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.

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.

Resuscitative endovascular balloon occlusion of the aorta in the treatment of severe hemorrhagic shock caused by upper gastrointestinal bleeding

Hemorrhagic shock is a life-threatening disease often encountered in emergency departments(EDs).Hemorrhagic shock caused by extensive bleeding from multiple sites is often associated with high mortality and morbidity.In recent years,resuscitative endovascular balloon occlusion of the aorta(REBOA)has been widely used in traumatic hemorrhagic shock and is considered to be an effective resuscitation measure.[1]Some studies reported that REBOA was also effective for non-traumatic hemorrhage.[2,3]In this study,we report a case of hemorrhagic shock caused by acute upper gastrointestinal bleeding that was successfully treated and received REBOA to obtain a transition time.This report may provide feasible options for emergency physicians,gastroenterologists,or surgeons to more actively treat refractory gastrointestinal bleeding.

Multiple endocrine neoplasia type 1 with upper gastrointestinal hemorrhage and perforation:A case report and review

Multiple endocrine neoplasia type 1(MEN1) is a rare hereditary syndrome known to predispose subjects to endocrine neoplasms in a variety of tissues such as the parathyroid glands,pituitary gland,pancreas and gastrointestinal tract.We herein report a patient with a past history of pituitary adenoma,presenting with symptoms of chronic diarrhea for nearly one year and a sudden upper gastrointestinal hemorrhage as well as perforation without signs.Nodules in the duodenum and in the uncinate process and tail of pancreas and enlargement of the parathyroid glands were detected on preoperative imaging.Gastroscopy revealed significant ulceration and esophageal reflux diseases.The patient underwent subtotal parathyroidectomy and autotransplantation,pylorus-preserving pancreaticoduodenectomy and pancreatic tail resection and recovered well.The results observed in our patient suggest that perforation and bleeding of intestine might be symptoms of ZollingerEllison Syndrome in patients with MEN1.

Characteristics of nonvariceal upper gastrointestinal hemorrhage in patients with chronic kidney disease

AIM:To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage(NGIH)in patients with chronic kidney disease(CKD).METHODS:From 2003 to 2010,a total of 72 CKD patients(male n=52,72.2%;female n=20,27.8%)who had undergone endoscopic treatments for NGIH were retrospectively identified.Clinical findings,endoscopic features,prognosis,rebleeding risk factors,and mortality-related factors were evaluated.The characteristics of the patients and rebleeding-related data were recorded for the following variables:gender,age,alcohol use and smoking history,past hemorrhage history,endoscopic findings(the cause,location,and size of the hemorrhage and the hemorrhagic state),therapeutic options for endoscopy,endoscopist experience,clinical outcomes,and mortality.RESULTS:The average size of the hemorrhagic site was 13.7±10.2 mm,and the most common hemorrhagic site in the stomach was the antrum(n=21,43.8%).The most frequent method of hemostasis was combination therapy(n=32,44.4%).The incidence of rebleeding was 37.5%(n=27),and 16.7%(n=12)of patients expired due to hemorrhage.In a multivariate analysis of the risk factors for rebleeding,alcoholism(OR=11.19,P=0.02),the experience of endoscopists(OR=0.56,P=0.03),and combination endoscopic therapy(OR=0.06,P=0.01)compared with monotherapy were significantly related to rebleeding after endoscopic therapy.In a risk analysis of mortality after endoscopic therapy,only rebleeding was related to mortality(OR=7.1,P=0.02).CONCLUSION:Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD,especially when a patient is an alcoholic.

Super-selective arterial embolization in the control of acute lower gastrointestinal hemorrhage

BACKGROUND Acute gastrointestinal bleeding is an emergency condition that can lead to significant morbidity and mortality.Embolization is considered the preferred therapy in the treatment of lower gastrointestinal bleeding when it is unrealistic to perform the surgery or vasopressin infusion in this population.Treatment of acute lower gastrointestinal(GI)bleeding(any site below the ligament of Treitz)using this technique has not reached a consensus,because of the belief that the risk of intestinal infarction in this condition is extremely high.The purpose of the study is to evaluate the effectiveness and safety of this technique in a retrospective group of patients who underwent embolization for acute lower GI bleeding.AIM To evaluate the efficacy and safety of super-selective arterial embolization in the management of acute lower GI bleeding.METHODS A series of 31 consecutive patients with angiographically demonstrated small intestinal or colonic bleeding was retrospectively reviewed.The success rate and complication rate of super-selective embolization were recorded.RESULTS Five out of thirty-one patients(16.1%)could not achieve sufficiently selective catheterization to permit embolization.Initial control of bleeding was achieved in 26 patients(100%),and relapsed GI bleeding occurred in 1 of them at 1 wk after the operation.No clinically apparent bowel infarctions were observed in patients undergoing embolization.CONCLUSION Super-selective embolization is a safe therapeutic method for acute lower GI bleeding,and it is suitable and effective for many patients suffering this disease.Importantly,careful technique and suitable embolic agent are essential to the successful operation.

