Life-threatening gastrointestinal bleeding in Crohn disease

Massive gastrointestinal bleeding is a very rare complication in Crohn's disease. Its occurrence has been quoted as 1-2% in the literature. A case of a 16-year old boy is reported here, who had a three-year history of Crohn's disease. After a three-day's therapy of bronchopneumonia a massive rectal bleeding began and an emergency operation had to be made. Site of the bleeding was localised by intraoperative colonoscopy and an ileocolic resection was made. The patient recovered and has done well since. Some characteristics, diagnostic and therapeutic problems of the massive bleeding in Crohn's disease are discussed.     

Henoch-Sch?nlein purpura with ileitis terminalis

Gastrointestinal manifestations of Henoch-Sch?nlein purpura commonly include abdominal pain and gastrointestinal bleeding as well as extraintestinal signs and symptoms. We report here on a 24-year-old man with gastrointestinal pain in whom the classical features of Henoch-Sch?nlein purpura appeared only 6 days after acute abdominal symptoms. At endoscopic investigation inflammation with aphthous lesions was detected at the terminal ileum, which is a common feature of Crohn's disease. The observation that vasculitic disorders such as Henoch-Sch?nlein purpura can present with inflammatory lesions at the terminal ileum which are indistinguishable from those of Crohn's disease underlines the potential vasculitic basis of the latter condition.     

Gastrointestinal hemorrhage in patients with systemic sclerosis and CREST syndrome

OBJECTIVES: Systemic sclerosis (SSc) and calcinosis, Raynaud's phenomenon, esophageal disease, sclerodactyly, telangiectasia (CREST) syndrome present distinctive microvasculature lesions that are thought to be responsible for tissue damage and disease progression. Involvement of the gastrointestinal tract may lead to the occurrence of profuse hemorrhage. We performed a study to assess the incidence and characteristics of gastrointestinal hemorrhage in a large group of patients with SSc and CREST syndrome. METHODS: We reviewed the medical records of 144 patients with SSc/CREST seen at our institution during the period 1985-1996. Endoscopic findings and clinical data were correlated. Data are expressed as means +/- SD. RESULTS: Twenty-two of 144 (15.2%) patients had at least one episode of gastrointestinal hemorrhage (16 women, 6 men; mean age, 59.4 +/- 17.6 yr). Eight patients (8/22; 36%) had multiple episodes and four (4/22; 18%) required chronic transfusion therapy. Mucosal telangiectasias were the most common cause of bleeding (9/22; 40.9%), followed by peptic ulcer disease (7/22; 31.8%) and erosive gastritis (3/22; 13.6%). Bleeding telangiectasias occurred in the entire gastrointestinal tract, including oral cavity (n = 1), esophagus (n = 1), stomach (n = 3), duodenum (n = 1), ileum (n = 1), cecum (n = 2), and colon (n = 2). Mortality was 22.7% in patients with gastrointestinal bleeding, compared with 7.3% in patients without bleeding. CONCLUSIONS: Patients with SSc/CREST syndrome are at risk of developing severe gastrointestinal hemorrhage. This complication is associated with frequent hospitalization, blood transfusions, and increased mortality. Mucosal telangiectasias are the most common source of bleeding. Appropriate endoscopic intervention is recommended in evaluating and preventing bleeding in patients with SSc/CREST.     

Tuberculous colitis mimicking Crohn's disease

Intestinal tuberculosis is a rare disease in western countries and may mimic a variety of gastrointestinal disorders. Here, we report the case of a 63-yr-old patient who presented with profuse bleeding from a deep rectal ulcer. Similar lesions were found in different parts of the colon. Multilocular colorectal carcinoma was suspected based on the macroscopic appearance. Histology, however, suggested Crohn's disease. Intestinal tuberculosis was initially ruled out by negative staining for acid-fast bacilli, mycobacterial culture, and polymerase chain reaction analysis. A treatment for Crohn's disease was started. Endoscopic reexamination revealed progressive disease with extensive ulcerations of the terminal ileum. Histopathological examination then revealed acid-fast bacilli in the colonic mucosa typical for mycobacterium tuberculosis infection. This case emphasizes the need to include intestinal tuberculosis in the initial differential diagnosis of ulcerative colorectal lesions also in the western population.     

