Nursing Care of Labor Induction in 2 Cases of Upper GI Bleeding in Pregnancy Complicated with Decompensated Cirrhosis

Objective: To summarize the nursing experience of induced labor of upper gastrointestinal bleeding in pregnancy complicated with decompensated cirrhosis. Methods: To treat two pregnant women with upper gastrointestinal bleeding complicated with decompensated cirrhosis with early labor induction, strengthen the nursing of upper gastrointestinal bleeding before operation, monitor changes of the patient’s condition closely after operation, and strengthen the prevention and treatment of postpartum complications and health guidance. Results: No serious complications occurred in the 2 patients after operation. They were hospitalized for 11 and 17 days after operation and were discharged stably. Conclusion: The pregnant women with upper gastrointestinal bleeding complicated with decompensated cirrhosis should terminate pregnancy in time and strengthen perinatal nursing, which can improve the liver function and blood coagulation and improve the prognosis of the patients.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Ileoscopy in 39 hematochezia patients with normal colonoscopy

AIM： To assess the role of retrograde terminal ileoscopy in hematochezia patients with normal colonoscopy. METHODS： Between January 1997 and March 2005, 39 hematochezia patients （males 36, females 3, mean age 44.7 years） with a reported normal colonoscopy underwent a repeat colonoscopy. After reaching the cecum, attempt was made to localize the ileocecal valve and intubate the terminal ileum. Any abnormality in the mucosa of the terminal ileum was carefully recorded and biopsies were obtained from suspiciouslooking lesions. RESULTS： During the study period there were 39 patients admitted for hematochezia in whom colonoscopy till cecum did not reveal any abnormality. Fulllength colonoscopy till the cecum could be performed in all the patients. The terminal ileum could be intubated in 36 patients. No abnormality was noted in 31 patients. Ileal ulcers were noted in two patients. Noclularity along with ulceration of the ileal mucosa, a Dieulafoy＇s lesion, and an angiomatous malformation were noted in one patient each. Histological examination of the biopsies obtained from the ulcers revealed typical tuberculous lesion in the patient with nodularity and ulceration. One of the patients had typhoid ulcers and another had non-specific ulcers. CONCLUSION： Retrograde terminal ileoscopy gives limited but valuable information, in patients with hematochezia and should be attempted in all such patients.

Clinical presentation and endoscopic management of Dieulafoy's lesions in an urban community hospital

AIM:To identify rates of occurrence,common clinical and endoscopic features,and to review the outcome of endoscopic management of Dieulafoy's lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting. METHODS:Endoscopic data from esophagogastroduo denoscopies (EGDs),done at Wyckoff Heights Medical Center,Brooklyn,NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy's lesions. Demographic data,medical history,examination findings,lab data,endoscopic findings and details of therapy for patients treated for Dieulafoy's lesions were reviewed retrospectively. RESULTS:Dieulafoy's lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding,while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding,prevalence of Dieulafoy's lesions approached 10 percent. The most common location of the lesion was the body of stomach (7),followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection,in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.CONCLUSION:Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy,especially in patients with multiple co-morbid conditions,can be very effective and life saving.

Blue rubber bleb nevus syndrome complicated with disseminated intravascular coagulation and intestinal obstruction: A case report

BACKGROUND Blue rubber bleb nevus syndrome is a rare vascular malformation syndrome with unclear etiopathogenesis and noncurative treatments.It is characterized by multiple vascular malformations of the skin,gastrointestinal tract,and other visceral organs.The most common symptoms are intermittent gastrointestinal bleeding and secondary iron deficiency anemia,thus requiring repeated blood transfusions and hospitalizations.It is easily missed and misdiagnosed,and there is no specific treatment.CASE SUMMARY We report a case of blue rubber bleb nevus syndrome combined with disseminated intravascular coagulation and efficacy of treatment with argon plasma coagulation under enteroscopy and sirolimus.A 56-year-old female patient was admitted to the hospital with 3-year history of fatigue and dizziness that had aggravated over the past 10 d with melena.The patient had a history of repeated melena and multiple venous hemangiomas from childhood.After treatment with argon plasma coagulation combined with sirolimus for nearly 8 wk,the patient’s serum hemoglobin increased to 100 g/L.At the 12-mo follow-up,the patient was well with stable hemoglobin(102 g/L)and no recurrent intestinal bleeding.CONCLUSION Argon plasma coagulation and sirolimus may be an efficacious and safe treatment for blue rubber bleb nevus syndrome,which currently has no recommended treatments.

Hepatic Artery Aneurysm: An Unusual Cause of Upper Gastrointestinal Bleed in 49 Years Old Patient

Hepatic artery aneurysm (HAA) is a rare disease. HAA is generally asymptomatic disease when symptomatic, they usually present with abdominal pain, upper gastrointestinal (GI) bleeding and/or jaundice, hypovolaemia secondary to rupture or GI bleeding with normal GI endoscopy. Surgical repair and endovascular treatment are the two therapeutic options available at present. Case report: A 49-year-old male presented at the emergency department with high gastrointestinal bleeding, abdominal pain and jaundice. Gastroscopy showed an ulcer with flat pigmented haematin on ulcer base (Forrest IIc) that was controlled by medical treatment. CT angiography was done and showed aneurysm of the proper hepatic artery almost totally thrombosed measuring 100 × 59 mm associated with signs of contained rupture. Emergency surgery was indicated. The laparotomy objectified a rupture of the aneurysm in the biliary tree in per operative excision of aneurysm and ligation of the hepatic pedicle was carried out. After surgery, the evolution was favorable with a follow-up of 8 months. Conclusion: HAA rupture is a rare cause of upper GI bleeding. The mortality rate after rupture is relatively high. CT angiography or MRI can diagnose a ruptured of HAA. Urgent surgery should be the first choice in patients with a ruptured HAA with active hemorrhage causing hemorrhagic shock.