An unpredictable gastrointestinal bleed

A 65-year-old male complained of persistent melena for 6 days, and displayed anemia symptoms without hematemesis, vomiting, and abdominal distention. He was diagnosed as ruptured aneurysm of aortic sinus Valsalva, and had received coronary artery occlusion 1 month ago. After the operation, he was continually prescribed clopidogrel 75 mg once daily. The laboratory examination showed blood hemoglobin concentration was 60 g/L without other conspicuous abnormality. Unfortunately, neither esophagogastroduodenoscopy (EGD) nor colonoscopy found no obvious bleeding lesions. And abdominal computed tomography angiography (CTA) and enhanced computed tomography (CT) showed no obvious abnormal findings. Moreover, capsule endoscopy revealed small intestinal with mucosal erosion (Figure 1A). After discontinued clopidogrel, blood transfusion, and support therapy, his symptoms was resolved with negative fecal occult blood, continued clopidogrel 75 mg once daily, and uneventfully discharged 1 week later.

Spontaneous duodenal wall hematoma

59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms.

Overt gastrointestinal bleeding secondary to left inferior phrenic artery pseudoaneurysm postgastric bypass surgery

Bleeding from a visceral artery pseudoaneurysm (VAPA) is a rare but significant complication of bariatric surgery. Patients may present with gastrointestinal (GI) haemorrhage in the forms of haematemesis, melaena, haematochezia or haemodynamic compromise. Although CT angiogram, endoscopy and laparoscopy form essential parts of diagnostic assessment, small pseudoaneurysms with intermittent bleeding may be overlooked. We report the case of a man in his 40s who presented to the emergency department with massive GI bleeding and subsequent haemodynamic instability, secondary to a pseudoaneurysm from a vascular injury during a recent bariatric procedure. This case highlights the diagnostic challenges of obscure, intermittent bleeding involving the bypassed stomach with unremarkable investigation findings, and aims to raise awareness among clinicians in considering the less common postgastric-bypass complications.

Phlegmonous gastritis associated with invasive Pseudomonas aeruginosa infection

We report the case of a 49 years-old female that was hospitalized due to a recent diagnosis of acute lymphoblastic leukemia. As a consequence of induction chemotherapy (CALGB 10403 scheme), she developed severe neutropenia (0.04 10^3/ul). On day 6 of chemotherapy, she complained of epigastric pain, fever, coffee ground emesis, and melena.

Black esophagus

A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar amputation) came to the emergency with coffee ground emesis and mild anemia. Urgent gastroscopy showed diffuse circumferential black mucosa covered by fibrin affecting the middle and distal esophageal third. Acute esophageal necrosis is a rare cause of gastrointestinal bleeding that should be suspected in patients with cardiovascular risk factors with an image of a black esophagus that is abruptly interrupted at the EGJ.

Prospective observational study on clinical and epidemiological profile of adult patients presenting to the emergency department with suspected upper gastrointestinal bleed

BACKGROUND AND OBJECTIVE

Bleeding from the upper gastrointestinal (GI) tract is one of the common medical emergencies. In this study, we assessed patients' socio-demographic and clinical characteristics and the association of clinical characteristics with treatment outcomes among patients with suspected upper gastrointestinal bleed (UGIB) presenting to the emergency department (ED). At present, there is a scarcity of data on UGIB in Northern part of India.

MATERIAL AND METHOD

The study was a single-center, prospective observational study conducted at an urban tertiary care center. Consecutive patients with suspected UGIB were enrolled in the study from August 2020 to February 2022. A detailed history was obtained, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction, and drug history. Pre-endoscopic Rockall and Glasgow-Blatchford Score were calculated for each patient. The patients were subsequently followed up till discharge from the hospital. The final outcomes with regard to mortality, need for blood transfusion, length of emergency department stay, and discharge were noted.

RESULT

141 patients were included in the study. The mean age of the patients with suspected UGIB was 48 ± 14 years. 115 (81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%). The most frequent presenting complaint in this study was hematemesis (96; 68.1%), followed by melena (76;53.9%). The mean (Standard Deviation, SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15 in patients with UGIB.

CONCLUSION

In our study, hematemesis was the most prevalent symptom of suspected UGIB, followed by melena. Portal hypertension was the most common cause of UGIB. Most frequent comorbidities in patients suspected of UGIB were alcohol intake, Nonsteriodal Antiinflammatory Drugs (NSAIDs) abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes. Early endoscopy can be of great utility to reduce morbidity and mortality.

