Intermittent melena and refractory anemia due to jejunal cavernous lymphangioma:A case report

BACKGROUND Lymphangiomas in the gastrointestinal tract are extremely rare in adults.As a benign lesion,small intestine lymphangiomas often remain asymptomatic and pose challenges for definitive diagnosis.However,lymphangiomas can give rise to complications such as abdominal pain,bleeding,volvulus,and intussusception.Here,we report a case of jejunal cavernous lymphangioma that presented with intermittent melena and refractory anemia in a male adult.CASE SUMMARY A 66-year-old man presented with intermittent melena,fatigue and refractory anemia nine months prior.Esophagogastroduodenoscopy and colonoscopy were performed many times and revealed no apparent bleeding.Conservative management,including transfusion,hemostasis,gastric acid secretion inhibition and symptomatic treatment,was performed,but the lesions tended to recur shortly after surgery.Ultimately,the patient underwent capsule endoscopy,which revealed a more than 10 cm lesion accompanied by active bleeding.After singleballoon enteroscopy and biopsy,a diagnosis of jejunal cavernous lymphangioma was confirmed,and the patient underwent surgical resection.No complications or recurrences were observed postoperatively.CONCLUSION Jejunal cavernous lymphangioma should be considered a cause of obscure gastrointestinal bleeding.Capsule endoscopy and single-balloon enteroscopy can facilitate diagnosis.Surgical resection is an effective management method.

Glutamine depletion induces murine neonatal melena with increased apoptosis of the intestinal epithelium

AIM:To investigate the possible biological outcome and effect of glutamine depletion in neonatal mice and rodent intestinal epithelial cells.METHODS:We developed three kinds of artificial milk with different amounts of glutamine;Complete amino acid milk (CAM),which is based on maternal mouse milk,glutamine-depleted milk (GDM),and glutaminerich milk (GRM).GRM contains three-fold more glutamine than CAM.Eighty-seven newborn mice were divided into three groups and were fed with either of CAM,GDM,or GRM via a recently improved nipple-bottle system for seven days.After the feeding period,the mice were subjected to macroscopic and microscopic observations by immunohistochemistry for 5-bromo-2'deoxyuridine (BrdU) and Ki-67 as markers of cell proliferation,and for cleaved-caspase-3 as a marker of apoptosis.Moreover,IEC6 rat intestinal epithelial cells were cultured in different concentrations of glutamine and were subject to a 4-[3-(4-iodophenyl)-2-(4-nitrophenyl)2H-5-tetrazolio]-1,3-benzene disulfonate cell proliferation assay,flow cytometry,and western blotting to examine the biological effect of glutamine on cell growth and apoptosis.RESULTS:During the feeding period,we found colonic hemorrhage in six of 28 GDM-fed mice (21.4%),but not in the GRM-fed mice,with no differences in body weight gain between each group.Microscopic examination showed destruction of microvilli and the disappearance of glycocalyx of the intestinal wall in the colon epithelial tissues taken from GDM-fed mice.Intake of GDM reduced BrdU incorporation (the average percentage of BrdU-positive staining;GRM:13.8%,CAM:10.7%,GDM:1.14%,GRM vs GDM:P < 0.001,CAM vs GDM:P < 0.001) and Ki-67 labeling index (the average percentage of Ki67-positive staining;GRM:24.5%,CAM:22.4% GDM:19.4%,GRM vs GDM:P=0.001,CAM vs GDM:P =0.049),suggesting that glutamine depletion inhibited cell proliferation of intestinal epithelial cells.Glutamine deprivation further caused the deformation of the nuclear membrane and the plasma membrane,accompanied by chromatin degeneration and an absence of fat droplets from the colonic epithelia,indicating that the cells underwent apoptosis.Moreover,immunohistochemical analysis revealed the appearance of cleaved caspase-3 in colonic epithelial cells of GDM-fed mice.Finally,when IEC6 rat intestinal epithelial cells were cultured without glutamine,cell proliferation was significantly suppressed after 24 h (relative cell growth;4 mmol/L:100.0% ± 36.1%,0 mmol/L:25.3% ± 25.0%,P < 0.05),with severe cellular damage.The cells underwent apoptosis,accompanied by increased cell population in sub-G0 phase (4 mmol/L:1.68%,0.4 mmol/L:1.35%,0 mmol/L:5.21%),where dying cells are supposed to accumulate.CONCLUSION:Glutamine is an important alimentary component for the maintenance of intestinal mucosa.Glutamine deprivation can cause instability of the intestinal epithelial alignment by increased apoptosis.

