outcome (i.e., transfusion requirements, length of hos- pital stay, rebleeding rate, and mortality). Endoscopic evaluation of the bleeding lesion in the case of peptic ulcer was defined according to the Forrest classification system as follows: FI (FIa and FIb), FII (FIIa, FIIb and FIIc), and FIII . Patients who had a variceal type of upper GI bleeding were classified endoscopically ac- cording to the severity of varices into four grades (i.e., grades I–IV) . The grade assigned to each of the pa- tients was based on the highest grade observed in each patient. Gastric extension of the oesophageal varices were classified using Sarin’s classification into GOV-1 or GOV-2, while isolated gastric varices were classified as IGV-1 and IGV-2. Endoscopic diagnosis was consid- ered to be accurate if stigmata of active or recent bleed- ing were present, independently of the nature of the bleeding lesion. Normal examination was defined by the absence of any endoscopic abnormality. Shock was defined as a systolic blood pressure below 90 mmHg at presentation. Rebleeding was defined as a new bleeding episode from the same source within 6 months after the initial bleeding had stopped. The post-endoscopy Rockall risk scoring system, which uses clinical (e.g., age, co-morbidity, and presence of shock) and endo- scopic (e.g., diagnosis of stigmata of recent haemor- rhage) criteria, was used to predict patients at risk for developing adverse outcomes after acute UGIB .
symptoms. The ulcer had subsequently healed after med- ical management. There was no history of alcohol abuse or intake of NSAIDs. There were no significant findings on clinical examination apart from pallor and tachycardia (Heart rate – 110/minute). His hemoglobin was 6.8 gm/ dl and hematocrit was 20%. Coagulation parameters were normal. The nasogastric aspirate was clear. An upper GI endoscopy revealed normal esophagus and stomach. The duodenal bulb was deformed but no active ulcer was seen. Few clots were seen adherent to the postbulbar mucosa that appeared grossly normal (Figure 1). The patient re- bled the next day. A repeat endoscopy showed an actively bleeding vessel in the postbulbar duodenum. The sur- rounding mucosa was normal (Figure 2). These findings were suggestive of a DL of the duodenum. A peri and int- ralesional injection of 1:10,000 adrenaline solution con- trolled the bleeding. Subsequent recovery was uneventful. The video recording of the first endoscopy was reviewed
Upper gastro intestinal bleeding is one of the most common reasons of emergency department visits, totaling up to 400,000 annual admissions in the United States. Peptic ulcer disease and variceal bleeding are two of the most common causes of GI bleeding. Several studies have been done, and major advancements were made in its management leading to significant drop in morbidity and mortality. Our aim is to study the common causes of upper gastrointestinal bleeding that come to the emergency department and understand the latest guidelines to manage them. We conducted this review using a comprehensive search of PubMed, MEDLINE, and EMBASE from March 1981, through November 2017. The following search terms were used: upper gastro intestinal bleeding, management of upper GI bleeding, variceal bleeding, peptic ulcer bleeding, hemorrhage in the emergency department. Acute upper gastrointestinal bleeding is one of the most common cases encountered in the emergency department and leading to significant morbidity and mortality. Clearing airway and breathing and stabilizing the vitals of the patient by achieving hemodynamic stability and bleeding control is the primary goal in the emergency department.
GI bleeds are a commonly observed complication after LVAD placement . The incidence of GI bleed in patients with LVAD is estimated to be roughly 20%, and most of these patients have continuous flow (CF) LVAD . Most of the GI bleeds in these patients occur due to the formation of AVMs , which is thought to be caused by intestinal hypoperfusion from reduced pulse pressure in CF-LVADs leading to regional hypoxia and vascular dilation , but also due to an acquired von Willebrand disease, characterized by decreased or absent levels of high molecular weight von Willebrand factor multimers . The reduction in these factors is also thought to be secondary to the narrow pulse pressure in CF-LVADs, mimicking Heyde’s Syndrome seen in aortic stenosis . In addi- tion, CF-LVAD use requires the use of anticoagulation because of the hyper- coagulable state associated with the device. Unfortunately, the risk for both thrombotic and hemorrhagic complications are increased compared to those on anticoagulation without LVAD, likely due to the impaired platelet aggregation secondary to acquired von Willebrand disease .
Please cite this article as: de Steur WO, Henneman D, Allum WH, Dikken JL, van Sandick JW, Reynolds J, Mariette C, Jensen L, Johansson J, Kolodziejczyk P, Hardwick RH, van de Velde CJH, , Common data items in seven European oesophagogastric cancer surgery registries: Towards a European Upper GI Cancer Audit (EURECCA Upper GI), European Journal of Surgical Oncology (2014), doi: 10.1016/ j.ejso.2013.11.021.