Postembolic colonic infarction

From a total of 23 cases from five hospitals, acute colonic mucosal necrosis developed in three patients following transcatheter embolotherapy for colonic hemorrhage. Although embolic therapy for lower gastrointestinal bleeding is associated with appreciable risk, these risks are less than those of emergency operation for hemorrhage. The alternative transcatheter therapeutic modality, vasopressin infusion, is often associated with continued or recurrent hemorrhage, is relatively contraindicated in patients with coronary disease, and produces numerous complications. Transcatheter embolotherapy is recommended for patients with colonic bleeding who have a contraindication to vasopressin administration, who are refractory to vasopressin, or who rebleed following treatment with vasopressin.     

Pancreaticoduodenal artery aneurysm--a life-threatening cause of gastrointestinal hemorrhage: case report and review of the literature

Gastrointestinal bleeding caused by erosion of a pancreaticoduodenal artery aneurysm in patients with pancreatitis is a rare but potentially life threatening disease. In this case report, the successful treatment of a patient bleeding from a ruptured pancreaticoduodenal artery aneurysm is described. A review of the literature of reported cases discusses the value of early angiographic intervention in patients with unexplained gastrointestinal hemorrhage and suspected rupture of an aneurysm.     

Application of cloud-point extraction-reversed-phase high-performance liquid chromatography. A preliminary study of the extraction and quantification of vitamins A and E in human serum and whole blood

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.     

Patterns of increased in vivo fundus autofluorescence in the junctional zone of geographic atrophy of the retinal pigment epithelium associated with age-related macular degeneration

BACKGROUND: The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy). METHODS: Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices. RESULTS: Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (-31%: 95% CI [-44%, -14%). CONCLUSION: In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery.     

Endoscopic hemostasis of nonvariceal, non-peptic ulcer hemorrhage

The majority of patients who present with acute upper gastrointestinal hemorrhage are found to be bleeding from acid peptic disease including ulcer, esophagitis and gastritis, and variceal disease. Mallory-Weiss tear, Dieulafoy's lesion, cancer, and other rare lesions account for the bleeding source in the remaining patients. Endoscopic hemostasis may be effective in many of the conditions, but only Mallory-Weiss tear and Dieulafoy's lesion are encountered frequently enough to be clinically significant.     

Acute bleeding after bone marrow transplantation (BMT)- incidence and effect on survival. A quantitative analysis in 1,402 patients

Acute bleeding after bone marrow transplantation (BMT) was investigated in 1,402 patients receiving transplants at Johns Hopkins Hospital between January 1, 1986 and June 30, 1995. Bleeding categorization was based on daily scores of intensity used by the blood transfusion service. Moderate and severe episodes were analyzed for bleeding sites. Analysis of the cause of death and the interval of the bleeding episode to outcome endpoints was recorded. Survival estimates were computed for 1,353 BMT patients. The overall incidence was 34%. Minor bleeding was seen in 10.6%, moderate bleeding was seen in 11.3%, and severe bleeding was seen in 12% of all patients. Fourteen percent of patients had moderate or severe gastrointestinal hemorrhage, 6.4% had moderate or severe hemorrhagic cystitis, 2.8% had pulmonary hemorrhage, and 2% had intracranial hemorrhage. Sixty-one percent had 1 bleeding site and 34.4% had more than 1 site. Moderate and severe bleeding was more prevalent in allogeneic (31%) and unrelated patients (62.5%) compared with autologous patients (18.5%). Significant distribution of incidence was found among the different diagnoses, but not by disease status in acute myeloid leukemia, acute lymphoblastic leukemia, chronic myelogenous leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma. Bleeding was associated with significantly reduced survival in allogeneic, autologous, and unrelated BMT and in each disease category except multiple myeloma. Survival was correlated with the bleeding intensity, bleeding site, and the number of sites. Although close temporal association was evident to mortality, bleeding was recorded as the cause of death in only the minority of cases compared with other toxicities after BMT (graft-versus-host disease, infections, and preparative regimen toxicity). Acute bleeding is a common complication after BMT that is profoundly associated with morbidity and mortality. Although bleeding was not a direct cause of death in the majority of cases, it has a potential prognostic implication as a predictor of poor outcome in clinical assessment of patients after BMT.     

