Successful hemostasis of active lower GI bleeding using a hemostatic powder as monotherapy, combination therapy, or rescue therapy.

BACKGROUND AND AIMS: Acute lower GI bleeding is a frequent cause of hospital admission. The objective of this study was to evaluate the safety and performance of a hemostatic powder (TC-325/Hemospray) in the treatment of nonvariceal lower GI bleeding. METHODS: Patients were enrolled into this prospective, multicenter, single-arm study at 4 tertiary care centers in Canada. Fifty patients with active lower GI bleeding of multiple different causes (52 bleeding sites) underwent topical endoscopic application of hemostatic powder. The primary endpoint was powder-related adverse events within 30 days of the index procedure. Secondary endpoints were initial hemostasis as well as recurrent bleeding and mortality within 30 days of the index procedure. RESULTS: Most patients (96%) had a single bleeding site, and most bleeding (73%) was due to polypectomy. Overall, the powder was applied as monotherapy in 13 bleeding sites (25%), as combination therapy in 22 bleeding sites (42.3%), and as rescue therapy in 17 bleeding sites (32.7%). Hemostasis was achieved in 98% of patients. No patient experienced a powder-related adverse event. Five patients (10%) developed recurrent bleeding within 30 days. One patient (2%) died within 30 days of powder application, but the death was not directly related to hemostatic powder use. CONCLUSIONS: The hemostatic powder is a safe and effective option for patients with lower GI bleeding of varying causes, and in particular, postpolypectomy hemorrhage. The hemostatic powder is effective as monotherapy, part of a combination approach, or as a rescue therapeutic option for the treatment of nonvariceal lower GI bleeding. (Clinical trial registration number: NCT02099435.).

Diverticulitis of the cecal appendix: a case report.

Appendicular diverticulosis is a rare condition. It is important to know its insidious form of presentation for its early diagnosis and treatment, thus diminishing morbimortality. In case of incidental findings, an appendicectomy will be performed to prevent complications and the development of malignancy.

Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey.

BACKGROUND: Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards. METHODS: IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated. RESULTS: A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001). CONCLUSIONS: EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.

Tuberculosis ileocecal: revisión de la literatura a partir de un caso clínico / Ileocecal tuberculosis: literature review from a case report

Tuberculosis (TB) remains a major public health challenge. The true incidence of intestinal TB is unknown, as it can be asymptomatic, and by its nature, often diverts its diagnosis to neoplastic diseases or inflammatory bowel disease. Therefore, we must have a high index of suspicion, not only in high risk populations and immunocompromised patients. Diagnostic tests that certify the pathology, don’t always achieve excellent performance. Endoscopic findings are not always clear in differentiating malignancy, and in some cases, a therapeutic trial may be needed to confirm the disease. We present the case of a patient with chronic diarrhea, consumptive syndrome and without respiratory symptoms at its onset.

La tuberculosis (TBC) sigue siendo un reto importante de salud pública. La verdadera incidencia de TBC intestinal es desconocida, ya que puede ser asintomática, y por su naturaleza a menudo desvía su diagnóstico a patologías neoplásicas o de enfermedad inflamatoria intestinal. Por lo tanto, se debe tener un alto índice de sospecha, no sólo en poblaciones de alto riesgo y en pacientes inmunocomprometidos. Las pruebas diagnósticas que certifiquen la patología no siempre se logran ni tienen un excelente rendimiento. Los hallazgos endoscópicos no siempre son claros para diferenciarla de una neoplasia, y en algunos casos una prueba terapéutica puede ser la confirmación de la enfermedad. Presentamos el caso de un paciente con diarrea crónica, cuadro consuntivo y sin síntomas respiratorios al inicio de su cuadro.

Outcome of Surgical and Medical Management of Cecal Impaction in 150 Horses (1991-2011).