A rare complication of people with inflammatory bowel disease after ileostomy: A case report

RATIONALE

Venous thromboembolism is one of the common complications of inflammatory bowel disease (IBD), which is a significant health problem worldwide. Factors such as inflammation, medications, and abdominal surgery, contribute to the increased risk of venous thromboembolism in patients with IBD. Cavernous transformation of the portal vein (CTPV) is a relatively rare complications of IBD. Subsequent portal hypertension could be fatal and the clinical treatment is difficult. Thus, early prevention is very crucial.

PATIENT CONCERNS

A 55-year-old man presented to our department with asthenia, hematemesis, and diarrhea. He was diagnosed with Crohn disease for 9 years. Two years ago, He suffered intestinal perforation and received enterectomy and ileostomy. And, anticoagulants were not given during perioperative period and after surgery because of the history of gastrointestinal bleeding.

DIAGNOSES

The patient was given endoscopy inspection showing the varices of esophagus and gastric fundus near cardia. Contrast enhancement CT scan showed portal hypertension, CTPV, gastroesophageal varices, and splenomegaly. Then percutaneous transhepatic portography was performed to make a clear diagnosis.

INTERVENTIONS

Concerned about the risk of surgery, he refused surgical shunting. Conservative treatment was recommended due to technical difficulties instead of interventional therapy.

OUTCOMES

And after a period of fasting, blood transfusion, and parenteral nutrition treatment, the patient did not experience any further vomiting or hematemesis.

LESSONS

Early identification and treatment of CTPV is difficult. Prevention such as early application of anticoagulant is necessary for patients with IBD undergoing surgery, particularly with simultaneous stoma formation. For IBD patients who are not suitable for anticoagulant therapy, postoperative follow-up monitoring should be more frequent and monitoring time should be extended.

Hemostatic spray as a therapy for pancreatic stump bleeding after cephalic duodenopancreatectomy

A 70-year-old man with a cholangiocarcinoma underwent a cephalic duodenopancreatectomy. On the 2nd postoperative day, he had hematemesis without hemodynamic instability. Upper endoscopy (EGD) revealed a massive clot at the pancreatic stump, suspected as the source of hemorrhage. After partial clot removal, no active bleeding was found and no therapy was performed. Pancreaticogastric and gastrojejunal anastomoses, as well as the efferent-limb, showed no suspicious lesions. Octreotide was initiated and heparin prophylaxis was temporarily stopped. Bleeding from pancreatic stump following pancreatoduodenectomy is a rare but a life-threatening condition. Conventional endoscopic therapies, including clip placement and cautery, are mostly ineffective and with high risk of pancreatitis. We report the second case of hemostatic powder as a safe and successful therapy in this scenario.

An Unusual Presentation of Chest Pain and Laryngeal Discomfort in a Pregnant Woman: A Case Report and Literature Review

Intramural esophageal dissection (IED), characterized by bleeding into the submucosal space, leads to mucosal separation and dissection. The most prevalent symptoms are sudden chest or retrosternal pain, hematemesis, and dysphagia. Therefore, acute coronary syndrome and aortic dissection are among its most notable differential diagnoses. A 31-year-old pregnant woman presented with acute chest pain, laryngeal discomfort, and hematemesis. Emergency esophagogastroscopy revealed longitudinal mucosal dissection (upper esophagus to esophagogastric junction). The patient was successfully treated by avoiding the ingestion of solid foods. Clinicians should consider a diagnosis of IED for pregnant patients with acute chest pain, especially if hematemesis is present.

Plug-assisted retrograde transvenous obliteration via gastrocaval shunt for the gastric variceal bleeding: A case report

RATIONALE

Most gastric varices at the fundus drain into the left renal vein via the gastrorenal shunt (80-85% of cases) or the inferior vena cava via the gastrocaval shunt (10-15%). Therefore, plug-assisted retrograde transvenous obliteration (PARTO) is usually performed via a gastrorenal shunt. Here, we report a case of gastric varix treated with PARTO via a gastrocaval shunt.

PATIENT CONCERNS

A 46-year-old woman with hepatitis B virus and liver cirrhosis visited the emergency room in our hospital with the main symptom of hematemesis and hematochezia.

DIAGNOSES

Endoscopy and computed tomography (CT) revealed a gastric varix and thrombotic-occluded transjugular intrahepatic portosystemic shunt (TIPS) stent.