Desiccant recovered, Crohn's disease discovered

Foreign bodies occasionally lodge in strictures due to Crohn's disease. Most cases involve patients known to have Crohn's disease. However, some patients deny or cannot recall ingestion of foreign bodies. Gastrointestinal obstruction caused by a foreign body is a rare presentation of Crohn's disease. We report the first case of Crohn's disease presenting as gastrointestinal obstruction resulting from accidental ingestion of a pharmaceutical desiccant.     

Ileal endometriosis masquerading as Crohn's ileitis

Endometriosis is usually confined to the pelvis but may involve distant organs. When the small bowel is affected, endometriosis has a propensity to develop in the distal ileum, which may lead to fibrosis and stricture formation that can be confused with Crohn's disease. Here were describe two women, one with antecedent Crohn's colitis in whom ileal endometriosis mimicked obstructing Crohn's disease of the terminal ileum. These reports illustrate that ileal endometriosis must be considered in the differential diagnosis of Crohn's disease of the ileum, even in the presence of Crohn's disease elsewhere in the gastrointestinal tract.     

The evaluation of argon laser photocoagulation in a series of animal models of upper gastrointestinal bleeding

During the past five years we have evaluated argon laser photocoagulation in various canine models of upper gastrointestinal hemorrhage. In gastric erosions, the eight-watt argon laser was uniformly effective in stopping bleeding. In our standard acute ulcer model the seven-watt argon laser was effective in stopping bleeding from most ulcers and only occasionally produced deep injury. With the addition of a jet of CO2 exiting the laser catheter coaxial to the laser beam, the argon laser was 100% effective and no deep injury resulted. The application of the argon laser in a more physiologic canine bleeding model using a single bleeding vessel in an ulcer base is currently under study. The development of improved animal models of gastrointestinal bleeding should contribute to the identification of effective and safe endoscopic hemostatic methods.     

Iron deficiency anemia caused by an arteriovenous malformation in the distal ileum

The case of a young woman with chronic iron deficiency anemia is described. Her consequent guaiac-positive stool suggested a gastrointestinal bleeding behind her anemia. The use of the conventional diagnostic techniques did not result in a definitive diagnosis. The source of the hemorrhage was later detected by the aid of selective mesenteric arteriography as an unusual form of arteriovenous malformations localized to the small intestine. 20 months passed since the resection of the affected intestinal segment. During this period of close follow up no clinical signs of recurrent gastrointestinal hemorrhage was observed. The authors briefly review the relevant literature.     

Rectovaginal septum adenomyotic nodules: a series of 500 cases

PURPOSE: Selective mesenteric angiography is an expensive, invasive, diagnostic, and therapeutic tool for lower gastrointestinal hemorrhage. Some institutions have required a positive nuclear medicine bleeding scan before angiography. We have attempted to determine if this is a valid screening test for mesenteric angiography. Are there any other factors to predict which patients are actively bleeding and who will benefit from angiography? METHODS: All cases of mesenteric angiography for hemorrhage performed during a 12-year period were reviewed. RESULTS: A total of 131 angiograms were performed during a 12-year period with 45 patients demonstrating active bleeding; 54 patients had a bleeding scan before angiography. A positive bleeding scan did not increase the percentage of positive angiograms. A history of prior gastrointestinal bleeding, transfusions, orthostatic hypotension, or tachycardia were not predictors for a positive angiogram. DISCUSSION: This study could not identify any single useful predictor that will increase the likelihood of obtaining a positive angiogram. Nuclear medicine scans should not be used routinely as a screening test for angiography.     