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Reflux oesophagitis is the sequelac and indicator of long standing and moderate to severe gasto-oestophageal reflux. It is more severe at the squamo- columnar junction. It can extend upwards to many centimeters, but visible changes are usually confined to the distal 5 cm. Grading the extent of the macroscopic reflux oesophagitis is of great importance as it is the best measure of severity and the best predictor of outcome with treatment. In our study we did not try to establish the cause effective mechanisms of reflux and asthma.We screened the patients with intractable asthma for the presence of reflux oesophagitis ,thus it would be beneficial to the patients to start anti – reflux treatment in them.Many published reports favour the point that effective anti – reflux medical and surgical management will reduce the severity of asthma and reflux associated bronchospasm .
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Upper gastrointestinal haemorrhage is one of the important causes of admission in Surgical Intensive care Unit. Despite modern techniques of resuscitation, anesthesia and surgery it has a significant mortality 1 . It was proposed to study the endoscopic evaluation and management of upper Gastrointestinal bleeding in Coimbatore Medical College Hospital , during the period of 2006- 2008, due to the prevalence of UGI (upper gastro intestinal) Bleeding.
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UGI bleed can occur from variety of mechanism that are consequent to chronic pancreatitis. The autodigestive process imparted by pancreatitis can lead to pseudoaneurysm formation of any arteries such as splenic artery, gastroduodenal artery, pancreaticoduodenal artery, left gastric artery. Rupture of an artery results in bleeding.
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Procedures and rehospitalizations were also evaluated 30 days following the index date. Inpatient and outpatient claims were used to identify cardiac revascularization for the AMI sample and GI endoscopy for the GI bleed sample. GI endoscopy was chosen as patients are likely to undergo an endoscopy to follow up on a lesion or if re-bleeding is suspected. Cardiac revascularization was chosen as many patients following an AMI have coronary disease requir- ing subsequent revascularization by either stent or surgery. In addition, pre-index health care costs from medical and pharmacy claims for services delivered in the six-month pre-index period were calculated as a function of health plan and patient liability. Reported costs reﬂ ect the total amounts paid by the health plan and the patient.
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No omental and liver metastasis were seen. Wide local excision of the tumour was carried out. Microscopic examination of the tumor was suggestive of GIST (Fig 5) while as lymph node showed reactive hyperplasia only. Tumour cells were positive for C kit, CD34 and DOG1. SMA was focally positive. Our complete diagnosis was Gastro Intestinal Stromal Tumor Stage III A (TNM Staging) presenting as massive upper GI bleed.
Methods: We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome.
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It has been reported that several distraction techniques based on visual, auditory, and olfactory stimulation were effective for the reduction of pain and anxiety during various medical inspections, care procedures, and treat- ments. In particular, music therapy has been used in a range of healthcare settings, including oncology, demen- tia, palliative care, and hospices [22, 23]. Recently, the positive effect of music for various different endoscopic procedures has been reported in several studies [1, 15, 24–29]. Kotwal MR et al. reported that there was a sta- tistically significant effect of music on blood pressure and respiratory rate during gastroscopy between patients with and without music . Bampton et al. reported that there was no significant difference in the overall tol- erance score between the music group and the no-music group; however, a significantly higher proportion of pa- tients described the experience of the GI endoscopic procedure as being at least moderately unpleasant in the no-music group . The number of positive effect arti- cles of music on anxiety levels for upper GI endoscopy may be slightly more than that of negative effect articles. Table 3 Comparison of the rate of decrease in vital sign
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Emergency surgery is usually carried out for only 15 to 25% of the patients that keep on bleeding in spite of treatment with non-surgical therapy [4,13,15]. Some Brazilian authors have demonstrated that it is possible to use the distal splenorenal shunt in the emergency period because of the satisfactory results obtained [19, 24]. Only nineteen patients (8.6%) were submitted to a surgi- cal treatment during the acute episode of bleeding. In this situation the process of esophagogastric devasculariza- tion associated with splenectomy (EGDS) was applied to 63.2% of the patients. There was a successful control of bleeding in 78.9% of the cases. In the first following year, 5.2% of the other patients were submitted to surgical treatment after new episodes of upper gastrointestinal bleeding caused by gastroesophageal varices.
Thus, a normal oral cavity may not exclude upper gastro intestinal injury. 80% of patients (n = 24) with Odynophagia & 83% of patients (n = 26) having dysphagia had severe oesopageal injury (IIB or more). Haemetemesis:- 16 patients of 25 patients with haemetemesis had severe injury of esophagus & stomach. Epigastric pain:- 19 of 30 patients with severe epigastric pain had severe injury of esophagus or stomach. Of 30 patients with epigastric tenderness 20 patients had esophageal burns & 16 patients had severe gastric burns. One patient with epigastric tenderness and 2 patients with diffuse tenderness had gastric perforation. However, 2 patients with normal abdominal findings had grade IIIA esophageal injury.