Melena:A rare complication of duodenal metastases from primary carcinoma of the lung

Small bowel metastases from primary carcinoma of the lung are very uncommon and occur usually in patients with terminal stage disease. These metastases are usually asymptomatic, but may present as perforation, obstruction, malabsorption, or hemorrhage. Hemorrhage as a first presentation of small bowel metastases is extremely rare and is related to very poor patient survival. We describe a case of a 61- year old patient with primary adenocarcinoma of the lung, presenting with melena as the first manifestation of small bowel metastasis. Both primary tumor and metastatic lesions were diagnosed almost simultaneously. Upper gastrointestinal endoscopy performed with a colonoscope revealed active bleeding from a metastatic tumor involving the duodenum and the proximal jejunum. Histological examination and immunohistochemical staining of the biopsy specimen strongly supported the diagnosis of metastatic lung adenocarcinoma, suggesting that small bowel metastases from primary carcinoma of the lung occur usually in patients with terminal disease and rarely produce symptoms. Gastrointestinal bleeding from metastatic small intestinal lesions should be included in the differential diagnosis of gastrointestinal blood loss in a patient with a known bronchogenic tumor.

Obstructive jaundice and melena caused by hemocholecyst: A case report

A hemocholecyst (HC) is a clot-filled gallbladder caused by bleeding into its lumen. Obstructive jaundice caused by the compression of HC to the hilar biliary tract is likely to be misdiagnosed as cholangiocarcinoma and is extremely rare. We herein report a case of obstructive jaundice and melena caused by HC. A 57-year-old male patient presented with right upper quadrant pain associated with icteric sclera and melena was suspiciously diagnosed as having malignant cholangiocarcinmoa by abdominal ultrasonography, computed tomography and magnetic resonance imaging. Laparotomy found a hematoma in the gallbladder. The hematoma spread to the left hepatic lobe forming an exogenous mass which compressed the hilar biliary tract. Radical cholecystectomy and bile duct exploration with T-tube drainage were performed. Histopathological examination revealed massive necrosis of the gallbladder mucosa with inflammatory cells infiltration as well as intraluminal hematoma formation. One month after operation, a T-tube cholangiography revealed a normal biliary tree. We suggest that HC should be considered in patients with obstructive jaundice and melena after common causes are ruled out.

Black licorice ingestion:Yet another confounding agent in patients with melena

We describe an 80-year-old woman with atrial fibrillation,anti-coagulated with warfarin,who on two separate occasions developed black tarry stools and an elevated international normalized ratio(INR) after eating a pound of Black Licorice.During her most recent episode,her hematocrit was 14(baseline 34) and her INR was 5.5(baseline 2.1).She was advised to restrict licorice consumption,and a follow-up INR two weeks later was 1.2.Black Licorice is derived from the root of the plant,Glycyrrhiza glabra.The components of its extract inhibit the P450 system enzymes that metabolize Warfarin,inhibit thrombin,and prolong fibrinogen clotting times.Hence,the anti-thrombotic activity and inhibition of warfarin metabolism might synergistically amplify anticoagulation.The presence of Black Licorice in the stool can also mimic melena and confound its clinical presentation.Health care providers should caution patients who are at risk for bleeding or on warfarin to avoid black licorice due to an elevated risk of gastroint estinal bleeding.

Trends in upper gastrointestinal bleeding management

Upper gastrointestinal bleeding(UGIB)can be attributed to either non-variceal or variceal causes.The latter is more aggressive with hemodynamic instability secondary to decompensated cirrhosis and portal hypertension.Non-variceal UGIB(NVUGIB)occurs due to impaired gastroprotective mechanisms attributed to several drugs such as anticoagulants and nonsteroidal anti-inflammatory drugs.Helicobacter pylori infection contributes to the development of peptic ulcer bleeding as well.NVUGIB presentation can be either hemodynamically stable or unstable.During the initial assessment a scoring system including patient-related factors(current cardiac,renal,and liver diseases and hemodynamic and labo-ratory parameters)is used to determine the patient’s prognosis.The Glasgow Blatchford score has been shown to be the most useful and precise.Those with high-risk NVUGIB require urgent assessment and upper endoscopy to achieve better short-term and long-term outcomes such as less hospitalization,blood transfusion,and surgery.

