Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes

Overt Gastrointestinal Bleeding in Patients with Cancer: Clinical Characteristics and Outcomes

BACKGROUND/GOALS

The aim of this study was to compare the clinical characteristics and outcomes of gastrointestinal bleeding (GIB) between cancer patients (CP) and non-cancer patients (NCP).

STUDY

This was a prospective study of patients admitted with overt GIB between 2013 and 2021. GIB etiology, management and outcomes including rebleeding and mortality, were compared between CP and NCP, and among patients with different types of cancer. The associations with categorical variables were assessed with the Chi-square test, and the t-test was used for continuous variables.

RESULTS

Of 674 patients admitted for GIB, 144 (21%) had cancer. 121(84%) CP had active disease, 49% had stage 4 cancer, and 78% had solid tumors, of whom 28 (20%) had luminal GI cancers. The most common were colorectal cancer, prostate cancer, and lymphomas. Compared to NCP, CP had higher age-adjusted Charlson Comorbidity Index, and were less likely to undergo endoscopy or endoscopic therapy. Severe GIB was equally prevalent in both groups, but CP had more severe anemia. Peptic ulcer was the most common etiology in both groups. Of 28 luminal cancer patients, 17(59%) bled from their tumors. Nine patients bled from cancer metastasis to the GI lumen. CP had higher in-hospital, one-month, one-year, and end-of-follow-up mortality. Length of hospital stay and re-bleeding rates did not differ between CP and NCP.

CONCLUSION

CP with GIB are less likely to have diagnostic and therapeutic endoscopy and have higher mortality than NCP. Steps to identify CP at risk for GIB and to improve their outcomes merit further investigation.

Hemostatic radiotherapy for bleeding gastrointestinal tumors

Hemostatic radiotherapy is a non-invasive treatment for bleeding gastrointestinal (GI) tumors, promoting tumor shrinkage, blood supply reduction, and fibrotic tissue formation. It is effective in cases where traditional interventions are insufficient or contraindicated and can prevent recurrent bleeding in patients with GI bleeding histories. Hypofractionation schedules are also effective for tumor control and patient compliance.

Efficacy of Endoscopic Tissue Adhesive in Patients with Gastrointestinal Tumor Bleeding

BACKGROUND

Gastrointestinal tumors bleeding remains a significantly clinical challenge due to its resistance to conventional endoscopic hemostasis methods. While the efficacy of endoscopic tissue adhesives (ETA) in variceal bleeding has been established, its role in gastrointestinal tumor bleeding (GITB) remains ambiguous.

AIMS

This study aims to assess the feasibility and effectiveness of ETA in the treatment of GITB.

METHODS

The study enrolled 30 patients with GITB who underwent hemostasis through Histoacryl® tissue glue injection. Hemostasis success rates, ETA-related adverse events, and re-bleeding rates were evaluated.

RESULTS

ETA application achieved successful hemostasis at all tumor bleeding sites, with immediate hemostasis observed in all 30 (100.0%) patients. Among the initially hemostasis cases, 5 patients (17.0%) experienced re-bleeding within 30 days, and the 60 day re-bleeding rate was 20.0% (6/30). Expect for one case of vascular embolism, no adverse events related with ETA application were reported. The 6 month survival was 93%.

CONCLUSION

ETA demonstrated excellent immediate hemostasis success rate in GITB cases and showed promising outcomes in prevention re-bleeding.

Mortality Risk Scoring System in Patients after Bleeding from Cancers in the Upper Gastrointestinal Tract

Background/Aims

: Risk scoring systems for upper gastrointestinal (UGI) bleeding have not been well validated for tumor bleeding. This study aimed to identify risk factors for mortality in patients with UGI cancer bleeding and to develop a predictive model.

Methods

: Consecutive patients with UGI cancers who underwent esophagogastroduodenoscopy for suspected bleeding were retrospectively included. Patient characteristics, endoscopic findings and 30-day mortality were assessed. A predictive model was made based on risk factors for mortality using logistic regression, and the area under the curve (AUC) of this model was calculated. It was then compared with other risk scoring systems.