Rare presentation of primary (AL) amyloidosis as gastrointestinal hemorrhage without systemic involvement

We are reporting a rare case of a patient with primary(AL) amyloidosis presenting with an acute non-varicealupper gastrointestinal hemorrhage in the absence ofother systemic involvement. The case report involves a58-year-old woman with significant cardiac history andhereditary blood disorder who came in complaining ofabdominal pain and coffee-ground emesis for two days.Computed tomography(CT) scan of the abdomen andpelvis with contrast revealed segmental wall thickeningof the proximal jejunum with hyperdense, heterog-enous luminal content. Similar findings were evident inthe left lower small bowel region, suspicious for smallbowel hematoma and the possibility of intraluminalclots. Esophagogastroduodenoscopy performed postresuscitation showed punctate, erythematous lesionsthroughout the stomach as well as regions of smallbowel mucosa that appeared scalloped, ulcerated, andhemorrhaged on contact. Despite initial treatment for immunostain-positive focal cytomegalovirus gastritis, follow-up esophagogastroduodenoscopy after two months continued to demonstrate friable and irregular duodenal mucosa hinting at a different underlying etiol-ogy. Pathology reports from analyses of biopsy samples highlighted infiltration and expansion of the lamina pro-pria and submucosa. Subsequent staining with congo red/crystal violet and appropriate subtyping established the diagnosis of AL(kappa)-type amyloidosis. The sig-nificance of this case lies in the fact that our patient did not have the typically seen diagnostic systemic involvements-namely of heart and kidneys-usually seen in primary(AL) amyloidosis patients. It was the persis-tent endoscopic findings and biopsy results which gave clues to the physicians regarding the possibility of an abnormal protein-deposition entity.

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.

Effect of adjuvant reduced glutathione therapy on vasoactive molecules and oxidative stress in patients with cirrhosis-induced upper gastrointestinal hemorrhage

Objective: To study the effect of adjuvant reduced glutathione therapy on vasoactive molecules and oxidative stress in patients with cirrhosis-induced upper gastrointestinal hemorrhage. Methods: Patients diagnosed with cirrhosis-induced upper gastrointestinal hemorrhage in No. 215 Hospital of Shaanxi Nuclear Industry between June 2015 and March 2017 were selected as the research subjects, and random number table was used to divide them into the GSH group who accepted reduced glutathione combined with conventional therapy and the control group who accepted conventional therapy. Serum levels of liver function indexes, vasoactive molecules and oxidative stress reaction molecules in two groups of patients were detected before treatment and 3 d after treatment. Results: 3 d after treatment, serum ALT, AST, γ-GT, TBIL, PRA, AT-Ⅱ, ALD, MDA, ox-LDL, AOPP and 8-OHdG levels of both groups of patients were significantly lower than those before treatment while SOD, GSH-Px and CAT levels were significantly high than those before treatment, and serum ALT, AST, γ-GT, TBIL, PRA, AT-II, ALD, MDA, ox-LDL, AOPP and 8-OHdG levels of GSH group were significantly lower than those of control group while SOD, GSH-Px and CAT levels were significantly higher than those of control group. Conclusion: The adjuvant reduced glutathione therapy for cirrhosis-induced upper gastrointestinal hemorrhage can improve the liver function, regulate the secretion of vasoactive molecules and reduce the oxidative stress response.

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.

Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review

Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.

Gastrointestinal hemorrhage due to ileal metastasis from primary lung cancer

We report a patient with small intestinal metastasis from lung squamous cell carcinoma.A 66-year-old man who underwent radical lung cancer surgery was admitted to our hospital.Before starting his fifth cycle of chemotherapy,he was found to have a positive fecal occult blood test.Abdominal computed tomography scan revealed an ileal tumor with mesenteric lymph node enlargement.He underwent laparoscopic resection of the involved small intestineand mesentery.Histopathological analysis confirmed metastasis from lung cancer.We conducted a review of the literature and 64 documented cases of small intestinal metastasis from lung cancer were found.The pathologic diagnosis,clinical presentation,site of metastasis,and survival time in these cases were reviewed.

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.

Gastric hyperplastic polyps causing upper gastrointestinal hemorrhage in a young adult

Here, we report a case of a young man who presented with a significant upper gastrointestinal bleed treated by endoscopic removal of multiple hyperplastic polyps. Gastric hyperplastic polyps are a relatively uncommon cause of overt gastrointestinal bleeding. While most hyperplastic gastric polyps are asymptomatic, they may present with abdominal pain, iron def iciency anemia or gastric outlet obstruction. These polyps are associated with conditions such as Helicobacter pylori gastritis and atrophic autoimmune gastritis, which predispose the epithelium to chronic inf lammation and epithelial repair.The patient presented to Northwestern Memorial Hospital in July 2011. The polyps were resected by clip-assisted snare polypectomy. Histopathologic assessment of the resected polyps demonstrated multiple, nonulcerative hyperplastic polyps measuring 1.3-1.8 cm in size, without evidence of dysplasia or malignancy. This case describes a young adult patient with multiple, large gastric polyps causing overt gastrointestinal bleeding. This is a rare presentation in a young individual, as these polyps are typically identifi ed in patients older than 60 years of age and less commonly, pediatric populations.

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.

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.

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.