Challenges in Diagnosing and Managing Dieulafoy’s Lesions: A Case Report Highlighting the Importance of Clinical Suspicion and Multidisciplinary Approach in Obscure Gastrointestinal Bleeding

Upper gastrointestinal bleeding remains a significant cause of hospital admissions. Even though the incidence of peptic ulcer disease and gastritis is decreasing, the incidence rates in neoplasm, Dieulafoy’s lesions, angiodysplasia, and esophagitis are trending up, which necessities physicians to be aware of those pathologies and their specifics. Here, we represent a case of a 62-year-old male on dual antiplatelet therapy who was transferred to our hospital due to severe melena with suspicion of upper gastrointestinal bleeding. Due to hemodynamic instability, the patient was intubated and started on vasopressors. However, several repeated EGDs and CTs of the abdomen with GI bleeding protocol did not reveal the location of active bleeding to stop it. At the same time, clinically, the patient was hemodynamically unstable with continued melena. On the last EGD, a small area of concern resembling gastric varix was clipped for identification purposes, and the patient underwent a selective angiogram with further diagnosis of Dieulafoy’s lesion, which was successfully embolized. Our case demonstrates that Dieulafoy’s lesions can present as severe life-threatening hemorrhage, hard to diagnose with traditional methods such as EGD or CTs, in which case it is recommended to proceed with an angiogram sooner rather than later for further diagnosis and treatment if needed.

紫斑脾不统血患者血小板相关抗体的实验研究

本文对97例紫斑患者和32例吐血黑便脾不统血证患者进行了PAIgG、PAIgM、PAIgA3项免疫学指标的测定.紫斑患者3项指标都明显增高.各证候中以紫斑脾不统血证增高突出,3项指标中以PAIgG增高的阳性率大.联合测定3项指标可使紫斑牌不统血证患者阳性率达到90.3%.本文就相同疾病不同证侯间、相同证候不同疾病间其血小板相关机体都存在着差异的意义和对脾不统血特异性研究的意义进行了探讨.

Italian survey on non-steroidal anti-inflammatory drugsand gastrointestinal bleeding in children

AIM: To investigate gastrointestinal complications associated with non-steroidal anti-inflammatory drug(NSAIDs) use in children.METHODS: A retrospective, multicenter study was conducted between January 2005 and January 2013, with the participation of 8 Italian pediatric gastroenterology centers. We collected all the cases of patients who refer to emergency room for suspected gastrointestinal bleeding following NSAIDs consumption, and underwent endoscopic evaluation. Previous medical history, associated risk factors, symptoms and signs at presentation, diagnostic procedures, severity of bleeding and management of gastrointestinal bleeding were collected. In addition, data regarding type of drug used, indication, dose, duration of treatment and prescriber(physician or selfmedication) were examined. RESULTS: Fifty-one patients, including 34 males, were enrolled(median age: 7.8 years). Ibuprofen was the most used NSAID [35/51 patients(68.6%)]. Pain was the most frequent indication for NSAIDs use [29/51 patients(56.9%)]. Seven patients had positive family history of Helicobacter pylori(H. pylori) infection or peptic ulcer, and 12 had associated comorbidities. Twenty-four(47%) out of 51 patients used medication inappropriately. Hematemesis was the most frequent symptom(33.3%). Upper gastrointestinal endoscopy revealed gastric lesions in 32/51(62%) patients, duodenal lesions in 17(33%) and esophageal lesions in 8(15%). In 10/51(19.6%) patients, a diagnosis of H. pylori gastritis was made. Forty-eight(94%) patients underwent medical therapy, with spontaneous bleeding resolution, while in 3/51(6%) patients, an endoscopic hemostasis was needed.CONCLUSION: The data collected in this study confirms that adverse events with the involvement of the gastrointestinal tract secondary to NSAID use are also common in

Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.

