabetes mellitus (DM) is not frequently the sole CRF but its coexistence with other CRFs ranks DM as the second most important CRF, with the largest percentage in the elderly. Dyslipipidemia is 4th CRF in order following the coronary heart disease (CHD). Taking into account that the provision of acute therapeutic intervention in elderly and over-aged ischemic stroke patients is in most cases difficult, because of their age and the high risk of thrombolysis in these patients, there is increased need to focus on primary prevention of ischemic stroke by treating associated CRF.

Sodium-lithium countertransport activity in healthy, dyslipidemic, and hypertensive individuals.

The aim of our study was to investigate the role of dyslipidemia on red blood cell sodium-lithium countertransport activity in healthy and hypertensive individuals. A total of 128 Caucasian individuals, aged 20 to 60 years old, were divided into 4 groups: dyslipidemic/ hypertensive, dyslipidemic/normotensive, normolipidemic/hypertensive, and normolipidemic/ normotensive (controls). Sodium-lithium countertransport activity was determined based on the Canessa et al method. Sodium-lithium countertransport activity was significantly higher in all patient groups compared with controls (P < .001) and similar in the 3 patient groups. Sodium-lithium countertransport activity was significantly and positively associated with triglyceride levels (P < .001), body mass index (P < .001), total cholesterol levels (P = .001), and systolic (P = .001) and diastolic blood pressure (P = .001). In multivariate regression analysis, triglycerides made the largest contribution to sodium-lithium countertransport variation among the variables tested (R(2) = 0.273). Our results suggest that dyslipidemia affects sodium-lithium countertransport activity independently of essential hypertension and even to a greater extent than hypertension.

Detection of CD55- and CD59-deficient granulocytic populations in patients with myelodysplastic syndrome.

Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by absence of CD55 and CD59 from the surface of affected cells. PNH has been associated with myelodysplastic syndromes (MDS). The aim of our study was to estimate the prevalence of the PNH clone in MDS patients by detecting CD55 and CD59 deficiency. We studied 90 MDS patients: 19 patients with RA, 15 with refractory anemia with ringed sideroblasts (RARS), 18 with refractory anemia with excess of blasts (RAEB), 17 with refractory anemia with excess of blasts in transformation (RAEB-t), and 21 with chronic myelomonocytic leukemia (CMML). Twenty healthy individuals were also studied as the control group. We studied the PNH clone on granulocytes of these patients with the aid of flow cytometry. CD55- and CD59-deficient granulocytic populations were detected in 15.5% of MDS patients compared to 2.8% of normal individuals. Among the subgroups of the study, significant difference was present in three cases: (1) between CMML and control, (2) between CMML and RA, and (3) between CMML and RARS. These data indicate a possible association between PNH phenotype and MDS. MDS patients of worse prognosis (CMML) express more strongly the PNH clone compared to those of better prognosis (RA and RARS). Perhaps, the examination of MDS patients for the PNH clone by flow cytometry could provide us with a valuable prognostic tool.

Acute pancreatitis as a possible consequence of metronidazole during a relapse of ulcerative colitis.

We present the first case of metronidazole-related acute pancreatitis during a relapse of ulcerative colitis. A 31-year-old male patient, with inflammatory bowel disease on mesalamine treatment for the last 5 months, suffered from a 48-h abdominal pain and nausea. He was also administered metronidazole during a relapse 5 days before. Laboratory and imaging investigation revealed acute pancreatitis. Conservative measures and metronidazole as well as mesalamine withdrawal resulted in complete recovery. Clinical remission of ulcerative colitis was obtained by prednisolone administration. Mesalamine was reintroduced and no recurrence was noticed for a year. Acute pancreatitis was mainly attributed to metronidazole owing to the absence of recurrence after mesalamine readministration, the time of onset after the initiation of metronidazole and the lower typical range between its onset and mesalamine exposure. Identifying acute pancreatitis as a possible consequence of a certain medication in inflammatory bowel disease patients may be particularly important to determine further treatment of their disease.

Incidence and etiology of acute non-malignant upper gastrointestinal bleeding in northern Greece.

AIM: To evaluate the incidence and etiology of acute non-malignant upper gastrointestinal bleeding (ANMUGIB) in northern Greece due to increased use of non-steroidal anti-inflammatory drugs (NSAIDs), including low-dose aspirin (L-A), exposure and geographical variability of Helicobacter pylori (Hp) seroprevalence. METHODS: A retrospective study of 110 patients admitted for hematemesis or melena during a 6-month period. All patients had undergone a gastrointestinal (GI) endoscopy during hospitalization. The presence of Hp was identified by biopsies and a (13)C-urea breath test in the case of Hp(-) biopsy bleeding peptic ulcer (BPU). The activity of ANMUGIB was assessed according to Forrest's classification. Statistical analysis was made by the chi(2)-test and Yates' correction. RESULTS: Most patients were in the two medium age groups with no significant difference between them (P < 0.001). NSAID or L-A (100 mg/day) use was reported in 42.73% of patients in a ratio 1:1 (P > 0.1) and Hp infection was found in 29.09% of patients. BPU, with approximately two-thirds in the bulb, erosions and varices were the most frequent sources. Hp infection was found in 60.65% of BPU, 65.57% were related to NSAIDs or L-A and 8.19% were non-Hp non-NSAID/L-A BPU. Flat spots were most commonly found with a significant difference (P < 0.001) to other stigmata of recent bleeding, except for clean base. CONCLUSIONS: In northern Greece, persons aged over 40 years are prone to ANMUGIB with a non-significant relationship to males. Hp infection and medication use, such as NSAIDS and L-A, are deeply involved in its etiology. Non-Hp non-NSAID/L-A BPU are a small proportion. ANMUGIB seems to have a generally good prognosis.

Public health and potential complications of novel fashion accessories: an unusual foreign body in the upper gastrointestinal tract of an adolescent.

Various foreign bodies (FB) may be ingested. Most of them harmlessly pass through the anus but sharp or pointed ones are likely to cause complications. Although FB's ingestion is commonly seen by the emergency room personnel, a case of an ingested tongue-ring in the stomach of a female adolescent has not been reported. A 16-year-old female was referred to us for swallowing a tongue-ring while eating, a day after she had swallowed its clip. After finishing her meal, she had replaced the ingested tongue-ring with a similar one! She had a history of accidental swollowing the clip during breakfast a day before as well. She had no history of mental illness, alcohol or drug abuse. An abdominal X-ray confirmed their presence in the gastrointestinal tract. On endoscopy, an intact esophagus' mucosa, a stomach filled with food, her tongue-ring in its greater curvature and a patulous pyloric channel were observed. She was turned in the right lateral position and small amounts of water were carefully used in order to shift the food residues to the antrum. The slippery object was grasped by a biopsy forceps and it was pulled out gently. The procedure was uneventful and she was discharged home on the same day. Our case of a tongue-ring ingested by an adolescent demonstrates a troublesome and possibly dangerous consequence of certain fashion accessories' easy adoption especially by younger subjects. It does not only send a social message, but it also might represent the first example of a potentially emerging medical condition.