There is a well-known close association between endo- scopy waiting times and test results in urgent referrals, particularly in the case of digestive bleeding . Clinical progress of malignancy is also influenced by time to exam  and this event may have also medical-legal con- sequences . From an organizational stand point, this evidence has led to the creation of on-call services for urgent endoscopy and implementation of the two-week rule for endoscopyreferrals.
or recurrent iron-deficiency anemia from chronic gastrointestinal blood loss. Patient’s data and follow- up information were collected from the hospital elec- tronic medical chart and CE database. The variable data included age, gender, co-morbidity, medication use (anticoagulant, antiplatelets, and non-steroidal anti-inflammatory drugs, NSAIDs), presentation of OGIB (overt or occult), history of previous overt GI bleeding, hemoglobin level, CE finding, type of specific treatment and time interval to re-bleeding event after CE. The study was reviewed and approved by the Hu- man Research Ethics Committee of the Faculty of Medicine, Prince of Songkla University.
Upper gastrointestinal bleeding is a common acute and severe disease in the di- gestive department. It mainly includes the digestive tract above the ligament of Treitz, including bleeding caused by esophageal, gastric, duodenalor pancreatic and gallbladder lesions. Massive bleeding refers to blood loss exceeding 1000 ml or 20% of circulating blood volume within a few hours . Its clinical manifesta- tions are mainly vomiting blood and/or black feces, and shock caused by acute peripheral circulation failure. The mortality rate is extremely high, even up to 12% - 35% of elderly patients  . Clinically, the causes are often divided into two categories: non-variceal bleeding and variceal bleeding. Endoscopic treat- ment mainly refers to the use of endoscopic hemostatic drug injection or other methods to get hemostasis. Now this article reviews recent domestic and foreign literature to summarize the progress of endoscopic treatment of upper gastroin- How to cite this paper: Fu, Q.H., Wu,
A consensus bleeding de nition has been proposed to address the ﬁ heterogeneity in bleeding de nitions used in cardiovascular trials in ﬁ acute coronary syndromes and percutaneous coronary interventions [ 10 ]. This de nition describes ve levels of bleeding from none to fatal, ﬁ ﬁ focuses heavily on procedural bleeding, and incorporates both clinical events and changes in hemoglobin levels. Other cardiovascular trial bleeding de nitions include Thrombolysis in Myocardial Infarction ﬁ (TIMI), International Society on Thromobosis and Hemostasis (ISTH), and Global Utilization of Streptokinase and Tissue Plasminogen Acti- vator for Occluded Coronary Arteries (GUSTO) trial criteria [ 12 ]. All three of these have subclassi cations of bleeding severity, and the TIMI ﬁ and ISTH major bleeding de nitions include change in hemoglobin ﬁ levels. Similarly, the de nition of major bleeding in the de nition ﬁ ﬁ proposed for trials of antihemostatic agents (anticoagulants, anti- platelet drugs, and brinolytic agents) includes a change in hemoglobin ﬁ level [ 13 ]. These trials regularly measure hemoglobin peri-procedu- rally, particularly with signi cant interventions. None of these de ni- ﬁ ﬁ tions was well-suited for a primary prevention trial in which there is no procedural intervention likely to precipitate bleeding and study he- moglobin measures are conducted annually.
A 45-year-old female patient, who is known to suffer from Diabetes Mellitus and Hyperlipidemia, presented to our emergency room department with dark tarry stool of two weeks’ duration which turned to bloody stool on the same day of admission. She also complained about general weakness and dizziness. Due to the aforementioned complaints, she was treated by her family physician with iron tablets supplements. On physical examination upon her admission, she looked pale, her vital signs were within normal limits. Abdominal examination revealed a soft and lax abdomen without tenderness, no palpable masses were detected. Digital rectal exam was consistent with dark cherry red stool, without palpable masses. Complete blood count showed very low hemoglobin level of 4.3 g/dL and normal white blood cell count. Liver and kidney function tests were within normal limits. A short rigid colonoscopy revealed cherry red stool mixed with melena without obvious bleeding source. A nasogastric tube showed bilious secretions. Two packed cells were transfused, and the patient was admitted with a diagnosis of lower gastrointestinal bleeding for further treatment and investigations.
included in this analysis reported on mortality, of which one reported a dose–response increase in all-cause mortality and rate of GI AEs or bleeds based on the low to high medication possession ratio (measured by repeat prescription frequency) (Table 1) . The other study reported an increase in stand- ardized mortality ratio for patients prescribed paracetamol compared with those not prescribed paracetamol, regardless of the specific cause of death, with a nearly doubled overall death rate . Four studies included in the meta-analysis showed a dose–response relationship with risk of cardiovas- cular AEs. One study reported an increasing risk ratio of all cardiovascular AEs based on dosing frequency (Table 1), and three studies included in the meta-analysis reported on the risk of renal AEs with paracetamol, with one study reporting a dose-ranging increase in odds ratio (OR) based on cumulative intake and measured as a ≥ 30% decrease in estimated glomerular filtration rate (eGFR), ranging from 1.80 with up to 500 g in a lifetime (95% CI 1.02–3.18) to 2.04 with > 3000 g (95% CI 1.28–3.25) .