Successful treatment of refractory gastric antral vascular ectasia by distal gastrectomy:A case report

Gastric antral vascular ectasia (GAVE) is an uncommon and often neglected cause of gastric hemorrhage. The treatments for GAVE include surgery, endoscopy and medical therapies. Here, we report an unusual case of GAVE. A 72-year-old man with a three-month history of recurrent melena was diagnosed with GAVE. Endoscopy revealed the classical &#x0201c;watermelon stomach&#x0201d; appearance of GAVE and complete pyloric involvement. Melena reoccurred three days after argon plasma coagulation treatment, and the level of hemoglobin dropped to 47 g/L. The patient was then successfully treated with distal gastrectomy with Billroth II anastomosis. We propose that surgery should be considered as an effective option for GAVE patients with extensive and severe lesions upon deterioration of general conditions and hemodynamic instability.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND Acute upper gastrointestinal bleeding(AUGIB)is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%.Despite recent newer innovations and advancements in endoscopic techniques and available medications,the mortality rate associated with AUGIB remained persistently elevated.AIM To explore mortality,characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital,and patients who initially present with AUGIB.METHODS This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically.Patients were divided in two groups:Group 1 comprised patients who developed AUGIB during their hospital stay;group 2 consisted of patients who initially presented with AUGIB as their main complaint.Patient characteristics,time to endoscopy,endoscopy findings and interventions,and clinical outcomes were collected and compared between groups.RESULTS A total of 336 patients were included.Group 1 consisted of 139 patients and group 2 of 196 patients.Mortality was significantly higher in the 1st group compared to the 2nd(20%vs 3.1%,P≤0.05).Increased length of stay(LOS)was noted in the 1st group(13 vs 6,P≤0.05).LOS post-endoscopy,vasopressor use,number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1.Inpatients were more likely to be on corticosteroids,antiplatelets and anticoagulants.Conversely,the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.CONCLUSION In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy.Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

急诊内镜治疗非静脉曲张性上消化道出血的临床疗效探讨

目的探讨急诊内镜治疗非静脉曲张性上消化道出血的效果。方法随机选择该院收治的非静脉曲张性上消化道出血患者60例,按照内镜治疗时间分为观察组(30例)和对照组(30例),观察组患者给予急诊内镜检查和止血治疗,对照组患者择期进行内镜检查和止血治疗,比较两组患者治疗效果。结果两组患者经内镜检查,均发现出血性病变,均为消化性溃疡检出例数最多。观察组患者总有效率为96.7%,对照组总有效率为73.3%,观察组显著高于对照组,组间差异有统计学意义(P<0.05)。结论非静脉曲张性上消化道出血患者接受急诊内镜治疗,可有效查明消化道出血病因,及时止血,可提高患者止血效果。

Dieulafoy病14例诊治分析

目的:分析Dieulafoy病诱发消化道大出血的发病机制,探讨其临床特点及治疗方法。方法:回顾性分析因消化道出血而收治的14例Dieulafoy病患者的临床资料。结果:14中首发表现为呕血伴黑便8例,仅呕血4例。仅黑便2例。14例中内镜治疗9例,其中注射高渗盐水或硬化剂4例,射频治疗3例,内镜下金属夹钳夹止血2例,均立即止血。手术5例,均治愈。所有患者随访1年均无复发。结论:消化道出血是Dieulafoy病的主要临床症状,内镜是诊断和治疗Dieulafoy病的首选方法;对于不能内镜治疗者,手术治疗可彻底解决血管畸形问题,仍为重要治疗手段。

Extensive abdominal lymphangiomatosis involving the small bowel mesentery: A case report

BACKGROUND Abdominal lymphangiomatosis is a rare benign condition accounting for less than 1%of all the cases of lymphangiomatosis.Management usually involves radical surgical excision;however,depending upon the extent of involvement,patient condition,and absence of complications,conservative management can be also considered.CASE SUMMARY We present the case of a 32-year-old male who presented with short onset abdominal pain and melena.Physical examination findings were within normal limits,except for left lower abdominal tenderness.Upper gastrointestinal endoscopy was within normal limits.Abdominal and pelvic ultrasound and computed tomography(CT)scan revealed numerous,variably-sized cystic lesions within the abdominal cavity,exclusively and extensively affecting the small bowel mesentery with sparing of the retroperitoneum.The diagnosis was confirmed by CT and cytological examination.Radical surgical excision was technically impossible in this patient because of the extensive involvement of the mesentery;therefore,the patient was managed conservatively.CONCLUSION Extensive and exclusive small bowel mesentery involvement in abdominal lymphangiomatosis is rare.Imaging modalities play an important role in establishing the diagnosis and conservative management can be considered when surgery is technically impossible.

