Surgical treatments of recurrent small intestine metastatic melanoma manifesting with gastrointestinal hemorrhage and intussusception:A case report

BACKGROUND Melanoma is the most aggressive form of skin cancer,with a tendency to metastasize to any organ.Malignant melanoma is the most frequent cause of skin cancer-related deaths worldwide.Small intestine cancers especially small intestine metastases are relatively rare.Small intestine metastases are seldom described and likely underdiagnosed.Intussusception is most common in pediatric age,and in adults are almost 5%of all cases.CASE SUMMARY A 75-year-old man with a history of acral malignant melanoma was admitted to the Gastroenterology Department of our hospital,complaining of intermittent melena for 1 mo.Magnetic resonance enterography showed partial thickening of the jejunal wall and formation of a soft tissue mass,indicating a neoplastic lesion with jejunojejunal intussusception.The patient underwent partial small bowel resection.Pathological findings and immunohistochemical staining indicated small intestine metastatic melanoma.The patient refused further anti-tumor treatment after the surgery.Ten months after the first surgery,the patient presented with melena again.Computed tomography enterography showed the anastomotic stoma was normal without thickening of the intestinal wall,and routine conservative treatment was given.Three months later,the patient developed melena again.The patient underwent a second surgery,and multiple metastatic melanoma lesions were found.The patient refused adjuvant anti-tumor treatment and was alive at the latest follow-up.CONCLUSION Small intestine metastatic melanoma should be suspected in any patient with a history of malignant melanoma and gastrointestinal symptoms.

Clinical features of AMPAR2 antibody-positive autoimmune encephalitis with gastrointestinal hemorrhage: a case report

Objective:To describe the clinical features of autoimmune encephalitis complicated with gastrointestinal hemorrhage.Methods:The clinical data of one patient whose initial symptom was mental abnormality were collected and the related examinations,such as cerebrospinal fluid and magnetic resonance imaging (MRI),were improved.Results: Cerebrospinal fluid examination found that anti-α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor(AMPAR)2 antibody was strongly positive,although the patient had repeated gastrointestinal hemorrhage but,after hormone combined with immunoglobulin treatment,the symptoms gradual-ly improved.Conclusion:Mental disorders are not all psychosis,and autoimmune encephalitis should not be ignored.It is very important to perform anti-AMPAR encephalitis antibody test;accurate diagnosis and timely treatment can improve the prognosis.

Inverted Meckel's diverticulum as a cause of occult lower gastrointestinal hemorrhage

Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly,but rarely it can present with hemorrhage.Over the last few years inverted Meckel's diverticulum has been reported in the literature with increasing frequency as an occult source of lower gastrointestinal hemorrhage.Here,we report a case of a 54-year-old male,who was referred for surgical evaluation with persistent anemia and occult blood per rectum after a work up which failed to localize the source over 12 mo,including upper and capsule endoscopy,colonoscopy,enteroclysis,Meckel scan,and tagged nuclear red blood cell scan.An abdominal computed tomography scan showed a possible mid-ileal intussusception and intraluminal mass.During the abdominal exploration,inverted Meckel's diverticulum was diagnosed and resected.We review the literature,discuss the forms in which the disease presents,the diagnostic modalities utilized,pathological findings,and treatment.Although less than 40 cases have been reported in the English literature from 1978 to 2005,19 cases have been reported in the last 6 years alone(2006-2012) due to improved diagnostic modalities.Successful diagnosis and treatment of this disease requires a high index of clinical suspicion,which is becoming increasingly relevant to general gastroenterologists.

Crohn's disease presenting as acute gastrointestinal hemorrhage

Severe gastrointestinal (GI) hemorrhage is a rare complication of Crohn’s disease (CD). Although several surgical and non-surgical approaches have been described over the last 2 decades this complication still poses significant diagnostic and therapeutic challenges. Given the relative infrequency of severe bleeding in CD, available medical literature on this topic is mostly in the form of retrospective case series and reports. In this article we review the risk factors, diagnostic modalities and treatment options for the management of CD presenting as GI hemorrhage.

Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Hemorrhage:A Retrospective Analysis

Objective:The role of urgent endoscopy in nonvariceal upper gastrointestinal hemorrhage(NVUGIH)remains controversial.We designed a retrospective study to compare the outcomes between urgent endoscopy(within 12 h)and non-urgent endoscopy for patients with NVUGIH.Methods:A total of 540 hospitalized patients with NVUGIH were included in our study.Patients who received endoscopy within 12 h or after 12 h were divided into two groups,the urgent and non-urgent endoscopy groups,respectively.The clinical outcomes including rebleeding,mortality,endoscopic re-intervention,need for emergency surgery and interventional radiotherapy were compared between the groups.Patients with Glasgow-Blatchford scores(GBS)<12 and>12 were defined as the lower-and high-risk groups,respectively,and the predictors of rebleeding and mortality in both groups were analyzed individually.Results:Patients with NVUGIH in the urgent endoscopy group had a higher rate of rebleeding(27.6%vs.16.9%,P=0.003)and blood transfusion(73.2%vs.55.5%,P<0.001)than those in the non-urgent endoscopy group,while the mortality and the length of hospitalization were not significantly different between the groups(P>0.05).For lower-risk patients,urgent endoscopy was independently associated with a higher likelihood of rebleeding(adjusted OR:1.73,95%CI:1.03-2.88),while it was not associated with in-hospital mortality.However,the urgent need for endoscopy was not associated with rebleeding and in-hospital mortality in high-risk patients.Conclusion:Endoscopy within 12 h did not provide any advantage in the outcomes of patients with NVUGIH,and may even lead to an increased rebleeding rate in lower-risk patients.

Upper gastrointestinal hemorrhage caused by superwarfarin poisoning

Superwarfarins are a class of rodenticides. Gastrointestinal hemorrhage is a fatal complication of superwarfarin poisoning, requiring immediate treatment. Here, we report a 55-year-old woman with tardive upper gastrointestinal hemorrhage caused by superwarfarin poisoning after endoscopic cold mucosal biopsy.

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.

Pseudoxantoma elasticum,as a repetitive upper gastrointestinal hemorrhage cause in a pregnant woman

Pseudoxantoma elasticum is a rare, hereditary, multisystemic disease affecting the skin, eye, and cardiovascular system. A twenty-eight-year-old female has presented to emergency unit with the complaint of gastrointestinal hemorrhage. This patient, who had been monitored in the gastroenterology clinic more than 10 times in the past 8 years, noted a repetitive hemorrhage during her previous pregnancy in her history. The examination of the patient revealed the following signs and symptoms： atrophy in the epithelium of the retina pigment; typical angioid streaks and peau d＇orange finding in the fundus; thinning of the retinal nerve fiber in OCT （optic coherence tomography）; bilateral and reticular papillary lesions with yellowish- color in the neck region （plucked chicken appearance）; presence of bleeding loci in fundus, and nephrocalcinosis in kidneys. In light of these symptoms, the patient was diagnosed with pseudoxantoma elasticum. Skin biopsy confirmed the pseudoxantoma elasticum diagnose. PXE is an uncommon, hereditary disease. Early diagnosis of pseudoxantoma elasticum cases, is important for minimalizing systemic complications and informing the other family members through genetic counseling.

Ileal Lymphangioma Presenting with Gastrointestinal Hemorrhage： A Case Report

Introduction Lymphangioma is a rare benign tumor of lymphatic vessel origin. The tumor often appears in the head and neck region at a young age and can occasionally be found in the abdomen of adults with protean degrees of symptoms depending on the tumor size and location. How- ever, lymphangioma of the small intestine is extremely rare with only a few cases reported in the literature. As the tumor is not well-recog- nized, many patients with small intestine lymphangioma have been given an incorrect preoperative diagnosis. The ideal treatment for the disease is surgical excision, and the prognosis is comparatively good. In this paper, we report a rare case of ileal lymphangioma with gas- trointestinal hemorrhage preoperatively diagnosed using enteroscopy and treated with surgery.

