Nebulized Vasopressin for the Control of Hematemesis and Hemoptysis in a Child With Recurrent, Refractory Stage III Burkitt Lymphoma.

BACKGROUND: Bleeding occurs with some regularity at the end of life. Patients often endure fatigue, weakness, pain, dyspnea and anxiety. These symptoms are magnified in visually apparent bleeds. Management can be particularly challenging as we attempt to balance therapies with goals of care. Children are at risk for such complications and symptoms; providers must ensure comfort for both the patient and family. CASE DESCRIPTION: A 7-year-old male with recurrent, refractory Burkitt lymphoma was frequently hospitalized for palliative chemotherapy and disease complications. On his final admission, he experienced gross hemoptysis and hematemesis: he was short of breath, fatigued and anxious due to his blood loss. His and his family's angst were heightened by "seeing" his bleed. Potential, especially invasive, treatments were limited by our goals to promote comfort, limit interventions, maintain alertness, poor intravenous access and a small bowel obstruction. Nebulized vasopressin, 10 units in 4ml of normal saline given over 10 minutes provided JC with needed relief. His bleeding remitted and he tolerated its administration. CONCLUSION: There are many treatments for hemorrhage; however, given the challenges of goals of care, administration, side-effects and tolerability, further investigation into nebulized vasopressin as a potential therapy for hemoptysis and hematemesis at the end-of-life is warranted.

Severe gastrointestinal hemorrhage related to everolimus: a case report.

Everolimus is an mTOR (the mammalian target of rapamycin) inhibitor, which is used for the treatment of advanced renal cell carcinoma. Life-threatening hemorrhages are extremely rare adverse effect of everolimus. We herein report a successfully treated case of severe everolimus-related gastrointestinal hemorrhage by emergency surgical resection for patient with advanced renal cell carcinoma. A 72-year-old male was diagnosed with renal cell carcinoma, for which everolimus was administered after unsuccessful treatment with sunitinib and sorafenib. The patient suddenly developed hematemesis 4 weeks after administration. Upper gastrointestinal endoscopy showed gastric antral vascular ectasia. Once the hemorrhage was successfully cauterized by argon plasma coagulation, everolimus was discontinued. However, the patient after re-administration of everolimus developed hematemesis again and exhibited hemorrhage shock. Since therapeutic endoscopy could not achieve hemostasis, the patient underwent emergency distal gastrectomy with Billroth I reconstruction. The patient's vital signs and hemoglobin level stabilized after the surgery. Thereafter, the patient made a satisfactory recovery, and was discharged on postoperative day 10.

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study.

BACKGROUND: Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD. METHODS: In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl. RESULTS: Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment. CONCLUSIONS: Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.

Advances and pitfalls in the management of small bowel polyps in Peutz-Jeghers syndrome

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Extrahepatic portal vein obstruction in Egyptian children.

BACKGROUND AND AIM: Extrahepatic portal vein obstruction (EHPVO) is an important cause of portal hypertension in children. The aim of this study was to describe the clinical presentation, possible risk factors, upper gastrointestinal endoscopic findings, and treatment modalities of children with EHPVO. METHODS: After ethical approval of our study protocol by our institution review board, we analyzed available data from medical records of patients with EHPVO presenting to the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Egypt, for a period of 15 years from January 1996 to December 2010. RESULTS: The study included 169 patients. Their ages at presentation ranged from 1 month to 12 years (median 2.5 years, interquartile range 5); 101 were boys. Hematemesis was a presenting symptom in 58%, splenomegaly was present in 87%, esophageal varices were present in 94%, and fundal varices were present in 23%. Possible risk factors, in the form of umbilical catheterization, umbilical sepsis, and exchange transfusion, were elicited in 18%. Propranolol was associated with reduction in bleeding episodes (P < 0.001), but was associated with increased chest symptoms (P < 0.01). Both injection sclerotherapy and band ligation were effective in the management of bleeding varices and for primary and secondary prophylaxis; however, injection sclerotherapy was associated with the development of secondary gastric varices (P = 0.03). CONCLUSIONS: This large study of children with EHPVO demonstrates the efficacy of propranolol in the reduction of gastrointestinal bleeding in children with EHPVO. Both injection sclerotherapy and band ligation were effective in the management of esophageal varices, although the former was associated with the development of secondary gastric varices. Randomized clinical trials to choose the best modalities for the management of portal hypertension in children are still lacking.

An odd lump in the oesophagus - diagnostic and therapeutic approach?

A 60-year-old woman initially presented with a history of mild haematemesis. The patient denied any dysphagia, weight loss, or fever, intake of non-steroidal anti-inflammatory drugs or excessive alcohol consumption. She did not have abdominal pain and had not observed blood in her stools or melaena. At upper endoscopy, a potential source of bleeding could not be detected, but a subepithelial mass in the mid-oesophagus was revealed. The diagnostic and therapeutic approach to subepithelial oesophageal lesions is discussed.

Continuous proton pump inhibitor treatment decreases upper gastrointestinal bleeding and related death in rural area in Japan.