Results

: In a total of 264 patients, 193 had tumor bleeding. Among them, 108 (56.0%), 76 (39.4%), and nine (4.7%) patients received conservative treatment, endoscopic therapy, and non-endoscopic hemostasis, respectively. Rebleeding occurred in 23 (21.3%), 26 (34.2%), and one (11.1%) patient(s), respectively. Our new model is composed of altered mental status, renal failure, rebleeding, age older than 65 years, and low serum albumin (all p<0.05). This model predicted 30-day mortality with an AUC of 0.79 (95% confidence interval, 0.72 to 0.86), which was significantly higher than AUCs of the Glasgow-Blatchford score, Rockall, and AIMS65 score (AUC=0.61, 0.64, and 0.69, respectively, all p<0.05).

Conclusions

: Our new scoring system provides a better prediction of 30-day mortality than existing scoring systems in patients with UGI cancer bleeding. This new scoring system can be used to predict and prepare these patients who are known to have high mortality.

Endoscopic Management of Tumor Bleeding: Techniques and Strategies

Endoscopic management of gastrointestinal (GI) tumor-related bleeding is challenging for many reasons including high rebleeding rates, poor tissue response to endoscopic therapies, altered wound healing and underlying coagulopathy. However, endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy. This article explores various endoscopic techniques in managing tumor bleeding from more traditional approaches of using thermal or mechanical therapy with injection therapy to newer topical agents.

Efficacy of endoscopic therapy and long-term outcomes of upper gastrointestinal tumor bleeding in patients with esophageal cancer

BACKGROUND

Upper gastrointestinal bleeding (UGIB) from malignancies is associated with a poor outcome. Only a small number of studies on gastrointestinal tumor bleeding have been published so far, focusing mainly on bleeding from gastric cancer. Since the information on patients with UGIB from esophageal cancer appears insufficient, this study aimed to present clinical and endoscopic findings, treatment options as well as clinical outcomes such as rebleeding and survival of those patients.

METHODS

This retrospective analysis included all patients admitted with UGIB from esophageal cancer at our university hospital during a 10-year period.

RESULTS

45 patients were analyzed of whom 26 (57.8%) already had cancer stage IV at index bleeding. 22 (48.9%) patients presented with hemodynamic instability and 30 (66.7%) patients received blood transfusions. Active bleeding was present in 24 (53.3%) patients, of whom 20 (83.3%) received endoscopic therapy. Successful hemostasis was achieved in 18 (90%) of 20 patients with Argon plasma coagulation used most frequently (52.4%). Early and delayed rebleeding occurred in 5 (12.5%) and 11 (27.5%) of all inoperable patients, respectively. Intake of anticoagulation or anti-platelet drugs were risk factors for delayed rebleeding and the median overall survival after index bleeding was 1.2 months.

CONCLUSION

UGIB from esophageal cancer occurred most frequently in advanced tumor stages and was associated with significant blood loss. Even though initial endoscopic therapy was effective, rebleeding occurred in a significant number of patients. Those taking anticoagulants or anti-platelet drugs should be closely monitored for rebleeding. The overall survival after index bleeding was poor.

The Rare Case of Esophageal Cancer Presenting With Hematemesis in a 29-Year-Old Adult

Esophageal cancer is a disease with high mortality. This is mainly due to late presentations with nonspecific symptoms. Despite advances in surgery and chemoradiotherapy, it is the eighth most common cancer but the sixth deadliest. It is reportedly common in older patients but rare in young ones. In this case report, we present a 29-year-old male patient with no prior medical condition who presented with hematemesis to the emergency unit and was found to have esophageal cancer with the biopsy. Not only is esophageal cancer rare in young adults, but hematemesis is a rare symptom in esophageal cancer patients.