Anorectal hemangioma, a rare cause of lower gastrointestinal bleeding, treated with selective embolization: A case report

BACKGROUND Anorectal hemangioma is a rare and frequently misdiagnosed cause of lower gastrointestinal(GI)bleeding.Here,we present a minimally invasive therapy with selective embolization.CASE SUMMARY A 21-year-old male patient experienced painless rectal bleeding since childhood and was treated for ulcerative colitis.Diagnostic studies later revealed specific characteristics for vascular lesions-anorectal hemangiomas.The severity of rectal bleeding caused symptomatic anemia and possible surgical treatment was asso-ciated with a high risk of fecal incontinence.Here,we present selective emboli-zation,a minimally invasive therapeutic approach that is proven as an alternative therapeutic method of choice.The patient significantly improved temporarily and had a small ischemic ulcer,which healed with a control colonoscopy and deve-loped no stenosis.CONCLUSION Awareness of the clinical and radiological features of GI hemangiomas may help improve diagnostics and avoid inappropriate therapeutic procedures.

Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum.Small bowel tuberculosis,characterized by predominant involvement of the small intestine,is an extremely rare condition with highly atypical clinical presentations,making diagnosis even more challenging.CASE SUMMARY We report three cases of small intestinal tuberculosis,two of the patients pre-sented primarily with abdominal pain,and one presented with gastrointestinal bleeding.All patients underwent blood tests and imaging examinations.Small bowel endoscopy(SBE)revealed that the main lesions in these patients were in-testinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers.One patient ultimately underwent surgical treatment.Following a complex diagnostic process and comprehensive analysis,all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment,leading to an improvement in their condition.CONCLUSION Patients with SBTs present with nonspecific symptoms such as abdominal pain,weight loss,and occasional gastrointestinal bleeding.Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagno-sis and complications.

Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis:A case report and literature review

BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis.It can lead to increased blood flow through mesenteric collaterals.This segmental hypertension may result in the development of colonic varices(CV)with a high risk of severe gastrointestinal bleeding.While clear guidelines for treatment are lacking,splenectomy or splenic artery embolization are often used to treat bleeding.Splenic vein stenting has been shown to be a safe option.CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding.She was anemic with a hemoglobin of 8.0 g/dL.As a source of bleeding,CV were identified.Computed tomography scans revealed thrombotic occlusion of the splenic vein,presumably as a result of a severe acute pancreatitis 8 years prior.In a selective angiography,a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed.The hepatic venous pressure gradient was within normal range.In an interdisciplinary board,transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting,as well as coiling of the aberrant veins was discussed and successfully performed.Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV.However,a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Upper gastrointestinal bleeding as an unusual manifestation of localized Ménétrier’s disease with an underlying lipoma:A case report

BACKGROUND Ménétrier’s disease is a rare condition characterized by enlarged gastric folds,usually located in the whole body and fundus of the stomach.This report presents an unusual case of localized Ménétrier’s disease elevated by a submucosal lipoma and thus looking like a polypoid mass and causing an episode of upper gastrointestinal bleeding.The mass was successfully removed with endoscopic submucosal dissection.CASE SUMMARY Esophagogastroduodenoscopy was performed on a 76-year-old male patient after an episode of upper gastrointestinal bleeding,manifesting as fatigue and melena.A large polypoid mass(4 cm×1 cm)with enlarged mucosal folds was found in the body of the stomach,between the lesser curvature and posterior wall.A small ulcer at the distal end of the mass was identified as the source of the bleeding.Biopsy was negative for neoplasia.Computed tomography showed a submucosal lesion beneath the affected mucosa,most likely a lipoma.The mass was removed en bloc with tunneling endoscopic submucosal dissection.Final pathology determined that the mass included Ménétrier’s disease and a submucosal lipoma.The patient was scheduled for follow-up esophagogastroduodenoscopy.CONCLUSION Localized Ménétrier’s disease can coexist with a submucosal lipoma creating a polypoid mass with risk of bleeding.