OBJECTIVE: To evaluate short- and long-term outcome after medical and surgical management of horses with cecal impaction and to determine reasons for death or euthanasia. STUDY DESIGN: Retrospective case series. ANIMALS: Horses (n = 150). METHODS: Data collected from medical records (1991-2011) of horses with a diagnosis of cecal impaction, included signalment, history of recent disease/surgical procedure, admission data, management (medical, typhlotomy alone, jejunocolostomy), complications, and outcome. Short-term outcome (alive or dead at discharge) and long-term outcome (alive or dead at ≥1 year) were determined by telephone interview. Data were analyzed using a χ(2) or Fisher's exact test. Level of significance was P < .05. RESULTS: Of 150 horses hospitalized with a diagnosis of cecal impaction, 102 (68%) had a history of recent disease or a surgical procedure. Thirty-eight horses (25%) had cecal perforation at admission and 3 horses (2%) were euthanatized without treatment. Of 109 horses treated, 59 (54%) were managed medically and 50 (46%) surgically (typhlotomy [26]; jejunocolostomy [24]). The proportion of horses alive at hospital discharge was significantly lower for horses managed medically (61%) compared with surgically (82%; P = .02) but there was no difference between horses managed with typhlotomy alone (77%) or with jejunocolostomy (88%; P = .47). There were 57% of horses managed medically alive at 1 year. There was a similar proportion of horses alive at 1 year after typhlotomy alone (73%) and jejunocolostomy (70%; P = .86). CONCLUSIONS: Compared to the recent reports, the proportion of horses alive at hospital discharge was lower for both medically and surgically managed horses with cecal impaction. There was decreased survival for horses treated medically than those treated surgically; however, no significant difference was seen in survival between horses managed with typhlotomy alone versus jejunocolostomy.

Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease.

AIM: We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS: We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS: In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION: Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.

Typhoid fever with caecal ulcer bleed: managed conservatively.

Typhoid fever is caused by enteroinvasive Gram-negative organism Salmonella typhi. The well-known complications of typhoid fever are intestinal haemorrhage and perforation. In the pre-antibiotic era, these complications were quite common, but in the current antibiotic era the incidence of these complications is on the decline. We report a case of a patient with typhoid fever who developed haematochezia during the hospital stay and was found to have caecal ulcer with an adherent clot on colonoscopy. He was managed successfully with conservative measures without endotherapy and there was no rebleed.

Cecal pneumatosis intestinalis in obstructing sigmoid cancer: emergency metallic stenting.

An 85-year-old man presented with acute abdomen. Abdominal computed tomography revealed obstructing sigmoid colon cancer with pneumatosis intestinalis of the ascending colon. A surgeon was consulted for colonic obstruction with impending sepsis, who declined surgery considering the patient's advanced age. After discussion, the patient consented for emergent endoscopic metallic colonic stent placement. Complete obstruction of the lumen was observed at the sigmoid colon, followed by successful metallic colonic stent placement through the obstructed area. Normal stool passage was achieved after this, and the patient survived the 9-month follow-up period. Acute colonic obstruction from obstructive colon cancer requires emergency management, wherein the presence of pneumatosis intestinalis poses a high risk of cecal perforation. Emergency endoscopic colonic metallic stent placement provides an alternative therapy, particularly when surgery is not feasible, as described here.

Tubercular duodenal, jejunal and ileocecal stricture in a patient.

Gastrointestinal tuberculosis is a major health problem in the developing countries. Duodenal involvement is uncommon and can mimic superior mesenteric artery syndrome. Our case presented as proximal intestinal obstruction had tubercular stricture in the third part of the duodenum, proximal jejunum and ileocecal region, an uncommon and difficult intraoperative situation.

A therapeutic barium enema is a practical option to control bleeding from the appendix.

BACKGROUND: Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix. CASE PRESENTATION: A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months. CONCLUSIONS: A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Massive per rectal bleeding in a child due to caecal arteriovenous malformation treated successfully by embolisation.

A 12-year-old girl presented with a sudden onset of per rectal bleeding. After admission, she had further episodes of large volume per rectal bleeding and developed hypotensive shock. Hence a massive haemorrhage protocol was activated. Surgical, paediatric and anaesthetic support was sought immediately. Further resuscitation with packed red cells, platelets and fresh frozen plasma was successful. An urgent CT angiogram of the abdomen confirmed active arterial bleeding from an arteriovenous malformation in the caecum. After a detailed discussion between the surgeons and the interventional radiologists, it was decided to attempt therapeutic embolisation first, failing which surgery was the option. The patient and family were fully informed. Through a right femoral approach under local anaesthesia, the superior mesenteric artery was catheterised and the bleeding vessel was successfully controlled with two microembolisation coils. Except for some initial abdominal discomfort, she made an uneventful recovery and was discharged home.

[Successful conservative treatment of coecal perforation in a patient with Ogilvie's syndrome]. / Vellykket konservativt behandlet caecumperforation ved Ogilvies syndrom.

The case report describes a 37-year-old woman who was diagnosed with Ogilvie's syndrome after caesarean section. Conservative treatment was initiated with minimal effect, and the patient was subsequently treated with IV neostigmine. A computed tomography of the abdomen revealed enlarged peritoneal cavity. However the patient was clinically unaffected without fever or signs of peritonitis. The perforation was managed with a conservative approach including antibiotics and close observation of the patient. After nine days the patient was discharged with normal gastrointestinal function and without further reported complications.