Uncommon, overlooked and underreported causes of upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to misdiagnosis and occasionally catastrophic outcomes. The lifestyles of those who are afflicted are mostly responsible for the underlying conditions that result in the hemorrhagic cases. The development of a novel approach targeted at raising public awareness of the issue and educating the public about it could significantly contribute to the elimination of gastrointestinal bleeding with no associated risks and to a nearly zero mortality rate. There are reports of UGB related to Sarcina ventriculi, gastric amyloidosis, jejunal lipoma, gastric schwannoma, hemobilia, esophageal varices, esophageal necrosis, aortoenteric fistula, homosuccus pancreaticus, and gastric trichbezoar in the literature. The common feature of these rare causes of UGB is that the diagnosis is difficult to establish before surgery. Fortunately, UGB with a clear lesion in the stomach itself is a clear sign for surgical intervention, and the diagnosis can only be verified by pathological examination with the help of immunohistochemical detection of a particular antigen for a specific condition. The clinical traits, diagnostic techniques, and the therapeutic, or surgical options of unusual causes of UGB reported in the literature are compiled in this review.

Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions

Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper^®, and, more recently, UI-EWD (Nexpowder^TM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.

Clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with upper gastrointestinal bleeding: a multicenter study

Background

Esophageal cancer is a highly malignant neoplasm with poor prognosis. Of its patients, upper gastrointestinal bleeding (UGIB) is one of the most challenging and threatening conditions in the emergency department (ED). However, no previous studies have analyzed the etiologies and clinical outcomes in this specific population. This study aimed to identify the clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with UGIB.

Methods

This retrospective cohort study enrolled 249 adult patients with esophageal cancer presenting with UGIB in the ED. Patients was divided into the survivor and non-survivor groups, and their demographic information, medical history, comorbidities, laboratory parameters, and clinical findings were recorded. The factors associated with 30-day mortality were identified using Cox's proportional hazard model.

Results

Among the 249 patients in this study, 30-day mortality occurred in 47 patients (18.9%). The most common causes of UGIB were tumor ulcer (53.8%), followed by gastric/duodenal ulcer (14.5%), and arterial-esophageal fistula (AEF) (12.0%). Multivariate analyses indicated that underweight (HR = 2.02, p = 0.044), history of chronic kidney disease (HR = 6.39, p < 0.001), active bleeding (HR = 2.24, p = 0.039), AEF (HR = 2.23, p = 0.046), and metastatic lymph nodes (HR = 2.99, p = 0.021) were independent risk factors for 30-day mortality.

Conclusions

The most common cause of UGIB in esophageal cancer patients was tumor ulcer. AEF, accounting for 12% of UGIB in our study, is not an uncommon cause. Underweight, underlying chronic kidney disease, active bleeding, AEF, and tumor N stage > 0 were independent risk factors for 30-day mortality.

A prospective, open-labeled, and randomized trial for assessing safety and clinical utility of gastric biopsies during emergency gastroscopy for patients with bleeding gastric ulcers

OBJECTIVE

There is no consensus on whether a gastroscopic biopsy is necessary during the emergency treatment of gastrointestinal (GI) diseases such as gastric ulcer bleeding. In this study, we examined the clinical utility and safety of an emergency gastroscopic biopsy for the assessment of gastric ulcer bleeding.

METHODS

We enrolled 150 patients with a single bleeding gastric ulcer after emergency gastroscopy (EG) from April 2020 to April 2022. The patients were randomly divided into the biopsy and no biopsy groups, and they were followed-up until June 2022 to examine whether recurrent gastric ulcer bleeding had occurred.

RESULTS

Re-bleeding occurred in 15 out of 150 (10%) patients. We diagnosed malignancies in 17 (11.3%) patients and validated 14 (9.3%) of them during the initial gastroscopy procedure. Factors that could predict the occurrence of gastric ulcer re-bleeding with biopsy during EG included an absence of ischemic heart disease (odds ratio [OR] = 0.395, confidence interval [CI]: 0.24-0.65, p ≤ .005), renal disease (OR = 1.74, CI: 0.77-1.59, p ≤ .005), and using warfarin or oral anticoagulants (OR = 11.953, CI: 3.494-39.460, p ≤ .005). No significant differences were observed in 60-day bleeding (p = .077) and the duration of hospitalization (p = .700) between the two groups.