INTERVENTIONS

The patient underwent PARTO via a gastrocaval shunt to manage gastric variceal bleeding after failed TIPS revision.

OUTCOMES

On CT, the gastric varix completely disappeared. The patient did not experience any additional bleeding events.

LESSONS

PARTO via a gastrocaval shunt is safe and effective.

Clinical and endoscopic characteristics of acute esophageal necrosis and severe reflux esophagitis

The similarities and differences between acute esophageal necrosis and severe reflux esophagitis have not been elucidated. We compared Los Angeles classification Grade C reflux esophagitis, Grade D reflux esophagitis, and acute esophageal necrosis to consider the similarities and differences between acute esophageal necrosis and severe reflux esophagitis.We retrospectively reviewed records of patients who underwent esophagogastroduodenoscopy at a tertiary referral center from January 2012 to December 2019. Data on patients diagnosed as Grade C reflux, Grade D reflux, or acute esophageal necrosis for the first time were extracted for analysis.A total of 213 patients were enrolled in the study, composed of 130 Grade C reflux, 74 Grade D reflux, and 9 acute esophageal necrosis patients. Compared to Grade C reflux patients, Grade D reflux and acute esophageal necrosis patients were more likely to be transfused (P = .013 and P = .011, respectively), to have duodenal ulcers (P = .025 and P = .049, respectively), and to have psychiatric illnesses (P = .022 and P = .018, respectively). Compared to both Grade C and D reflux, acute esophageal necrosis patients were more likely to present with shock (P = .003 and P < .001, respectively), have type 1 diabetes (P = .030 and P = .004, respectively), and present in winter (P < .001 and P < .001, respectively). Significant step-wise differences (Grade C < Grade D < acute esophageal necrosis) were observed in the need for admission (P < .001 and P = .009), coffee ground emesis (P < .001 and P = .022), and stigmata of hemorrhage on endoscopy (P = .002 and P < .001). Admission (P = .003) and coffee ground emesis (P = .003) independently predicted either Grade D reflux or acute esophageal necrosis over Grade C reflux on multivariate analysis.Shock, type 1 diabetes, and winter may predict acute esophageal necrosis, while the need for admission and coffee ground emesis may predict Grade D reflux or acute esophageal necrosis.

Clinical Profile, Severity and Outcome of Acute Upper Gastrointestinal Bleeding in Elderly Patients Compared to Non-elderly Patients: A Prospective Observational Study

AIM

To determine the clinical profile, severity and outcome of acute upper gastrointestinal bleeding (UGIB) in elderly subjects (>60 years) compared to the non elderly ones (<60 years).

METHODS

In a prospective observational study, 380 consecutive adult patients presenting with acute UGIB were enrolled. Patients were divided into two groups: elderly (≥60 years) and non-elderly (<60 years).

RESULTS

Out of 380 patients, 254(66.84%) patients were non-elderly and 126(33.15%) patients were elderly. The proportion of patients with co-morbidity and consumption of non-steroidal anti-inflammatory drugs was higher among elderly patients. The commonest mode of presentation was hematemesis and melena in the both groups, while isolated hematochezia (29% vs. 1.9%, p<0.01) was more common in elderly group. The variceal bleeding was significantly higher among non-elderly group (38.1% vs. 18.2%, p<0.01) and bleeding from gastric or duodenal ulcer was the predominant cause of bleeding among elderly group (65% vs. 43% p<0.01). The proportion of patients with tachycardia (68.2% vs. 20%, p<0.01), postural hypotension (29.3% vs. 14.9%, p<0.01) and blood transfusion requirement of 4 units or more (20.2% vs. 10.1%, p<0.01) was significantly higher among elderly group than in non-elderly group. Despite similar re-bleeding rates, mortality rate was significantly higher in elderly patients compared to the non-elderly patients (10.32% vs. 1.94%, p<0.01).

CONCLUSION

Nearly 33% of the patients with acute UGIB are over 60 years old. The severity of bleeding and mortality rates was higher in elderly in comparison to non-elderly patients.

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage (ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization (TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.

[Abdominal symptoms necessitating surgical intervention as the initial presentation of Henoch-Schönlein purpura in children - case reports]

Henoch-Schönlein purpura (HSP) is the most common pediatric autoimmune vasculitis. Gastrointestinal symptoms of HSP including abdominal pain, diarrhea, and vomiting may precede skin changes by several days. We present diagnostic challenges in two adolescents with HSP and severe abdominal symptoms necessitating surgical intervention before the development of skin changes.