Massive bleeding in small intestinal mucosa-associated lymphoid tissue lymphoma associated with COVID-19 infection:a case report

The increased risk of mucosa-associated lymphoid tissue(MALT)lymphoma is closely associated with chronic antigenic stimulation,with infection being the most common cause of recurrence.Lesions are usually associated with the gastrointestinal tract,and the involvement of small intestinal is rare.Recent studies have established a close relationship between novel coronavirus 2019(COVID-19)and the occurrence and progression of various diseases.This article presents a rare case of a small intestinal MALT lymphoma.The patient was initially admitted with COVID-19 pneumonia and subsequently developed gastrointestinal bleeding during hospitalization.Medical and endoscopic treatments were ineffective,and an emergency exploratory laparotomy was performed.The affected segment of the small intestine was excised,and a pathological biopsy confirmed the diagnosis of MALT lymphoma.This case underscores the significance of raising clinical awareness of this condition among health care professionals.

Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding:A meta-analysis

AIM: To analyze the accuracy of computed tomography (CT) angiography in the diagnosis of acute gastrointestinal (GI) bleeding. METHODS: The MEDLINE, EMBASE, Cancerlit, Cochrane Library database, Sciencedirect, Springerlink and Scopus, from January 1995 to December 2009, were searched for studies evaluating the accuracy of CT angiography in diagnosing acute GI bleeding. Studies were included if the ycompared CT angiography to a reference standard of upper GI endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute GI bleeding. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic. RESULTS: A total of 9 studies with 198 patients were included in this meta-analysis. Data were used to form 2 × 2 tables. CT angiography showed pooled sensi-tivity of 89% (95% CI: 82%-94%) and specificity of 85% (95% CI: 74%-92%), without showing significant heterogeneity (χ2 = 12.5, P = 0.13) and (χ2 = 22.95, P = 0.003), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.9297. CONCLUSION: CT angiography is an accurate, costeffective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management.

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

AIM： To identify clinical parameters, and develop an Upper Gastrointesinal Bleeding （UGIB） Etiology Score for predicting the types of UGIB and validate the score. METHODS： Patients with UGIB who underwent endoscopy within 72 h were enrolled. Clinical and basic laboratory parameters were prospectively collected. Predictive factors for the types of UGIB were identified by univariate and multivariate analyses and were used to generate the UGIB Etiology Score. The best cutoff of the score was defined from the receiver operating curve and prospectively validated in another set of patients with UGIB. RESULTS： Among 261 patients with UGIB, 47 （18%） had variceal and 214 （82%） had non-variceal bleeding. Univariate analysis identified 27 distinct parameters significantly associated with the types of UGIB. Logistic regression analysis identified only 3 independent factors for predicting variceal bleeding; previous diagnosis of cirrhosis or signs of chronic liver disease （OR 22.4, 95% CI 8.3-60.4, P 〈 0.001）, red vomitus （OR 4.6, 95% CI 1.8-11.9, P = 0.02）, and red nasogastric （NG） aspirate （OR 3.3, 95% CI 1.3-8.3, P = 0.011）. The UGIB Etiology Score was calculated from （3.1× previous diagnosis of cirrhosis or signs of chronic liver disease） ＋ （1.5× red vomitus） ＋ （1.2× red NG aspirate）, when 1 and 0 are used for the presence and absence of each factor, respectively. Using a cutoff ≥ 3.1, the sensitivity, specificity, accuracy, positive predictive value （PPV）, and negative predictive value （NPV） in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. The score was prospectively validated in cases （46 variceal and 149 another set of 195 UGIB non-variceal bleeding）. The PPV and NPV of a score ≥ 3.1 for variceal bleeding were 79% and 97%, respectively. CONCLUSION： The UGIB Etiology Score, composed of 3 parameters, using a cutoff ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy.

Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study

To determine the clinical characteristics of children with gastrointestinal bleeding (GIB) who died during the course of their admission.METHODSWe interrogated the Pediatric Hospital Information System database, including International Classification of Diseases, Current Procedural Terminology and Clinical Transaction Classification coding from 47 pediatric tertiary centers extracting the population of patients (1-21 years of age) admitted (inpatient or observation) with acute, upper or indeterminate GIB (1/2007-9/2015). Descriptive statistics, unadjusted univariate and adjusted multivariate analysis of the associations between patient characteristics and treatment course with mortality was performed with mortality as primary and endoscopy a secondary outcome of interest. All analyses were performed using the R statistical package, v.3.2.3.RESULTSThe population with GIB was 19528; 54.6% were male, overall mortality was 2.07%; (0.37% in patients with the principal diagnosis of GIB). When considering only the mortalities in which GIB was the principal diagnosis, 48% (12 of 25 principal diagnosis GIB mortalities) died within the first 3 d of admission, whereas 19.8% of secondary diagnosis GIB patients died with 3 d of admission. Patients who died were more likely to have received octreotide (19.8% c.f. 4.04%) but tended to have not received proton pump inhibitor therapy in the first 48 h, and far less likely to have undergone endoscopy during their admission (OR = 0.489, P < 0.0001). Chronic liver disease associated with a greater likelihood of endoscopy. Mortalities were significantly more likely to have multiple complex chronic conditions.CONCLUSIONGIB associated mortality in children is highest within 7 d of admission. Multiple comorbidities are a risk factor whereas early endoscopy during the admission is protective.

Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding:A systematic review

BACKGROUND Anemia is considered a public health issue and is often caused by iron deficiency.Iron-deficiency anemia(IDA)often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women,and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%.However,few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.AIM To review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.METHODS Five gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites.MEDLINE(via PubMed)searches combined medical subject headings(MeSH)terms and the keywords“gastrointestinal bleeding”with“iron-deficiency anemia”and“diagnosis”or“treatment”or“management”or“prognosis”or“prevalence”or“safety”or“iron”or“transfusion”or“quality of life”,or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding;retrieved studies were published in English between January 2003 and April 2019.Worldwide professional association websites were searched for clinical practice guidelines.Reference lists from guidelines were reviewed to identify additional relevant articles.The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.RESULTS From 494 Literature citations found during the initial literature search,17 original articles,one meta-analysis,and 13 clinical practice guidelines were analyzed.Based on the published evidence and clinical experience,the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding:(1)Evaluation of hemoglobin and iron status;(2)Laboratory testing;(3)Target treatment population identification;(4)Indications for erythrocyte transfusion;(5)Treatment targets for erythrocyte transfusion;(6)Indications for intravenous iron;(7)Dosages;(8)Monitoring;(9)Indications for intravenous ferric carboxymaltose treatment;and(10)Treatment targets and monitoring of patients.The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding,which should be implemented during the hospital stay and follow-up visits after patient discharge.CONCLUSION These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding,which ultimately may improve health outcomes in these patients.

Prognosis of hepatic cirrhosis patients with esophageal or gastric variceal hemorrhage: multivariate analysis

Objective: To study the effect of bacterial infection, use of antibiotics, active bleeding at endoscopy, and the severity of liver disease as prognostic factors in hepatic cirrhotic patients during the first 5 days after the episode of esophageal or gastric variceal hemor- rhage. Methods: Seventy-six hepatic cirrhosis patients with esophageal or gastric variceal bleeding were enrolled. Bleeding was managed in a standardized protocol u- sing octreotide and vasopressin in sclerotherapy or band ligation for active bleeding at endoscopy. The screening protocol for bacterial infection consisted of chest radiograph; blood, urine and ascitic fluid cul- tures; the severity of liver disease shown by Child- Pugh score. Results: Active bleeding was observed at endoscopy in 40 patients (53%). Failure to control bleeding Within 5 days occurred in 36 patients (45%). Empir- ical antibiotic treatment was used in 53 patients (67%), whereas bacterial infections were documen- ted in 43 patients (57%). Multivariate analysis showed that proven bacterial infection (P<0.01) or antibiotic use (P<0.05) as well as active bleeding at endoscopy (P<0.01) and Child-Pugh score (P< 0.01) were independent prognostic factors of failure to control bleeding. Conclusion: Bacterial infection is associated with fai- lure to control esophageal or gastric variceal bleeding in hepatic cirrhotic patients.