CONCLUSIONS

Patients undergoing biopsy during EG did not exhibit an increased risk of re-bleeding compared with those who did not undergo a biopsy. An early biopsy facilitates an early pathologic diagnosis, early clinical intervention, safe discharge of low-risk patients, and improved outcomes in high-risk patients.

Endoscopy for the diagnosis and treatment of gastrointestinal bleeding caused by malignancy

BACKGROUND AND AIM

The diagnosis and treatment of gastrointestinal (GI) bleeding secondary to malignancy can be challenging. Endoscopy is the gold standard to diagnose and treat gastrointestinal bleeding but clinical characteristics and outcomes of patients with malignancy-related bleeding are not well understood. This study aims to look at clinical characteristics, endoscopic findings, safety and clinical outcomes of endoscopic interventions for GI malignancy-related bleeding.

METHODS

We retrospectively reviewed outcomes of patients with confirmed GI malignancies who underwent endoscopy for GI bleeding at MD Anderson Cancer Center between 2010 and 2019. Cox hazard analysis was conducted to identify factors associated with survival.

RESULTS

A total of 313 patients were included, with median age of 59 years; 74.8% were male. The stomach (30.0%) was the most common tumor location. Active bleeding was evident endoscopically in 47.3% of patients. Most patients (77.3%) did not receive endoscopic treatment. Of the patients who received endoscopic treatment, 57.7% had hemostasis. No endoscopy-related adverse events were recorded. Endoscopic treatment was associated with hemostasis (P < 0.001), but not decreased recurrent bleeding or mortality. Absence of active bleeding on endoscopy, stable hemodynamic status at presentation, lower cancer stage, and surgical intervention were associated with improved survival.

CONCLUSIONS

This study indicates that endoscopy is a safe diagnostic tool in this patient population; while endoscopic treatments may help achieve hemostasis, it may not decrease the risk of recurrent bleeding or improve survival.

Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions

BACKGROUND

Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC.

AIM

To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC.

METHODS

This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality.

RESULTS

Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001].

CONCLUSION

The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Upper gastrointestinal bleeding as the initial manifestation of gastroenteropancreatic neuroendocrine tumors

A 78-year-old man presented with upper gastrointestinal bleeding, which was biopsy proven to be from a gastric neuroendocrine tumor. By the time of diagnosis, he developed liver metastasis and died 2 months later. Upper gastrointestinal bleeding is an uncommon feature in gastroenteropancreatic neuroendocrine tumor.

Gastrointestinal bleeding in critically ill immunocompromised patients

BACKGROUND

Acute gastrointestinal bleeding (GIB) may be a severe condition in immunocompromised patients and may require intensive care unit (ICU) admission. We aimed to describe the clinical spectrum of critically ill immunocompromised patients with GIB and identify risk factors associated with mortality and severe GIB defined by hemorrhagic shock, hyperlactatemia and/or the transfusion of more than 5 red blood cells units. Finally, we compared this cohort with a control population of non-immunocompromised admitted in ICU for GIB.