CASE REPORT 1

A 15-year old boy with 7 day history of abdominal pain, and bloody vomiting (1-2 x per day) without diarrhea. A suspicion of acute appendicitis was raised and the boy was operated on the 7th day since the initial symptoms. The appendix showed some reactive inflammation and was removed during laparotomy which also revealed enlarged mesenteric lymph nodes and a modest amount of fluid in the pelvic cavity. During the first day after the surgery, skin changes typical for HSP developed on lower limbs and buttocks.

CASE REPORT 2

A 12-year old girl with 7 day history of abdominal pain, without diarrhea or vomiting. On the day of admission hemorrhagic rash appeared on lower limbs. Laparotomy was performed on 14th day after onset of abdominal pain - large amounts of serous, blood-stained fluid, massive dilation of small intestine with ecchymoses in mucous membrane, segmental infiltration and stiffening of intestinal wall were found. Normal appendix was removed.

CONCLUSIONS

Severe abdominal symptoms may precede skin changes in children with HSP, resulting in diagnostic and therapeutic challenges. When considering laparotomy in children with an atypical "acute abdomen" presentation, other manifestations of HSP should be sought.

Intramural haematoma of the esophagus: multimodality imaging findings and clinical triad

Intramural haematoma of the esophagus (IHE) is an uncommon clinical condition, which can mimic other cardiothoracic emergencies in both clinical and imaging perspectives. We presented the case of a 54-year-old female who presented to the emergency department with a clinical triad of retrosternal chest pain, odynophagia, and haematemesis for 3 days. Multi-detector computed tomography (MDCT) revealed long-segmental, well-defined, isodense mass in postero-lateral wall of esophagus with smooth arc-shaped indentation into the lumen and no obvious enhancement after IV contrast administration. The preserved fat plane between the thickened esophagus and the aorta allows exclusion of aortic dissection. Subsequent esophagogram and endoscopy confirmed the finding of IHE and thus, patient was successfully treated with conservative treatment and discharged uneventfully. Owing to the presence of clinical and image mimickers of IHE, the recognition of clinical triad of retrosternal pain, odynophagia, and haematemesis, and the typical MDCT and esophagographic presentation of submucosal haematoma are important in avoiding misdiagnosis with inappropriate treatment.

Left subclavian arterioesophageal fistula induced by chicken bone with upper gastrointestinal hemorrhage and unexpected death: report of a case

Left subclavian arterioesophageal fistula resulting from chicken bone ingestion is a rare occurrence. The authors report the death of a 42-year-old Thai female with mental retardation who presented to the hospital with severe hematemesis and arrested Death occurred about 24 hours after laparotomy due to hypovolemic shock Postmortem examination revealed a chicken bone embedded in middle part of esophagus with fistula between the esophagus and the left subclavian artery.

[Case report: Budd-Chiari syndrome and esophageal variceal bleeding due to alveolar echinococcosis]

Alveolar echinococcosis of the liver is a rare larval cestode disease which is due to the intrahepatic growth of the tapeworm Echinococcus multilocularis. This cestode naturally evolves as a larval stage within cysts in the body of carnivores. Humans are accidental intermediate hosts and become infected, either by eating food contaminated with carnivore-originated eggs or by touching foxes. It behaves as malignant liver tumour and rarely causes Budd-Chiari syndrome and variceal bleeding. Budd-Chiari syndrome is a hepatic venous outflow tract obstruction and may be present abdominal pain, hepatomegaly and ascites. Parasitic cysts may cause compression and thrombosis of the hepatic venous outflow tract. It may present as portal hypertension and variceal upper gastrointestinal bleeding. We here in report a 47-year-old woman without a prior history of liver disease presented with Budd-Chiari syndrome and variceal bleeding due to Alveolar echinococcosis. The course of this rare disease is demonstrated by means of the most important laboratory, serologic and radiologic parameters.

Intestinal Ischemia Complicating Ascending Aortic Dissection: First Things First

Typically acute dissections of the ascending aorta are considered operative emergencies with delays in treatment potentially resulting in considerable morbidity and mortality. However, occasionally associated unstable or poorly defined problems (such as neurologic impairment or end-organ ischemia) may warrant further investigation and possible treatment to facilitate safe aortic repair. We present a case of acute ascending aortic dissection associated with an intra-abdominal vascular and enteric catastrophe that was successfully managed prior to aortic repair.

