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.

Multidisciplinary diagnosis and treatment nutritional support intervention for gastrointestinal tumor radiotherapy:Impact on nutrition and quality of life

BACKGROUND Gastrointestinal tumors are a major cause of cancer-related deaths and have become a major public health problem.This study aims to provide a scientific basis for improving clinical treatment effects,quality of life,and prognosis of patients with gastrointestinal tumors.AIM To explore the clinical effect of the multidisciplinary diagnosis and treatment(MDT)nutrition intervention model on patients with gastrointestinal tumors.METHODS This was a case control study which included patients with gastrointestinal tumors who received radiotherapy at the Department of Oncology between January 2021 and January 2023.Using a random number table,120 patients were randomly divided into MDT and control groups with 60 patients in each group.To analyze the effect of MDT on the nutritional status and quality of life of the patients,the nutritional status and quality of life scores of the patients were measured before and after the treatment.RESULTS Albumin(ALB),transferrin(TRF),hemoglobin(Hb),and total protein(TP)levels significantly decreased after the treatment.The control group had significantly lower ALB,TRF,Hb,and TP levels than the MDT group,and the differences in these levels between the two groups were statistically significant(P<0.05).After the treatment,the MDT group had significantly more wellnourished patients than the control group(P<0.05).The quality of life total score,somatic functioning,role functioning,and emotional functioning were higher in the MDT group than in the control group.By contrast,pain,fatigue,nausea,and vomiting scores were lower in the MDT group than in the control group(P<0.05).CONCLUSION MDT nutritional intervention model effectively improves the nutritional status and quality of life of the patients.The study provides a rigorous theoretical basis for improving the prognosis of cancer patients.In the future,we intend to provide additional treatment methods for improving the quality of life of patients with cancer.

Gastrointestinal tuberculosis:Diagnostic approaches for this uncommon pathology

A case report entitled“Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction”recently published in the World Journal of Clinical Cases presented a rare cause of gastric outlet obstruction and highlighted the atypical manner in which gastrointestinal tuberculosis(TB)can present.The literature with regards to this rare pathology is limited to case reports and case series with the largest being published using data from between 2003 and 2013.However,since then the diagnostic tools available have significantly changed with more modern and increasingly accurate tests now available.This editorial reviews the current state of the art with regards to diagnosis in gastrointestinal TB.

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.

Velamentous Cord Insertion: Interest of Antenatal Diagnosis and Review of the Literature

Velamentous insertion of the umbilical cord corresponds to the insertion of the cord directly on amniotic membranes. It is a rare situation whose frequency varies from 0.5% to 1.69% of single pregnancies. It must be diagnosed during the morphological ultrasound of the 2nd trimester, actively looking for the association with a vasa previa, due to the risk of fetal haemorrhagic threat. We report an antenatal diagnosis of velamentous cord insertion and its management with literature review.

Current guidelines for diagnosis and management of hepatic involvement in hereditary hemorrhagic teleangiectasia

Hereditary hemorrhagic teleangiectasia(HHT),also known as Rendu-Osler-Weber syndrome,is the most common cause of hepatic vascular malformations in adults.Different vascular shunts(arteriovenous,arterioportal or portovenous)lead to different clinical manifestations.Even though no hepatic-related symptoms are reported in the majority of cases,the severity of liver disease could lead to refractory medical conditions,in some cases requiring liver transplantation.The aim of this manuscript is to provide an updated overview of the current evidence regarding the diagnosis and treatment of HHT liver involvement and liver-related complications.

Chinese consensus guidelines for diagnosis and management of gastrointestinal stromal tumor

In order to further promote the standardization of diagnosis and treatment of gastrointestinal stromal tumor （GIST） in China, the members of Chinese Society of Clinical Oncology （CSCO） Expert Committee on GIST thoroughly discussed the key contents of the consensus guidelines, and voted on the controversial issue. In final, the Chinese consensus guidelines for the diagnosis and management of GIST （2017 edition） was formed on the basis of 2013 edition consensus guidelines, which is hereby announced. The consensus included the pathological diagnosis, recurrence risk classification evaluation, targeted agent therapy, surgery and principles of surveillance of GIST.

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.

Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is notapparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia. Obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine. Accurate clinical diagnosis is crucial and guides definitive investigations and interventions. This review summarizes the overall diagnostic approach to gastrointestinal bleeding and provides a practical guide for clinicians.

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.

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.

Endoscopic difficulties in the diagnosis of upper gastrointestinal bleeding

INTRODUCTIONBleeding from the upper gastrointestinal ( GI ) tract remains common ,with a reported annual incidence of up to 172 per 100 000 [1],which has of anything increased from earlier series. Case fatality was recently reported as 14%[2] ,which has probably not changed over several decades .These figures may reflect a rising proportion of elderly patients and increasing non 杝teroidal anti-inflammatory use ,but occur despite apparently better treatments and understanding of the underlying pathophysiology of peptic ulcer disease.

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.

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.

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.

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.