RESULTS

Retrospective study in 3 centers including immunocompromised patients with GIB admitted in ICU from January, 1st 2010 to December, 31rd 2019. Risk factors for mortality and severe GIB were assessed by logistic regression. Immunocompromised patients were matched with a control group of patients admitted in ICU with GIB. A total of 292 patients were analyzed in the study, including 141 immunocompromised patients (compared to a control group of 151 patients). Among immunocompromised patients, upper GIB was more frequent (73%) than lower GIB (27%). By multivariate analysis, severe GIB was associated with male gender (OR 4.48, CI95% 1.75-11.42, p = 0.00), upper GIB (OR 2.88, CI95% 1.11-7.46, p = 0.03) and digestive malignant infiltration (OR 5.85, CI95% 1.45-23.56, p = 0.01). Conversely, proton pump inhibitor treatment before hospitalization was significantly associated with decreased risk of severe GIB (OR 0.25, IC95% 0.10-0.65, p < 0.01). Fifty-four patients (38%) died within 90 days. By multivariate analysis, mortality was associated with hemorrhagic shock (OR 2.91, IC95% 1.33-6.38, p = 0 .01), upper GIB (OR 4.33, CI95% 1.50-12.47, p = 0.01), and long-term corticosteroid therapy before admission (OR 2.98, CI95% 1.32-6.71, p = 0.01). Albuminemia (per 5 g/l increase) was associated with lower mortality (OR 0.54, IC95% 0.35-0.84, p = 0.01). After matching with a control group of non-immunocompromised patients, severity of bleeding was increased in immunocompromised patients, but mortality was not different between the 2 groups.

CONCLUSION

Mortality is high in immunocompromised patients with GIB in ICU, especially in patients receiving long term corticosteroids. Mortality of GIB is not different from mortality of non-immunocompromised patients in ICU. The prophylactic administration of proton pump inhibitors should be considered in this population.

Colonoscopic Evaluation of Lower Gastrointestinal Bleeding (LGIB): Practical Approach

BACKGROUND

Haematochesia (Lower Gastrointestinal Bleeding (LGIB) is the most common reason for endoscopic examination. Generaly it is caused by hemorrhoids and diverticular disease, but other anorectal conditions can also lead to LGIB. Recurrent bleeding may result in secondary iron deficiency anemia. Colonoscopy is the primary diagnostic option for establishing a diagnosis of colonic bleeding.

OBJECTIVE

This study aimed to analyze symptoms and endoscopic finding (specialy hemorrhoids) who may be sources of LGIB.Second goal of this study is to estimate time from onset of symptoms to performance of a colonoscopy.

METHODS

A retrospective study included 603 adult patients who underwent colonoscopy in General Hospital "Sv. Apostol Luka", Doboj, Bosnia and Herzegovina, between 1.1.2020 and 31.12.2020.

RESULTS

Average age of the examined population was 62±13,3years. According to the gender they were mostly men. To be exact,by percentage it was 53.7% of men and 46,3% of women, or by number: 324 men and 279 women. The most common indications for colonoscopy were LGIB (48,8%), abdominal pain and irregular stool. Most frequent endoscopic findings were hemorrhoids 42%. Normal findings had almost one third of all examinated patients. Combined findings-presence of more clinical entities in one patient were presented in 95 cases. In the group with hemorrhoids were almost two thirds of males, but there was no gender difference noted in between group with LGIB and without LGIB. More than half patients were older than 61 years. Anemia was presented in almost 20% of cases. Significantly it is higher frequency of abdominal pain, irregular stool and weight loss observed on the group without LGIB. Also, significantly more frequently patients with LGIB underwent colonoscopy in 0-30 days when compared with patients without LGIB (p=0,016).

CONCLUSION

In patients with haematochezia, taking a careful medical history is mandatory. Hemorrhoids, diverticular disease and colorectal cancers are the most common causes of bleeding. Patients with LGIB and abdominal pain were previously examined with colonoscopy. Completely colonoscopy is advocated to detect probable proximal lesions.

Influence of Severe Gastrointestinal Complications in Primary Gastrointestinal Diffuse Large B-Cell Lymphoma

Background

This study assessed the clinical characteristics of gastrointestinal bleeding (GIB), obstruction (GIO), and perforation (GIP) in patients with primary gastrointestinal diffuse large B-cell lymphoma (PGI-DLBCL) and the influence on long-term survival.

Methods

A retrospective analysis was performed of 148 patients with PGI-DLBCL admitted to Peking University First Hospital from August 1994 to May 2018. The clinical characteristics of GIB, GIO, and GIP before and after chemotherapy were recorded. The associated overall survival and progression-free survival were analyzed.

