Angiodysplasia of the appendix: a diagnostic challenge and the importance of colonoscopy.

The case report discusses the challenges in diagnosing gastrointestinal bleeding of unknown origin, with angiodysplasia (AD) of the appendix being a rare cause. The report presents a case of a man in his late 60s who presented with vomiting, diarrhoea and rectal bleeding. As a result of the bleeding, the patient developed a type II myocardial infarction (MI), which had to be simultaneously managed further complicating the diagnostic process. Despite a normal CT angiogram, ongoing bleeding led to suspicion of AD, which was diagnosed using colonoscopy with limited bowel preparation. The patient underwent an open appendicectomy and was found to have AD of the tip of the appendix as the cause of the bleeding. The case highlights the limitations of CT angiography in haemodynamically unstable patients and subsequent importance of colonoscopy with bowel preparation in diagnosing rare causes of bleeding, even with limited bowel preparation, and the potential life-threatening consequences of untreated AD.

Clostridium difficile in inflammatory bowel disease.

PURPOSE OF REVIEW: The chronic inflammatory bowel diseases (IBD), Crohn's disease, and ulcerative colitis, are associated with an increased risk of symptomatic Clostridium difficile infection (CDI). CDI may also masquerade as an IBD flare and complicate IBD management. This review provides a comprehensive overview of the epidemiology, diagnosis, and treatment of CDI in IBD patients. RECENT FINDINGS: CDI remains common in IBD with complications including flares in disease activity, recurrent CDI episodes, and prolonged hospital stays. Newer IBD therapeutics including vedolizumab, ustekinumab, and tofacitinib are less likely to cause severe CDI. A high index of suspicion, rapid testing via a two-step method, and prompt treatment with vancomycin or fidaxomicin are paramount to managing CDI in IBD patients. Strategies to prevent recurrent CDI (rCDI) include the monoclonal antibody bezlotoxumab as well as fecal microbiota transplantation (FMT). FMT has a robust profile of safety and effectiveness in preventing rCDI in adults and children. SUMMARY: Clinicians must remain vigilant in the prompt diagnosis and treatment of CDI in IBD patients. Corticosteroids, unnecessary antibiotics, and ongoing colonic inflammatory disease are modifiable risk factors. Improved infection control measures, newer IBD medications, and using effective CDI treatments will facilitate a reduced burden of severe CDI and complications for IBD patients.

Colonoscopic and Clinical Features of Colonic Angiodysplasia: A Study in 54 Patients.

OBJECTIVES: Colonic angiodysplasia is a rare disease, it is nevertheless a common cause of lower gastrointestinal (GI) bleeding in older adults. The study summarized the colonoscopic and clinical features of colonic angiodysplasia to raise awareness among endoscopists regarding this disease. MATERIALS AND METHODS: We performed a retrospective study of enrolled patients diagnosed with colonic angiodysplasia between September 2013 and April 2022. Clinical and colonoscopic features of the patients with active bleeding were analyzed and compared with those of patients without bleeding. The comparisons were also conducted between the patients with active lower GI bleeding caused by colonic angiodysplasia and those by other diseases. RESULTS: In total, 54 eligible patients were included in this study; 55.55% of the participants were aged over 60 years. Ten patients (3 men and 7 women) with colonic angiodysplasia suffered from active lower GI bleeding, which was mainly located in the left and total colon. The patients with type 2 diabetes mellitus, radiotherapy history, antiplatelet drug use, and multiple lesions were more likely to endure lower GI bleeding. The duration between bleeding and admission was longer in the colonic angiodysplasia group than in the other diseases group ( P = 0.043). In the colonic angiodysplasia group, bleeding relapsed in 3 patients, and the recurrence rate was higher than in the other diseases group ( P < 0.001). CONCLUSION: Endoscopists should perform colonoscopy scrupulously and consider colonic angiodysplasia as a differential diagnosis in patients with lower GI bleeding, especially for older women and adults with chronic diseases, such as type 2 diabetes mellitus.

Delayed Perforation after Endoscopic Detachable Snare Ligation for Colonic Diverticular Hemorrhage.