BACKGROUND AND AIMS: Proton pump inhibitors (PPI) have been rarely used for prevention of upper gastrointestinal bleeding (UGIB) induced by non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin in Japan. The increased incidence of UGIB in the aged society is becoming a serious problem. The aim of this study was to retrospectively evaluate whether PPI can prevent UGIB. METHODS: We examined records of 2367 patients (aged 67.9 ± 15.1 years, male 1271) attending the only hospital serving the rural area, with little population movement. We investigated the correlation between the frequency of usage of medicine (PPI, histamine 2 receptor antagonists [H2RA], NSAIDs, aspirin) and incidence of UGIB over 12 years. UGIB was defined as cases with hematemesis and/or melena and definite bleeding at upper gastrointestinal endoscopy. The annual incidence of UGIB of inhabitants (16,065 ± 375.3 persons/year) was evaluated. The frequency of usage of medicine was compared with the total number of patients prescribed any medication (1080 ± 33.2 persons/year). RESULTS: The frequency of PPI usage has increased significantly 4.6%→30.8% (P < 0.05). NSAIDs and aspirin usage increased significantly in the latter half of the survey period (P < 0.05). The annual incidence of UGIB significantly decreased 160.8 →23.6/100,000 inhabitants per annum (P ≤ 0.05) due to widespread use of PPI. No patients died due to UGIB after 2006. The incidence of UGIB and the prevalence of PPI usage were found to have a negative correlation (r = -0.804, P = 0.0016). CONCLUSIONS: By widespread use of PPI, UGIB and related death has declined significantly. This survey showed that continuous PPI treatment decreases UGIB and related death in community medicine.

Arterioportal fistula causing jejunal variceal hemorrhage.

Hepatoportal arteriovenous fistulas are an uncommon cause of portal hypertension and may lead to severe gastrointestinal bleeding. Esophageal varices are the main source of hemorrhage in patients with portal hypertension. We report a 40-year-old man with a hepatic arterioportal fistula, who had gastrointestinal bleeding from jejunal varices. He had had hematemesis four years previously and was diagnosed as esophageal variceal bleeding secondary to hepatic arterioportal fistula-complicated portal hypertension. The fistula had been successfully closed with a detachable balloon but it was found to have reformed during his recent hospitalization for jejunal variceal bleeding. Alcoholism and development of portal vein thrombosis afterwards were the other contributing factors for jejunal variceal formation. Hemorrhage was controlled with medical treatment. Since he refused any surgical intervention he was discharged and advised to continue follow-up.

Gastroesophageal reflux disease in intellectually disabled individuals: leads for diagnosis and the effect of omeprazole therapy.

OBJECTIVES: The therapeutic approach to gastroesophageal reflux disease (GERD) in intellectually disabled individuals has not been studied extensively. So far, only low response rates to medical and surgical therapy of GERD have been reported. However, the efficacy of proton pump inhibitors, to date the most effective medical therapy for GERD, has never been evaluated in this population. Our purpose, therefore, was to study the effect of omeprazole on healing and symptom relief in the intellectually disabled. METHODS: The treatment scheme was as follows: omeprazole 40 mg was given once daily (o.d.) as a healing dose for 3 months, and omeprazole 20 mg o.d. was given as a maintenance dose for another 3 months, to intellectually disabled subjects with endoscopically proven esophagitis, grades I-IV, according to Savary-Miller classification. After 3 and 6 months, the result of this treatment was evaluated by symptom scoring and/or endoscopy. In case of relapse, the dose was increased. RESULTS: At the first endoscopy, 40 of 107 patients (37%) had grade I, 36 (34%) grade II, 18 (17%) grade III, and 13 (12%) grade IV esophagitis. In 92 of 104 patients (88%), the treatment scheme was effective in healing the esophagitis and keeping patients in remission, independent of the severity of esophagitis. In 11 of 104 (11%) patients, a symptomatic relapse was observed after the dose was decreased to 20 mg o.d. However, all of these patients became symptom free again after the dose was increased to 40 mg o.d., and all were healed endoscopically at the end of the study. One (1%) patient needed omeprazole 60 mg o.d. for healing, but in this patient, no relapse was seen while on a maintenance dose of omeprazole 40 mg o.d. Marked improvement of persistent vomiting, hematemesis, regurgitation, food refusal, iron deficiency anemia, and depressive symptoms was seen at the end of the study. CONCLUSIONS: This study indicates that omeprazole is highly effective for all grades of esophagitis in the intellectually disabled. The dose needed to maintain them in remission can be titrated according to the reflux symptoms.

[Prevalence of hemorrhages due to vitamin K deficiency in The Netherlands, 1992-1994]. / Prevalentie van bloedingen door vitamine K-tekort in Nederland, 1992-1994.

OBJECTIVE: To determine the prevalence of vitamin K deficiency bleeding in the Netherlands, in order to evaluate the efficacy of recommendations on vitamin K prophylaxis. DESIGN: Descriptive. SETTING: University Hospital Nijmegen, the Netherlands. METHODS: Active surveillance of vitamin K deficiency bleeding (VKDB) by the Dutch Paediatric Surveillance Unit from October 1, 1992 to December 31, 1994. RESULTS: Of the 19 reported cases 5 could be validated as late vitamin K deficiency bleeding: 2 idiopathic cases, and 3 secondary cases due to liver disorders. One case had intracranial bleeding and died. None of the cases had received exactly the recommended prophylaxis. The incidence of late VKDB was calculated to be 1.1/100,000 live births. Before vitamin K prophylaxis was recommended the incidence was estimated to be 7/100,000. CONCLUSION: The present Dutch recommendations for prevention of vitamin K deficiency bleeding-1 mg vitamin K at birth and thereafter for breastfed infants daily 25 micrograms from 2 to 13 weeks-appear effective.