Results

Among 148 patients, 56.8% had gastrointestinal complications (GICs), including GIB, GIO, GIP, and multiple complications, and 22.6% of them occurred after chemotherapy, mostly during the first 4 cycles. The most common clinical manifestations of patients with GICs were abdominal pain or discomfort (79.8%), hematemesis or melena (22.6%), and abnormal bowel habits (17.9%). Patients with Eastern Cooperative Oncology Group (ECOG) score ≥2, tumor mass ≥10 cm, or intestinal involvement had significantly higher risk of severe GICs as initial manifestations. Among 130 patients who received chemotherapy, B symptoms, tumor mass ≥10 cm, and Lugano stage (IIE, IV) strongly correlated with GICs after chemotherapy (P < 0.05). Rituximab did not increase the risk of GICs. GICs which occurred before or after chemotherapy reduced the objective response rate at the end of chemotherapy. The prognosis of patients was significantly worsened by GIP, GIB, or multiple complications after chemotherapy (P < 0.05). GIB at presentation or GIO before or after chemotherapy had no prognostic value (both P > 0.05).

Conclusion

GICs adversely affect the quality of life, prolong the length of hospitalization, and shorten the long-term survival of patients with PGI-DLBCL.

Overview of spontaneous intraabdominal tumor hemorrhage: etiologies, imaging findings, and management

Hemorrhage is a potential complication of benign and malignant tumors and tumor-like conditions in the abdomen. Patients often have non-specific presentations, although they may present critically ill and hemodynamically unstable. Imaging plays an important role not only in the diagnosis of hemorrhage but also in the detection and characterization of an underlying mass. Ultrasound, computed tomography, and magnetic resonance imaging are utilized in evaluating these patients, with each having particular strengths and limitations. Spontaneous tumor hemorrhage is most commonly seen in hepatic and renal lesions, although it can arise from nearly every abdominal organ. In this article, we will review principles of tumor hemorrhage, illustrate common and uncommon imaging features, and highlight different options for management.

Inferior Vena Cava Filter in Cancer Patients: On Whom Should We Be Placing Them?

BACKGROUND

Standard treatment for venous thromboembolism is anticoagulation; vena cava filter placement is an alternative in special situations. We aimed to evaluate the outcomes in patients with cancer undergoing filter placement in a cancer center during a 10-year period and assess which preoperatory variables were associated with poorer survival.

METHODS

Retrospective unicenter analysis during a 10-year period was carried out in patients with cancer who had undergone placement of vena cava filter. Early deaths were those that occurred less than 30 days after the filter placement or that occurred during the same hospital stay of the placement.

RESULTS

About 250 patients were analyzed. About 51.6% were females; 77.2% had proximal lower limb deep vein thrombosis; 34.8% had contraindications to anticoagulation; 32.8% presented bleeding after the onset of anticoagulation; and 18.4% had the filter implanted because they were going to undergo surgery and could not be anticoagulated immediately after. About 51.2% of the filters were removable. However, only 2 had the filter removed. About 59.2% had metastatic disease at the time of filter placement. About 31.2% fulfilled criteria for early death. Of those, 34 patients were put in palliative care after filter insertion (median, 13.5 days). Body mass index >18 kg/m², the absence of metastatic disease, and filter placement during the same anesthesia of another surgery (especially if elective and curative) were associated with a higher chance of survival.

CONCLUSIONS

Multidisciplinary evaluation (and possibly consideration for palliation) should take place before the decision to insert a vena cava filter in severe oncologic cases depending on overall status. Patients with a greater chance of survival at a 3 or 5 years interval seem to be those whose filters were placed in the perioperative context of other surgeries (specially elective and curative), who were not undernourished, and whose disease was not metastatic at that time. For patients who survived, an active investigation protocol for filter removal should be implemented.