False-positive gliadin and endomysium antibodies and exocrine pancreatic insufficiency as pitfalls in the differential diagnosis of duodenal Crohn's versus celiac disease

We report a 13-yr-old boy with Crohn's disease in the upper gastrointestinal tract presenting with abdominal pain, failure to thrive, recurrent fever, iron-deficient anemia, and exocrine pancreatic insufficiency. Initially, latent celiac disease was suggested because of normal endoscopic findings, the finding of non-specific inflammation on histological evaluation of duodenal biopsies, positive IgA and IgG gliadin, as well as endomysium antibodies and exocrine pancreatic insufficiency. There was no response to a gluten-free diet. A reevaluation revealed Crohn's disease.     

Adrenal hemorrhage complicating ACTH therapy in Crohn's disease

Huge dose ACTH therapy is used in some severely ill patients with inflammatory bowel disease. We report a teenage girl with Crohn's disease who developed an acute abdomen following ACTH therapy. CT revealed the mass to be a hemorrhagic adrenal gland; the opposite adrenal gland was hypertrophied but without signs of hemorrhage.     

Dieulafoy colonic ulcer. A rare cause of lower gastrointestinal hemorrhage

Dieulafoy's disease is an unusual cause of gastrointestinal hemorrhage, reported to account for less than 2% of acute gastrointestinal bleeding episodes. Bleeding occurs from a defect in an unusually large submucosal artery, through a minute mucosal erosion. Endoscopic diagnosis is sometimes difficult, but primary endoscopic therapy may be successful and should be attempted. In most cases the lesion is found in the proximal stomach. Sixteen cases of Dieulafoy's lesion located in the colon have been reported in the literature but only nine have been confirmed by histology. We present the case of a 63 year-old male with Dieulafoy's lesion of the transverse colon which was diagnosed by endoscopy and confirmed by histology.     

Prognosis and treatment of burns

The experience in therapeutic digestive endoscopy is presented using injection technique with adrenalin-polidocanol of gastrointestinal hemorrhage lesions. One hundred and twenty nine patients were treated endoscopically; the medium age was 60 years; in almost 80% of the cases, peptic ulcer disease were found. The effectiveness was 91.4% when one session procedure was used and in some cases two sessions were applied, giving a final total arrest of hemorrhage of 95.3%. The total mortality still remain high (16.3%) even without bleeding, due to coexisting poor general conditions of the patients. The technique of endoscopic injection is reviewed and the final results of our work are presented.     

Surgical treatment of Crohn's disease

Of 93 children with Crohn's disease treated at the H?pital Sainte-Justine between 1967 and 1979, 39 were operated on. Ten had abscesses and anal fistulas drained and in 29 the bowel was resected. The mean age of the children was 13 years. The average time between onset and diagnosis for both the medical and surgical groups was 13 months. Medical treatment failed in 25 patients after an average time of 22 +/- 17 months. Fourteen patients had an initial laparotomy, with a false diagnosis of appendicitis in 8, abdominal tumour in 2 and Meckel's diverticulum in 1. Indications for operation were: intestinal obstruction, bowel fistula, intra-abdominal abscess, gastrointestinal hemorrhage, growth failure and toxic megacolon. There were no deaths and only two postoperative infections. Crohn's disease seems to be becoming more frequent, more severe and starting earlier in life. Three to 6 weeks of preoperative preparation with enteral and parenteral nutrition allows operation to be performed under safer conditions. Although the recurrence rate after operation is still high, there is no doubt that the children enjoy a better quality of life, growth and a 50% chance of being disease-free 10 years later.