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Singh M, Chiang J, Seah A, Liu N, Mathew R, Mathur S. A clinical predictive model for risk stratification of patients with severe acute lower gastrointestinal bleeding. World J Emerg Surg 2021; 16:58. [PMID: 34809648 PMCID: PMC8607718 DOI: 10.1186/s13017-021-00402-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients. METHODS A retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention. RESULTS 226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP < 90 mmHg), anaemia (Hb < 9 g/dL), metabolic acidosis, use of antiplatelet/anticoagulants, and active per-rectal bleeding. The optimum cut-off score of ≥ 1 had a sensitivity of 91.9%, specificity of 39.8%, and positive and negative predictive Values of 45% and 90.2%, respectively, for predicting severe LGIB. The area under curve (AUC) was 0.77. CONCLUSION Early diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.
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Affiliation(s)
- Manraj Singh
- Department of General Surgery, Singapore General Hospital, 20 College Rd, Singapore, 169856 Singapore
| | - Jayne Chiang
- Department of General Surgery, Singapore General Hospital, 20 College Rd, Singapore, 169856 Singapore
| | - Andre Seah
- Department of General Surgery, Singapore General Hospital, 20 College Rd, Singapore, 169856 Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
- Department of Trauma and Acute Care Surgery, Singapore General Hospital, Singapore, Singapore
| | - Nan Liu
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Ronnie Mathew
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Sachin Mathur
- Department of General Surgery, Singapore General Hospital, 20 College Rd, Singapore, 169856 Singapore
- Department of Trauma and Acute Care Surgery, Singapore General Hospital, Singapore, Singapore
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Ribeiro AM, da Silva S, Reis RA, Romero I, Costa S, da Silva JB. Dieulafoy's lesion in the cecum: A rare case report presentation. Int J Surg Case Rep 2021; 84:106157. [PMID: 34225059 PMCID: PMC8261652 DOI: 10.1016/j.ijscr.2021.106157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance Dieulafoy's lesion is a rare entity, normally present in the stomach and more rarely in the colon, and it is responsible for 1% to 5% of acute gastrointestinal bleeding cases. Its true incidence may be underrated, since most cases are asymptomatic and difficult to diagnose despite endoscopic advances. We present a clinical case of acute gastrointestinal bleeding due to Dieulafoy's lesion in the cecum. Case presentation An 85-year-old woman presented with a clinical condition of haematochezia associated with anaemia and haemodynamic instability, needing blood transfusion. Colonoscopy demonstrated a Dieulafoy's lesion in the cecum with active bleeding, and haemostasis was performed successfully with localized adrenaline injection and haemostatic clip placement. Hospitalization occurred without further complications. Discussion The diagnosis of Dieulafoy's lesion is difficult because it is a rare condition and thus, usually not included in the differential diagnosis of gastrointestinal bleeding. Its endoscopic diagnostic and therapeutic approach is the standard method in the event of an acute gastrointestinal bleeding episode, with greater efficiency with the combined use of haemostatic techniques. Surgery is necessary in less than 5% of cases when bleeding is not effectively controlled by endoscopic or angiographic techniques. Conclusion It is essential to be aware of this lesion as a possible cause of gastrointestinal bleeding and differentiate it from other causes. Advances in endoscopy have increased the rate of diagnosis of these lesions and reduced their associated mortality. Dieulafoy's lesion is a rare entity and is mostly found in the stomach. This lesion is an uncommon cause of acute gastrointestinal bleeding. Its diagnosis is difficult due to its rarity. This case report presents a Dieulafoy's lesion in the colon, an even rarer location.
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Affiliation(s)
- Ana Matos Ribeiro
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal.