Severe Small Bowel Bleeding Associated With Metastatic Clear Cell Renal Cell Carcinoma to the Jejunum

Clear cell renal cell carcinoma is a malignancy of the kidneys that most commonly metastasizes to lung, bone, lymph nodes, liver, adrenal glands, and brain. We present a 75-year-old man with severe and chronic gastrointestinal bleeding who was eventually discovered to have clear cell renal cell carcinoma metastatic to his jejunum as the source of his bleed. This is a rare phenomenon and an unusual cause of gastrointestinal bleeding.

Esophagus and Gastrointestinal Junction Tumors

Esophageal squamous cell carcinoma and adenocarcinoma account for 95% of all esophageal malignancies. The rates of esophageal adenocarcinoma have increased in Western countries, making it the predominant type of esophageal cancer. Treatment of both types of cancer has transformed to a more minimally invasive approach, with endoscopic methods being used for superficial cancers and more frequent use of video-assisted and laparoscopic modalities for locally advanced tumors. The current National Comprehensive Cancer Network guidelines advocate a trimodal approach to treatment, with neoadjuvant chemoradiation and surgery for locally advanced cancers.

Risk factors of tumor invasion and node metastasis in early gastric cancer with undifferentiated component: a multicenter retrospective study on biopsy specimens and clinical data

Background

Early gastric cancer (EGC) with undifferentiated component (UDC) is a more aggressive entity, where the significance of preoperative data to tumor invasion and lymph node metastasis (LNM) remains unclarified.

Methods

A total of 5,020 GC patients undergoing radical gastrectomy in three centers were reviewed, of which, EGC with UDC in preoperative biopsy specimens were enrolled. The histology of biopsy and surgical specimens was graded according to the proportion of UDC and signet ring cells (SRCs). Risk factors of tumor invasion and LNM were evaluated with histological, clinical and demographic data.

Results

Lower body mass index (BMI), melena and larger tumor size were the independent preoperative risk factors of both LNM and LVI, while ulcerative lesion (UL) and the lower third stomach were only correlated with LNM. No relevance was found between the histological features of biopsy specimens and LNM, but SRC or >50% UDC lowered the risk of lymphovascular invasion (LVI) and/or submucosal (SM) invasion. When surgical data (depth of invasion and LVI included) were added, lower BMI, melena and the lower third stomach were still the independent preoperative risk factors of LNM, and LVI, SRC and SM invasion also showed relevance to LNM. The performance of predictive models using pre- or postoperative histological data was comparable.

Conclusions

The preoperative data were significantly relevant to tumor invasion and LNM, showing comparable risk strength with surgical specimens in histology.

Dual-energy CT evaluation of gastrointestinal bleeding

Gastrointestinal bleeding is a common cause for hospital admissions and is an important cause of morbidity and mortality. Although endoscopy is accepted as the standard initial diagnostic modality for the evaluation of gastrointestinal bleeding, multiphasic computed tomography (CT) imaging has become an alternative diagnostic tool. Dual-energy CT with post-processing techniques may have additional advantages over single-energy computed tomography in evaluation of gastrointestinal bleeding. In this article, we discuss the role of dual-energy CT in the evaluation of gastrointestinal bleeding with potential advantages over conventional CT and limitations.

Application of Data Mining for the Prediction of Mortality and Occurrence of Complications for Gastric Cancer Patients

The development of malign cells that can grow in any part of the stomach, known as gastric cancer, is one of the most common causes of death worldwide. In order to increase the survival rate in patients with this condition, it is essential to improve the decision-making process leading to a better and more efficient selection of treatment strategies. Nowadays, with the large amount of information present in hospital institutions, it is possible to use data mining algorithms to improve the healthcare delivery. Thus, this study, using the CRISP methodology, aims to predict not only the mortality associated with this disease, but also the occurrence of any complication following surgery. A set of classification models were tested and compared in order to improve the prediction accuracy. The study showed that, on one hand, the J48 algorithm using oversampling is the best technique to predict the mortality in gastric cancer patients, with an accuracy of approximately 74%. On the other hand, the rain forest algorithm using oversampling presents the best results when predicting the possible occurrence of complications among gastric cancer patients after their in-hospital stays, with an accuracy of approximately 83%.