Pregnancy in biliary atresia after kasai operation complicated by portal hypertension

Hepatic portoenterostomy or Kasai operation has been widely accepted as the standard therapy for biliary atresia. Recently, more female patients have grown up and reached adulthood; therefore, pregnancy in women with biliary atresia is sometimes inevitable. The authors report a 17-year-old woman with biliary atresia post Kasai operation at 3 months of age. After the operation, she became jaundice-free but developed portal hypertension with abnormal liver function. She had several episodes of esophageal variceal bleeding and was treated by beta-blocker and endoscopic sclerotherapy. Since then, she was lost to follow up for nearly 2 years. She came back again with 12 weeks of gestation with no symptoms of gastrointestinal bleeding for antenatal care. At 32 weeks of gestation, she presented with severe hematemesis from variceal bleeding and had thrombocytopenia from hypersplenism. She was treated with somatostatin analogue, fluid and blood component replacement and other supportive treatments. Cesarean section was performed when she was stable at 33 weeks of gestation. After the operation, her clinical status was improved and had no other complications. Her baby experienced complications of prematurity but improved after treatment. Pregnancy may affect the natural course of portal hypertension and worsen the clinical outcome. Pregnancy should be avoided in patients with portal hypertension, however it is not contraindicated. Pregnancy in biliary atresia patients needs intensive prenatal care.

ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis

OBJECTIVES

In patients with gastrointestinal (GI) tract bleeding, the bleeding source is uncertain in the absence of hematemesis. We sought to identify clinical variables predictive of an upper GI bleeding source.

METHODS

This retrospective cohort study involved patients admitted via the ED for GI tract bleeding without hematemesis, who underwent confirmatory testing. We used logistic regression analysis to identify clinical variables independently associated with an upper GI source.

RESULTS

Among 325 patients, odds ratios for the strongest predictors were as follows: black stool, 16.6 (95% confidence interval [CI], 7.7-35.7); age less than 50 years, 8.4 (95% CI, 3.2-22.1); and blood urea nitrogen/creatinine ratio 30 or greater, 10.0 (95% CI, 4.0-25.6). Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors.

CONCLUSION

Black stool, age less than 50 years, and blood urea nitrogen/creatinine ratio of 30 or greater independently predict an upper GI tract bleeding source.

Acute promyelocytic leukemia: an unusual cause of fatal secondary postpartum hemorrhage

INTRODUCTION

Postpartum haemorrhage can rarely be associated with an underlying coagulation or haematological disorder. We wish to discuss a case of acute promyelocytic leukemia (APL) presenting as secondary postpartum hemorrhage (PPH), its clinical and pathological features and maternal outcome.

CASE REPORT

We describe a 28-year-old woman who presented with secondary PPH accompanied by bleeding from gums, marked pallor, hematemesis, ecchymotic and purpuric spots all over the body, 8 days post-partum. Investigations revealed her to be having APL, a diagnosis not suspected by the referring clinic. She was given supportive therapy but died before chemotherapy could be started.

CONCLUSION

The case emphasizes the importance of suspecting, investigating and energetically treating uncommon causes such as acute leukemia when an unusually severe clinical picture in a postpartum setting suggests such a possibility. This may prove to be life saving, particularly if the leukemia happens to be APL, a cancer with a very high cure rate.

Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis

STUDY OBJECTIVE

We estimate the test characteristics of nasogastric aspiration to diagnose upper gastrointestinal tract hemorrhage in patients without hematemesis.

METHODS

In this retrospective cohort study, medical records from patients admitted to 2 urban hospitals between 1997 and 2002 for gastrointestinal tract bleeding without hematemesis were reviewed. Positive nasogastric aspiration results were classified by the severity of hemorrhage, and negative results were classified by the presence or absence of bile. The reference standard for nasogastric aspiration was the source of bleeding-upper versus non--upper gastrointestinal tract--from the hospital discharge summary. Confidence intervals (CIs) for proportions and likelihood ratios (LRs) were calculated.

RESULTS

Of 333 eligible patients, 235 were offered nasogastric aspiration, and 220 accepted the test. Results of 220 attempts were distributed as follows: negative, 158 (72%), including 9 (4%) with bile; nasogastric aspiration aborted, 13 (6%); and positive, 49 (23%), including 4 (2%) that were strongly positive (> or =450 mL red blood). Test characteristics of nasogastric aspiration to detect upper gastrointestinal tract bleeding in 213 patients with a reference standard diagnosis were as follows: sensitivity 42% (95% CI 32% to 51%), specificity 91% (95% CI 83% to 95%), negative predictive value 64% (95% CI 56% to 71%), and positive predictive value 92% (95% CI 79% to 97%). The nasogastric aspiration accurately predicted the source of bleeding in 66% of patients (95% CI 59% to 72%). The likelihood ratio of a positive nasogastric aspiration was 11 (95% CI 4 to 30), and the likelihood ratio of a negative nasogastric aspiration was 0.6 (95% CI 0.5 to 0.7).