A 74-year-old man was admitted to our hospital with severe hematochezia. Abdominal enhanced computed tomography (CT) demonstrated extravasation of contrast material from the descending colon. Colonoscopy revealed recent bleeding in the descending colon diverticulum. Bleeding was stopped using detachable snare ligation. Eight days later, the patient developed abdominalgia, and CT revealed free air caused by delayed perforation. The patient underwent emergency surgery. Perforation at the ligation site was detected using intraoperative colonoscopy. This report is the first to describe a case of delayed perforation after endoscopic detachable snare ligation for colonic diverticular hemorrhage.

Vaseline gauze packing for the treatment of acute hemorrhagic rectal ulcer: Two case reports.

RATIONALE: Acute hemorrhagic rectal ulcer (AHRU) is a relatively rare condition characterized by sudden onset, painlessness, and massive hematochezia in patients with severe underlying conditions. When AHRU is encountered, they can often be successfully controlled endoscopically, though recurrent bleeding is common and an alternative treatment must be sought if initial endoscopic treatment fails. We report 2 cases of AHRU which were successfully treated with Vaseline gauze packing after the failure of endoscopic hemostasis. PATIENT CONCERNS: The first patient was an 88-year-old female that visited our emergency department with hematochezia. She was immobilized because of a left pelvic bone fracture resulting from a slip-down. The initial endoscopy showed fresh blood in her rectum with diffuse ulceration near the dentate line but no active bleeding. However, Massive hematochezia has recurred during conservation. A second patient, an 86-year-old female, debilitated because of schizophrenia, dementia, and past subdural hemorrhage, visited our emergency department, also with massive hematochezia. Her initial endoscopy showed deep ulceration near the dentate line. After admission, she experienced massive hematochezia from an AHRU with an exposed vessel but endoscopic hemostasis failed to control bleeding. DIAGNOSES: Both patients were diagnosed as AHRU based on the endoscopic findings. INTERVENTIONS: In both cases, Vaseline gauze packing was performed for bleeding control. OUTCOMES: After Vaseline gauze packing, no further bleeding occurred and follow-up endoscopy showed definitive improvement of ulcers. LESSONS: Based on these cases, we suggest that Vaseline gauze packing may be the alternative treatment for the AHRU which is located near the dentate line when endoscopic hemostasis is difficult or failed. Although further research is needed, Vaseline gauze packing has several potential advantages for the treatment of AHRU, especially in cases involving critically ill elderly patients.

Primary Epiploic Appendagitis: Not Rare But Rarely Diagnosed Pathology.

OBJECTIVE: The aim of this study is to determine the clinical and laboratory parameters which may be suggestive of or even pathognomonic for primary epiploic appendagitis (PEA) and to discuss the diagnostic efficacy of ultrasound (US) compared to computed tomography (CT) in patients with PEA. MATERIALS AND METHODS: For this retrospective study, 92 patients diagnosed with PEA using US, CT or both modalities were included. All patient symptoms, clinical findings and laboratory parameters were reviewed. The CT and US images of the PEA were evaluated for lesion size and location, the relationship of the lesion to the colon and the distance of the lesion to the skin. RESULTS: There were 16 female and 76 male patients in the study group. The mean age was 35 years (range: 38-79 years). Well-localized abdominal pain was the primary symptom in all patients. The mean leukocyte count was 7857±1326 mm-3. The most frequent localization of PEA was sigmoiddescending colon junction (79/92). In patients who were examined by both US and CT, the size of the fatty central core was between 15-48 mm (mean:28.10 mm) and 9-22 mm (mean:15.07 mm) in its long-axis and short-axis diameter, respectively on US, whilst that by CT was between 15-46 mm (mean:26.88 mm) and 9-21 mm (mean:14.40 mm) in its long-axis and short-axis diameter, respectively. In patients who were examined by both US and CT, the mean distance of the lesions to the skin was 20.80 mm and 33.97 mm, respectively. All patients were treated conservatively with complete resolution of symptoms within a week of presentation. CONCLUSION: PEA is an unrare self-limiting condition that should be considered in the differential diagnosis of acute abdomen. To support clinicians and radiologists regarding PEA and its clinical, laboratory and radiological findings, targeted sonographic examination - which is radiation and contrast agent-free - could be highly sufficient for the diagnosis of PEA and may prevent unnecessary further imaging and mistreatment.