Low-Stage Gastric MALT Lymphoma Causing Life-Threatening Upper Gastrointestinal Bleeding

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is an uncommon tumor of the stomach that only comprises around 1–6% of all tumors of the stomach. Non-Hodgkin lymphoma more commonly affects the lymph nodes and may spread to the spleen and bone marrow, whereas extranodal non-Hodgkin lymphoma is less common. Primary gastric lymphoma is further divided based on histologic features; one of the types is MALT lymphoma, which is strongly associated with Helicobacter pylori infection. The first sign of the disease is usually mimicking gastritis. However, in the case reported here, the first sign of gastric MALT lymphoma was massive gastrointestinal (GI) bleeding with hemodynamic instability in a 75-year-old male. The patient came to the emergency department and was immediately resuscitated, intubated, and admitted to the intensive care unit. Urgent endoscopy (<6 h) was done to identify the source of bleeding, which were oozing ulcerated polypoid masses; endoscopic hemostasis was done, which successfully stopped the bleeding. However, the next day, rebleeding occurred and a second endoscopic hemostasis was performed. The bleeding stopped and the patient showed gradual improvement. The biopsy result of a gastric MALT lymphoma of grade IE1 with H. pylori infection warranted a treatment regimen for Helicobacter eradication. The patient recovered, with follow-up endoscopy at 3 months, at 6 months, and yearly thereafter with no sign of recurrence. This case shows that gastric MALT lymphoma, even at a low stage (1E1), can cause life-threatening upper GI bleeding that requires aggressive resuscitation and urgent endoscopy.

Endoscopic management of bleeding gastrointestinal tumors

Bleeding due to primary or metastatic gastrointestinal (GI) tumors remains clinically challenging. Bleeding is further complicated in the setting of underlying friable neovascularization of tumors and coagulopathy. Endoscopic hemostatic therapeutic options have traditionally involved the use of thermal/mechanical therapy in conjunction with injection therapy. This review looks at the role of endoscopy in managing tumor-related GI bleeding, specifically contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and, most recently, Hemospray. Overall, current data show that endoscopic therapy is limited, with high rebleeding rates and a failure to improve overall outcomes. Larger clinical trials are needed to determine the efficacy of current techniques and establish therapeutic algorithms, with the goal of achieving primary hemostasis and reducing rebleeding rates.

[Optimization of surgical care for the hemorrhagic colorectal cancer]

AIM

To optimize surgical care for the hemorrhagic colorectal cancer.

MATERIAL AND METHODS

77 patients diagnosed with hemorrhagic colorectal cancer were reviewed: 9 patients of them were efficaciously treated with conservative therapy (I group); 47 - underwent successful endoscopic coagulation (I); 4 - arterial embolization (I), 2 - ligation of internal iliac arteries (I), 15 - acute resection (II group). 20 of 62 patients I group underwent plan surgery and radiation or chemotherapy during 7-10 days after hemostasis and normalization hemoglobin. The 3-year cumulative survival after resections (acute versus plan) was plotted on a Kaplan-Meier chart in 31 patients.

RESULTS

Complications and postoperative mortality was significantly higher after acute resection (II group) compared with plan resection (I): 33,3% vs 20%; 15% vs 5%, respectively. The survival rate was higher after plan than acute resections: 0,8882 and 0,3571, respectively.

CONCLUSION

Acute surgery for hemorrhagic colorectal cancer should only be carried out by appropriately trained surgeons in multi-specialty hospital. Endoscopy and arterial embolization are the most effective means of successfully controlling hemorrhage while minimizing potential complications. A bridging strategy may be a valid alternative in some of patients with hemorrhagic colorectal cancer, because a significantly lower postoperative mortality rate.