CONCLUSION

In patients without hematemesis, a positive nasogastric aspiration, seen in 23%, indicates probable upper gastrointestinal tract bleeding (LR+ 11), but a negative nasogastric aspiration, seen in 72%, provides little information (LR- 0.6).

[Abdominal aortic aneurysm manifested by hematemesis in a 32 year old patient infected by HIV]

Aortic aneurysm is an uncommon in young patients. The purpose of this report is to describe a case of dissecting aortic aneurysm in a 32-year-old man with human immunodeficiency virus (HIV) infection. The presenting symptom was recurrent massive hematemesis. Diagnosis was suspected on the basis of clinical cardiovascular assessment and confirmed by ultrasonography and computed tomography. The clinical course was complicated by superior vena cava syndrome and kidney failure. Outcome in the absence of surgical treatment was fatal. Perusal of the literature indicates a rising incidence of large vessel disease in young patients with HIV infection. The underlying pathophysiological mechanisms is unclear. Assessment for arterial lesions should be performed in all patients with HIV infection since clinical signs may be misleading. Definitive diagnosis can be achieved by ultrasonography, Doppler ultrasound or computed tomography.

Bouveret's syndrome presenting as upper gastrointestinal hemorrhage without hematemesis

A 74-year-old woman with a recent diagnosis of peptic ulcer disease diagnosed by endoscopy after presentation with an episode of upper gastrointestinal bleeding returned 6 1/2 weeks later with a 5-day history of nausea and vomiting without associated symptoms. An ultrasound was nondiagnostic except for a large gallstone and a poorly visualized gallbladder. Repeat endoscopy revealed a hard mass that was presumed to have formed secondarily to an ulcer-induced stricture, and a 6-cm filling defect just proximal to the duodenal bulb was seen on a preoperative upper gastrointestinal series. At laparotomy the mass was actually a large gallstone and two smaller stones, which had eroded into and become impacted in the duodenal bulb creating a gastric outlet obstruction. The stones were extracted via a duodenotomy, and the remaining portion of the gallbladder was removed with repair of the cholecystoduodenal fistula. The patient was discharged home after an uncomplicated postoperative course. Gastric outlet obstruction by a duodenal gallstone is a condition known as Bouveret's syndrome, which is a rare complication of gallstone disease. Upper gastrointestinal hemorrhage is an especially rare form of presentation.

Influence of climatic factors in the incidence of upper gastrointestinal bleeding

BACKGROUND AND AIM

Previous reports have indicated seasonal fluctuations in the incidence of peptic ulcer activity, but the reasons for the seasonal pattern are not clear. We assessed the seasonal incidence of hematemesis caused by peptic ulcers or gastroesophageal varices, and the correlations between those and climatic factors.

METHODS

We examined the number of cases of upper gastrointestinal (GI) bleeding caused by gastric ulcer (GU), duodenal ulcer (DU), or gastroesophageal varices (varix) diagnosed by urgent endoscopies between 1 January 1996 and 31 December 1999 in our hospital (Tokyo Metropolitan Bokutou Hospital). We evaluated the monthly and seasonal incidence of them and investigated correlations among the incidence and climatic factors.

RESULTS

Four hundred and forty-one patients participated in this study, including 275 patients with GU (62.4%), 51 (11.6%) with DU, and 115 (26.0%) with varix. The number of cases of hematemesis caused by GU showed significant monthly and seasonal fluctuations (P = 0.0002, P = 0.0018): it decreased in summer and increased in autumn-winter. Moreover, there were inverse relations between the monthly number of cases of hematemesis caused by GU and the mean temperature (P = 0.0016) and vapor pressure (P = 0.0013), and a parallel relation to the mean atmospheric pressure (P = 0.0057). In contrast, the number of cases of hematemesis caused by DU and varices did not show any monthly or seasonal fluctuations.

CONCLUSIONS

We found that the incidence of hematemesis because of GU had an inverse relationship to temperature and vapor pressure, and had a parallel relation to atmospheric pressure. Therefore, climatic factors may play an important role in hemorrhage from GU.