How to manage lower gastrointestinal bleeding in 2022?

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.

Surgery for no palpable testis before the age of one year: a risk for the testis?

INTRODUCTION: Surgery for undescended testis is now commonly recommended before the age of one year. However, the risk of testicular atrophy or miss location after surgery at a young age has not been clearly evaluated. OBJECTIVE: The objective of this study is to evaluate the rate of testicular atrophy after surgery for non-palpable testis before the age of one year. MATERIALS: Fifty-five patients operated between 2005 and 2014 for non-palpable testes were reviewed for clinical and ultrasound (US) evaluation. Median follow-up after surgery was of 68.5 months (range 26-130 months). The median age at surgery was of months (5-12 months). Eight patients (14.5%) had bilateral non-palpable testis; thus, 63 testes were evaluated. At surgery, 38 (60%) testes were located in the high inguinal canal; 25 (40%), in the abdominal cavity. Orchiopexy was performed with preservation of the testicular vessels for 58 testes. Fowler-Stephens (FS) procedure was performed for 5 testes. Testicular location was clinically evaluated, and testicular volume was measured using a standard sonogram technique in our pediatric radiology department. Ratio comparing the volume of the descended testis to the spontaneously scrotal located testis was calculated in unilateral forms. RESULTS: After surgery, testes had scrotal location in 62 cases and inguinal location in one case. Seven cases of atrophy were confirmed after US control (11%), more frequently (odds ratio, OR 11.68 [1.9-72.5]) in abdominal testis (24%) than in inguinal testis (2.6%). Atrophy testicular was more frequent with FS technique (OR 7.1 [1.3-40.1]), but the population was weak (N = 5). Median volume ratio for unilateral form was 0.88 [0-1.8]; 14 patients presented a ratio greater than 1. DISCUSSION: The influence of the young age at surgery and the risk of post operative testicular atrophy had not been clearly evaluated. The term of 'no palpable testis' supports an heterogeneous group mixing abdominal and extra-abdominal testis sharing a uniform clinical presentation. Our rate of atrophy in the group of abdominal testes (24%) and inguinal testes (2.6%) is similar to the literature, which concerns older patients. The long-term sonogram assessment demonstrated a good development of the testis after surgery, especially in inguinal cases. CONCLUSION: Surgery for no palpable testis before the age of one year does not lead to a superior risk of testicular atrophy compared with surgery at an older age and allows a good development of the testis.

[Growth discordance in dichorionic twin pregnancies: risk factors, diagnosis and management]. / Conflits d'intérêt prénatals entre les jumeaux. Discordance de croissance foetale des jumeaux bichoriaux: facteurs de risque, diagnostic et prise en charge.

OBJECTIVE: To analyse the risk factors and perinatal consequences of growth discordance among dichorionic twin pregnancies. Subjects and methods. A cohort of 346 dichorionic twin pregnancies delivered at one institution between January 1996 and December 1999 was analyzed. Two groups were compared, according to the presence or absence of growth discordance (n=72 and 274, respectively). Birth weight discordance was defined as a difference of 20% or more of the weight of the heavier twin, associated with an intra-uterine growth restriction (10(th) percentile) of at least one twin. Ultrasound discordance was defined as a difference of estimated fetal weight>20%. The two groups were compared by univariate and multivariate analysis. RESULTS: The main risk factors for birth weight discordance in multivariate analysis were ovulation induction (OR=1.6 [1.0-2.4]), multifetal pregnancy reduction (OR=2.3 [1.3-4.2]), and fetal malformations (OR=2.4 [1.0-5.4]). Ultrasound shows a poor performance in predicting discordance with a sensitivity of 55.6%, a specificity of 94.2%, a positive predictive value of 71.4% and a negative predictive value of 89.0%. Birth weight discordance was associated with a poor fetal and neonatal outcome: gestational age at delivery was 34.4 weeks versus 35.4 weeks, there were more caesarean deliveries (OR=1.9 [1.3-2.8]), a higher perinatal mortality (OR=3.7 [1.6-8.5]), and more neonatal intensive care unit admissions (OR=1.8 [1.2-2.7]). Multivariate analysis shows that growth discordance is an independent risk factor for mortality but not for cerebral adverse outcome or respiratory distress syndrome. CONCLUSION: Ovulation induction and multifetal pregnancy reduction are independent risk factors for twin birth weight discordance, which carries a poor perinatal prognosis.