Acute Hemorrhagic Rectal Ulcer Complicated by Cytomegalovirus Enteritis following Steroid Pulse Therapy for Acute Exacerbation of Interstitial Pneumonia.

We herein report a rare case of acute hemorrhagic rectal ulcer (AHRU) complicated by cytomegalovirus enteritis following steroid pulse therapy for interstitial pneumonia. An 86-year-old woman underwent steroid pulse therapy for interstitial pneumonia. She was bedridden with dyspnea and suddenly developed melena. Colonoscopy revealed AHRU, which did not improve with conservative treatment, but did improve with ganciclovir administration for cytomegalovirus enteritis. This gastrointestinal complication has not received much attention by pulmonologists who perform steroid pulse therapy for interstitial pneumonia. Delayed treatment of this complications can be fatal. Caution should be taken when administering steroid pulse therapy to bedridden patients with interstitial pneumonia.

Jejunal Angiodysplasia in an Elderly Patient with Aortic Stenosis: Significance of Von Willebrand Factor as an Etiologic Factor.

Heyde's syndrome is a disease in which patients with aortic stenosis (AS) bleed from angiodysplasia. An 80-year-old woman with a history of severe AS was referred to our hospital with melena and anemia. The patient underwent jejunal resection after repeated blood transfusions. A pathological examination revealed angiodysplasia, and the patient's plasma lacked high-molecular-weight von Willebrand factor (VWF) multimers, leading to the diagnosis of Heyde's syndrome. The patient underwent transcatheter aortic valve implantation (TAVI) one year after the diagnosis, and the VWF index recovered. This is a valuable case in which the pathological analysis of angiodysplasia associated with Heyde's syndrome was possible.

Rectal cytomegalovirus ulcer in an immunocompetent patient: an uncommon cause of lower gastrointestinal bleeding.

We report the case of an 80-years-old male patient who presented with hematochezia without hemodynamic compromise and with a history of laryngeal squamous-cell carcinoma that was operated on 2 weeks before the bleeding episode.

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.

Intraoperative discovery of melanosis coli during emergent bowel resection for perforation.

A patient was taken to the operating room with a presumptive diagnosis of necrotic small bowel and colon. During the procedure, it was noted that she had black mucosa throughout the colon. Several factors suggested viable colonic tissue, and the decision was made to not resect the colon as originally planned. Final pathology of the specimen would later reveal melanosis coli, an ultimately benign diagnosis. Further questioning of the patient found that she had taken a herbal laxative supplement containing several components which are known to cause melanosis coli. We hope that this case report will serve as a reminder to surgeons and clinicians to remember melanosis coli as a clinical entity when confronted with blackened or darkened colonic mucosa. On review of available literature, we identified other cases in which melanosis coli was discovered intraoperatively, and we propose a number of factors to support intraoperative decision making.

[Cholecystocolonic fistula as a complication of advanced gallbladder cancer] / [Fístula colecistocolónica como complicación de cáncer de vesícula avanzado]

Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula, associated in most cases with stone disease. Symptoms are usually minimal or nonspecific, and preoperative diagnosis is uncommon. Although the incidence of FCC caused by gallbladder cancer comprises 1.7% of cases, it is necessary to suspect it in order to adopt the best therapeutic strategy.

La fístula colecistocolónica (FCC) es la segunda fístula colecistoentérica más común, asociada en la mayoría de los casos a enfermedad litiásica. Los síntomas suelen ser mínimos o inespecíficos, siendo infrecuente su diagnóstico preoperatorio. Si bien la incidencia de FCC causada por cáncer de vesícula biliar comprende el 1,7 % de los casos, es necesario sospecharla para adoptar la mejor estrategia terapéutica.