Radiological evaluation of complications of intestinal tuberculosis

Complications of intestinal tuberculosis may be masked. This study aims to heighten awareness of these unusual clinical complications and the radiological findings in such cases. Over a period of 5 years, 21 patients with proven intestinal tuberculosis, 13 of whom presented with complications, are presented in this report. Radiological diagnosis was by barium gastrointestinal studies and computed tomographic (CT) evaluation. Surgical specimens and histopathology confirmed the diagnosis. The commonest complication was intestinal obstruction (N = 6). Others were esophagobronchial and duodenocolic fistulas (N = 2), significant gastrointestinal hemorrhage (N = 3) caused by ulcers in the small bowel and colon, and malabsorption syndrome (N = 3) caused by diffuse small bowel infiltration in 2 cases and duodenocolic fistula in the third case. None of the patients presented were immunocompromised. Though uncommon, tuberculosis should be considered in patients presenting clinically with intestinal obstruction, significant gastrointestinal hemorrhage and malabsorption state.

Angiographic evaluation and management of nonvariceal upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool used in the evaluation and treatment of patients with upper gastrointestinal bleeding. When endoscopy is unsuccessful in identifying or controlling GI hemorrhage, however, arteriography is useful in both the evaluation and treatment of upper GI hemorrhage.

[X-ray diagnostic features of giant bleeding ulcers in stomach and duodenum]

The study was based on the analysis of clinical, X-ray, and morphological examinations made in 64 patients with giant gastric and duodenal ulcers. All the patients were admitted for gastroduodenal hemorrhage. Among the examinees, there were 28 patients with giant ulcer of the stomach and 26 with that of the duodenum. The authors present the methods of X-ray examinations and the X-ray symptomatology of giant ulcers of the stomach and duodenum. Gastroscopic and X-ray examinations were comparatively analyzed. The paper gives evidence that the X-ray examination has many advantages in estimating the size and ratio of ulcers to the adjacent organs and tissues. The paper outlines giant duodenal ulcers. The authors identify two groups of patients with giant ulcers of the duodenal bulb, which differ in its size and the extent of deformity. One of valid signs of the penetration of giant ulcers is not only their size, but their depth and fixation to the adjacent organs and tissues.

[Segmental "portal hypertension". A rare cause of severe tractable variceal bleeding]

We present a 33 year-old man with massive upper gastrointestinal bleeding caused by a rare form of segmental portal hypertension. The patient developed a pancreatic abscess, which caused an isolated thrombosis in the splenic vein and the development of pronounced collaterals and bleeding fundus varices. The patient underwent splenectomy and recovered quickly hereafter. The literature is sparse on severe bleeding complications due to acute pancreatitis. The present case emphasizes the importance of recognition of unusual manifestations of common clinical conditions.

Sonographic detection of intragastric blood clot

An intragastric blood clot suggested by sonography and later confirmed at upper gastrointestinal series and at gastroscopy is reported. Sonographic findings were a moveable mass within stomach presenting as an arc-like hyperechoic surface with a strong posterior resonance artifact. Compression of the mass with a transducer induced the mass to move from antrum to corpus within stomach. We think that the demonstration of a blood clot within stomach can be suggested on the basis of typical sonographic findings as a secondary sign of a bleeded gastric or duodenal ulcer.

[X-ray diagnosis features of acute bleeding ulcers of the stomach and duodenum]

The paper is based on the analysis of clinical, X-ray, and morphological studies in 74 patients with massive gastrointestinal hemorrhage who were treated at the hospitals of the N.V. Sklifosofsky Research Institute of Emergency Care, in 1991-1994. Among the examinees, there were 28 with medio-gastric ulcer and 44 with parapyloric ulcers. In 2 patients bleeding occurred with the anastomosis ulcers of the stomach operated on. The paper presents the specific features of X-ray studies of patients with bleeding gastroduodenal ulcers. X-ray studies should be twice performed in these patients. The first study is conducted if gastroscopic findings are unclear, the repeated one is carried out while assessing changes in disease regression. The emergency gastroscopic and subsequent X-ray studies have demonstrated that acute ulcers may be at various sites and multiple. X-ray diagnosis of bleeding ulcers is determined by their sites and the nature of an ulcerous process. The X-ray diagnosis of chronic callous gastric ulcers accompanied by hemorrhage was based on the detection of two direct symptoms of a "niche" on the gastric outlines and configuration and an inflammatory mound on the gastric outline and configuration. That of chronic bleeding ulcers of the duodenal bulb is based not only on searches for the basic symptom of peptic ulcer -"niche", but other signs of the disease-the deformed organ, and the magnitude of a periprocess. Gastroduodenoscopy is applied not only for the primary diagnosis of a hemorrhagic source, but a therapeutical technique. However, the use of endoscopy alone in patients with gastroduodenal hemorrhage did not give a comprehensive idea of the magnitude of ulcerous changes, organ-specific deformity, and a periprocess.