Wandering small intestinal stromal tumor:A case report

BACKGROUND The occurrence of gastrointestinal stromal tumors(GISTs)in the small intestine is rare,and a case of wandering small intestinal stromal tumor has been rarely reported to date.Dissemination of this case can help inform future diagnosis and effective treatment.CASE SUMMARY A 68-year-old patient presented to us with tarry stools.Computed tomography showed a mobile tumor moving widely within the abdominal cavity.As the laboratory data showed a low range of red blood cells and an immediate surgery was not indicated,we performed digital subtraction angiography and embolization to achieve hemostasis.Surgical resection was performed after the patient’s condition improved.The tumor was successfully removed laparoscopically.Histological examination revealed submucosal GIST with infarction,which was of intermediate-risk,with mitotic count<1 per 10 high-power field.Immunohistochemical studies revealed the following:CD117+,Dog1+,CD34+,SMA+,S100-,CK-,Des-,SOX-11-,STAT6-,Ki67 Hotspots 10%+.The patient was ultimately diagnosed with wandering small intestinal stromal tumor.CONCLUSION When a highly vascularized tumor is clinically encountered in the small intestine,the possibility of stromal tumors should be considered.However,when the tumor cannot be visualized at its original location,the possibility of tumor migration is considered.

不明原因消化道出血的临床特点对气囊辅助小肠镜进镜路径选择的指导意义

目的探讨不明原因消化道出血临床特点对指导选择气囊辅助小肠镜进镜途径的作用和临床意义。方法回顾性分析空军总医院2003年9月—2015年3月因不明原因消化道出血(obscure gastrointestinal bleeding,OGIB)行气囊辅助小肠镜(balloon assisted enteroscopy,BAE)检查的222例住院患者临床资料,按进镜途径的不同,分为经口进镜组和经肛进镜组,比较分析2组患者的临床特点、BAE检查结果和并发症。结果接受BAE检查的222例OGIB患者中,130例发现病变,病变总检出率为58.56%(130/222)。结果显示,临床表现以黑便为主者,尤其首次大便为柏油样黑便者选择经口进镜病变检出率明显高于经肛进镜;而以暗红色血便或鲜血便为主者,经肛进镜较经口进镜病变检出率高,二者差异有统计学意义(P<0.05)。结论对于OGIB患者行BAE检查前,依据大便颜色改变情况选择进镜途径,可有效提高单侧进镜发现小肠出血病变的检出率。

杭州市大肠癌危险因素分析

对杭州市区在１９８６年１月１日～１９８９年１２月３１日内被诊断的２４５例大肠癌进行了１∶１配对的病例对照研究。对所有调查因素都进行了单因素及多因素的统计分析，结果表明：饮酒史、饮自来水、慢性腹泻史、血便史及重体力活动与大肠癌有阳性联系，轻体力活动则有保护作用，以上因素均具有显著的统计学意义。

以黑便就诊的危重症阑尾出血1例

目的:通过分析1例以黑便为首发症状的阑尾出血病例的临床特点和诊疗过程,以期为特殊类型疾病致下消化道出血病例提供治疗经验。方法:以1例最先出现黑便的阑尾出血危重症病例为研究对象,并通过学习相关文献,对其病因、临床表现、诊断、治疗等进行分析。结果:患者通过积极输血输液抗休克治疗,接受胃镜、血管介入、肠镜仍无法止血,通过剖腹探查发现阑尾出血并给予切除阑尾才得到控制,术后通过积极对症治疗后痊愈出院。结论:阑尾出血导致的下消化道出血很罕见,且多见于上消化道出血的黑便症状也增加了诊治难度,因此此类患者需要多学科团队进行仔细甄别和积极治疗。

黑便对显性潜在小肠出血患者小肠镜检查进镜路径的指导意义

目的探讨黑便对显性潜在小肠出血患者小肠镜检查进镜路径选择的指导意义。方法回顾性分析空军特色医学中心2003.10-2019.11期间经气囊辅助内镜诊治的显性潜在小肠出血患者,分为黑便(A组)、血便(B组)两组,对两组患者临床特点,不同进镜途径疾病检出率进行比较,分析黑便患者与小肠镜不同进镜途径病变检出阳性率之间的相关性。结果208例患者符合纳入标准,111例黑便患者(A组)经口小肠镜检查的病变阳性检出率为67.57%(75/111),明显高于经肛检查的病变阳性检出率12.6%(14/111);另外也明显高于97例血便患者(B组)经口小肠镜阳性检出率25.77%(25/97),差异具有统计学意义(P<0.05)。结论临床除外屈氏韧带以上消化道出血的黑便患者,病情允许的情况下可首选经口小肠镜检查,可以提高病变检出率,减轻了患者的经济负担。