| | - Sílvia da Silva
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Rui Almeida Reis
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Inês Romero
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Susana Costa
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - João Barros da Silva
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Arabi NA, Musaad AM, Mohammed FAH, Ahmed EE, Abdelaziz MSE. Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre. Arab J Gastroenterol 2018; 19:84-87. [PMID: 29885783 DOI: 10.1016/j.ajg.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/22/2016] [Accepted: 03/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND STUDY AIMS Lower gastrointestinal bleeding originates from a site distal to the ligament of Treitz. It can present as an acute life-threatening or chronicbleeding. It is common among older patients and those with comorbidity. The common causes are diverticular disease, angiodysplasias, neoplasms, colitis, ischaemia and anorectal disorders. The aim of this study is to determine the prevalence and causes of acute lower gastrointestinal bleeding among Sudanese patients. PATIENTS AND METHODS In a period of 2 years we studied 301 patients with fresh rectal bleeding out of 5625 patients with gastrointestinal bleeding in Ibn Sina Specialized Hospital, Khartoum, Sudan, This is a cross sectional observational hospital based study. All patients with fresh rectal bleeding within 24 h were included and consented. RESULT Lower gastrointestinal bleeding constituted 5.37% of total cases of gastrointestinal bleeding. The mean age of patients was 55.43 ± 17.779, male: female ratio was 2:1. The most common cause (if upper gastrointestinal bleeding is excluded) was diverticular disease 39.6% (n = 61) followed by piles 24.1% (n = 35), colonic tumours 12.34% (n = 19), ulcerative colitis 5.19% (n = 8), Crohn's 5.19% (n = 8), colonic polyps 3,89% (n = 6), angiodysplesia 4.5% (n = 7), colonic ulcer 2.59% (n = 4), ischaemic colitis 1.3%, nonspecific colitis 1.3% (n = 2), and small bowel source in 1.3% (n = 2). The majority of those patients with diverticular disease were male and with first presentation. The commonest cause in those patients younger than 20 years was polyps, and in those between 21 and 40 was piles followed by inflammatory bowel disease, and in those between 41 and 60 years old was piles followed by diverticular disease and tumours, and in those above 60 years was diverticular disease followed by piles and tumours. The correlation between positive colonoscopy finding and diabetes and the use of nonsteroidal anti-inflammatory drugs were statistically significant. The one-month mortality rate was 2.3% CONCLUSION: Acute lower gastrointestinal bleeding is common among elderly patients and the commonest cause is diverticular disease. Colonoscopy plays an important role in the diagnosis. Most patients respond to conservative therapy.
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Affiliation(s)
- Nassir Alhaboob Arabi
- Faculty of Medicine, Omdurman Islamic University, Department of GI Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan.
| | - Abdulmagid Mohammed Musaad
- Faculty of Medicine, Omdurman Islamic University, Department of GI Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | | | - Elsaggad Eltayeb Ahmed
- Faculty of Medicine, Al Nilin University, Department of GI Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Muataz Salah Eldin Abdelaziz
- Faculty of Medicine, Omdurman Islamic University, Department of GI Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
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Prakash JS, Samraj A, Kumar GS, Vijai R. A Diagnostic Surprise For A Right Iliac Fossa Mass - A Perforated Ileal Gastrointestinal Stromal Tumour. J Clin Diagn Res 2017; 11:PD03-PD04. [PMID: 29207774 DOI: 10.7860/jcdr/2017/27704.10560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 05/31/2017] [Indexed: 11/24/2022]
Abstract
Gastrointestinal Stromal Tumours (GISTs) are tumours of the gut found mostly in stomach and small intestine. The complications are Gastrointestinal (GI) bleeding, obstruction, pain and rarely perforation. We are reporting an abnormal presentation of GIST masquerading as an acute abdomen with Right Iliac Fossa (RIF) mass in 60-year-old lady. Contrast Enhanced Computed Tomography (CECT) of abdomen revealed a peripherally enhancing encapsulated abscess in RIF in close contact with base of caecum and adjacent peritonitis suggesting caecal perforation. On laparotomy, a gangrenous perforated ileal GIST was identified along the antimesenteric border of ileum. Pathological examination confirmed the tumour to be a GIST of spindle cell type, further reiterated by immunohistochemistry. Our case report emphasizes, GIST as a rare and unusual differential diagnosis of RIF mass, and to have high degree of clinical suspicion when a similar situation is encountered in an emergency scenario, keeping in mind the poor outcome due to delay in appropriate management of the disease.
