Sedación paliativa en hemorragia digestiva alta masiva (hematemesis) / Palliative sedation in massive upper gastrointestinal bleeding (haematemesis)

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Successful treatment of repeated hematemesis secondary to postsclerotherapy esophageal ulcer in a cirrhotic patient: A case report.

Esophageal variceal bleeding is a common lethal complication of cirrhosis. Endoscopic injection sclerotherapy (EIS) is one of the major endoscopic approaches for treating esophageal variceal bleeding. However, complications may occur after EIS, which mainly include retrosternal discomfort/pain, dysphagia, re-bleeding, esophageal ulcer, esophageal strictures, and esophageal perforation, etc. In this article, we reported a 36-year-old male who developed esophageal ulcer related bleeding after EIS. Currently, there is no consensus on the treatment strategy for esophageal ulcer-related bleeding after EIS. In the present case, the following treatment strategy may be effective for ulcer related bleeding. The first step is to inhibit gastric acid secretion and reduce portal pressure by intravenous infusion of esomeprazole and somatostatin, respectively. The second is local hemostasis by oral norepinephrine and lyophilizing thrombin powder. The third is to protect digestive tract mucosa by oral Kangfuxin Ye and aluminum phosphate.

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.

Terlipressin-induced hyponatremic seizure in a child.

Terlipressin, an analog of the natural hormone arginine-vasopressin, is a splanchnic constrictor that is used to control variceal bleeding in portal hypertension. It has a very good safety profile compared to vasopressin. Although rare, adverse effects such as hyponatremia and seizure can occur. We describe a 7-year-old male child who developed hyponatremia induced by infusion of terlipressin which resulted in a generalized seizure. After withdrawal of terlipressin, the serum sodium level became normal. Through this case, we emphasize the importance of monitoring patient's electrolyte levels during the course of terlipressin therapy.

Portal venous gas emboli after accidental ingestion of concentrated hydrogen peroxide.

BACKGROUND: Hydrogen peroxide is a common household product. It is clear and odorless making it easy to confuse with water, especially when improperly stored. Concentrated formulations are also available for consumer purchase. OBJECTIVE: We report a case of hydrogen peroxide ingestion in a child and discuss the potential consequences and treatment of such an exposure. CASE REPORT: A 12-year-old boy accidentally ingested a sip of concentrated hydrogen peroxide. He rapidly developed hematemesis and presented to the Emergency Department. His initial work-up was unremarkable, and his symptoms resolved quickly. However, diffuse gas emboli were found within the portal system on abdominal computed tomography. The child was treated with hyperbaric oxygen therapy and later found to have gastric irritation as well as an ulcer on endoscopy. He recovered fully from the incident. CONCLUSIONS: We present this case to increase awareness of the dangers of hydrogen peroxide ingestion in children. Fortunately, the child in this case recovered fully, but emergency physicians should be aware of the potential consequences and therapeutic options.

A normal response to Synachten test does not rule out corticosteroid effectiveness in weaning from catecholamine after septic shock.

Corticosteroids may improve haemodynamics and facilitate weaning from catecholamines in septic shock. According to some authors, such effects are only accomplished in the presence of absolute or relative adrenal insufficiency. Consequently, corticosteroids are usually given only to patients that present low blood cortisol values or show an inadequate response to cosyntropin (Synachten test). We report the case of a woman affected by septic shock secondary to pneumonia and dependent on norepinephrine infusion for 26 days, who was weaned from catecholamines with hydrocortisone, 100 mg/day i.v. She exhibited a normal response to Synachten, but corticosteroid therapy was continued because haemodynamics improved promptly. A pharmacological effect was hypothesized; the contemporary increase of platelet, decrease of white blood cells, and decrease of plasma fibrinogen supported this hypothesis.

Upper gastrointestinal mucosal abnormalities and blood loss complicating low-dose aspirin and antithrombotic therapy.

BACKGROUND: Little is known about the site and nature of bleeding lesions related to low-dose aspirin and other antithrombotic agents. AIM: To describe the mucosal abnormalities in patients presenting with upper gastrointestinal bleeding while being treated with these drugs. METHODS: The endoscopic findings and clinical details were analysed in all patients presenting with haematemesis and/or melaena at a single centre during three calendar years. Associations between endoscopic findings and risk factors, including the intake of non-steroidal anti-inflammatory drugs, low-dose aspirin (75 mg daily) and other antithrombotic drugs including warfarin, clopidogrel, and dipyridamole, were assessed by logistic regression analysis. RESULTS: In 674 upper gastrointestinal bleeders, we found that the odds ratio for the presence of erosive oesophagitis in aspirin users was 2 (95% CI, 1-3; P = 0.03) and 3 (2-5; P = 0.0003) in patients taking other antithrombotic agents. In 41 patients with oesophagitis and taking these drugs, 36 (88%) had cardiovascular disease and only 4 (10%) had peptic symptoms. CONCLUSIONS: Erosive oesophagitis is common in patients with upper gastrointestinal bleeding taking low-dose aspirin or antithrombotic agents, and could potentially be confused with the coexisting heart disease.

Ruptured left gastric artery aneurysm successfully treated by thrombin injection: case report and literature review.

Aneurysms of the gastric and gastroepiploic arteries account for only about 4% of all splanchnic artery aneurysms. However, rupture is associated with a mortality of up to 70% and usually warrants urgent surgical intervention. We present an interesting case of a patient who presented with haematemasis following rupture of a left gastric artery aneurysm that was successfully treated by percutaneous thrombin injections. A review of the literature for this rare condition is also presented.