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Affiliation(s)
- J Sanjay Prakash
- Assistant Professor, Department of General Surgery, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Anita Samraj
- Professor, Department of General Surgery, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - G Sabarish Kumar
- Senior Resident, Department of General Surgery, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - R Vijai
- Postgraduate Student, Department of General Surgery, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
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Solanke DB, Pipaliya NM, Chaubal AN, Ingle MA, Sawant PD. Post Colonoscopy Ischaemic Colitis in a Patient without Risk Factors for Colon Ischemia: A Case Report. J Clin Diagn Res 2016; 10:OD10-OD11. [PMID: 27891381 DOI: 10.7860/jcdr/2016/21044.8706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 07/21/2016] [Indexed: 01/29/2023]
Abstract
Ischaemic colitis is the most common form of intestinal ischaemia and is more common in the elderly and in the people having risk factors for colonic ischaemia. Colonoscopy procedure itself is a rare cause of ischaemic colitis. Fewer than 20 cases of ischaemic colitis caused by colonoscopy procedure have been reported in the english literature till date. This patient presented to us within hours of routine colonoscopy with rectal bleeding and lower abdominal pain. On repeat colonoscopy, the patient had mucosal oedema and ulcerations in the descending colon and sigmoid colon. Computed tomography of abdomen and biopsy of the involved segment confirmed ischaemic colitis. The patient recovered with conservative management.
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Affiliation(s)
- Dattatray Balasaheb Solanke
- Senior Resident, Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital , Sion, Mumbai, Maharashtra, India
| | - Nirav Madhukant Pipaliya
- Senior Resident, Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital , Sion, Mumbai, Maharashtra, India
| | - Alisha Nitin Chaubal
- Senior Resident, Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital , Sion, Mumbai, Maharashtra, India
| | - Meghraj Ananda Ingle
- Associate Professor, Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital , Sion, Mumbai, Maharashtra, India
| | - Prabha Dilip Sawant
- Professor and Head, Department of Gastroenterology, Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital , Sion, Mumbai, Maharashtra, India
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Abstract
PURPOSE Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. METHODS Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. FINDINGS The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. CONCLUSIONS There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.
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Affiliation(s)
- Andrew J Moss
- Department of Surgery, Peterborough City Hospital, Peterborough, Cambridgeshire, PE3 9GZ, UK
| | - Hussein Tuffaha
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK.
| | - Arshad Malik
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK
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Obonna G, Arowolo A, Agbakwuru A. Experience with colonoscopy in the riverine southwestern Nigeria. J West Afr Coll Surg 2012; 2:80-90. [PMID: 25452985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Colonoscopy is useful for diagnosis, treatment and surveillance of anal and colorectal lesions. It affords a good, less invasive and tolerable way to see and access the large intestine. AIM AND OBJECTIVE To determine the indications, finding and diagnosis at colonoscopy in a riverine setting in Southwestern Nigeria. TYPE OF STUDY Descriptive cross sectional study. PATIENTS AND METHODS Patients who presented in the State Specialist Hospital, Okitipupa and requiring colonoscopy in their management between January 2011 to April 2013 were included in this study. They were reviewed and their demographic and clinical data, indications for colonoscopy, the findings and the pathological diagnosis were entered in a proforma. RESULTS Colonoscopy was done in 100 patients out of which seventy seven (77%) were males and 23 (23%) were females. The indications were frank lower gastrointestinal bleeding 55 (55%) chronic diarrhea (11%), chronic constipation10(10%), occult gastrointestinal bleeding (7.0%), lower abdominal and anal pain 4 (4.0%), queried anorectal cancer 3 (3.0%) and enterocutaneous fistula 1(1%). Colonoscopic findings, include, normal finding 24(24%) colitis 24 (24.0%), hemorrhoid 20(20.0%), Anal fissure 16 (16.0%) colonic cancer 5 (5.0%), anorectal cancer 4 (4.0%), caecal cancer 2 (2.0%) faecal impaction 2 (2.0%), anal wart 2 (2.0%) , polyps 1 (1.0%) and anal fistula 1 (1.0%). The diagnostic yield was 76%. CONCLUSION Bleeding from the lower gastrointestinal tract was the commonest indication for colonoscopy and the most frequent pathology was amoebic in the riverine Southwestern Nigeria.
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Affiliation(s)
- Gc Obonna
- STATE SPECIALIST HOSPITAL, OKITIPUPA,ONDO STATE, NIGERIA
| | - Ao Arowolo
- OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL, OSUN STATE, NIGERIA
| | - A Agbakwuru
- OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL, OSUN STATE, NIGERIA
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