Bleeding esophageal duplication detected in utero

Peptic complications in duplications of the alimentary tract may occur when the duplication is lined by gastric mucosa. These complications commonly develop in the first year of life. We report a case of a bleeding esophageal duplication in a fetus.

[Bleeding peptic ulcers--concept for acute therapy]

Acute ulcer bleeding still is a life-threatening event. The therapeutic goal is to establish intensity, activity and location of the bleeding and to assess primary hemostasis by consequent endoscopic therapy, also preventing recurrence significantly. With the injection method, primary hemostasis accounts for over 90% success. Also recurrent bleeding can be stopped to the same extent. Endoscopic doppler allows a qualitative and quantitative registration of potentially dangerous vessels on the ulcer base. Drug therapy does serve for the acute treatment to a lesser extent; it is more valid for the initiation of the conservative ulcer therapy. Surgical interventions therefore confined to risk patients in whom a primary hemostasis failed or the ulcer is located in a dangerous site, for instance in the back wall of the duodenal bulb.

[Leiomyosarcoma of the stomach]

Leiomyosarcoma of the stomach is a rare occurrence, amounting to only 0.5-3% of all stomach malignancies. Because of its extragastral growth, it produce clinical symptoms, mostly with bleeding, only at a late stage. The decisive method of examination is computed tomography which demonstrates the extraluminal tumor lying apparently in the mesenterium with contrast medium up-take at the borders and central necrosis. A secure differential diagnosis to leiomyoma is not possible by angiography or by computed tomography; this distinction is even difficult by histology.

Does Doppler ultrasound improve the prognosis of acute ulcer bleeding?

The visible vessel in the floor of the ulcer seen on endoscopy is one of the most important prognostic factors of ulcer bleeding. With the ultimate aim of improving the purely visual interpretation of the base of the ulcer, we investigated the utility of an innovative pulsed endoscopic Doppler procedure in 140 patients with acute ulcer bleeding. Agreement between the endoscopic appearance and the Doppler ultrasonographic findings was observed in only 59% of the ulcers. In all Doppler-positive ulcers, injection therapy was performed irrespective of the endoscopic appearance of the ulcer. This was repeated if the ulcer was still Doppler-positive on repeat examination. With this strategy, only 9% recurrent hemorrhages were seen, and there was no hemorrhage-associated mortality. Among the Doppler-negative lesions, which received only medical treatment, no rebleeding was observed. On the basis of these results, it would appear that a Doppler ultrasound oriented classification of ulcer bleeding is superior to the Forrest classification based on a purely visual interpretation. The endoscopic Doppler verifies the visual impression of the ulcer, identifies the indication for operative endoscopy, and can monitor the effectiveness of the latter.

Bleeding peptic ulcer: surgical therapy

The management of bleeding peptic ulcer disease varies with multiple clinical and endoscopic variables. For the patient with rapid hemorrhage and hemodynamic instability refractory to endoscopic control, operation clearly is indicated. For patients with a low probability of recurrent ulcer hemorrhage because of the absence of endoscopic stigmata or clinical predictors of further ulcer bleeding, nonoperative management with selective use of endoscopic hemostasis is appropriate. For the remaining patients with a moderate risk of recurrent ulcer hemorrhage, the clinician must use what is known of the clinical and endoscopic predictors of recurrent hemorrhage and arrive at a judgment regarding the selective use of endoscopic hemostasis and subsequent early operation. For elderly patients with a large duodenal or gastric ulcer who have experienced significant blood loss precipitating an episode of hypovolemic shock and who have endoscopic stigmata of ulcer hemorrhage, early elective operation after endoscopic hemostasis is the most judicious course. Surgery also is the wise choice for those patients in whom an initially successful attempt at endoscopic hemostasis fails and who rebleed while hospitalized. Recommendations for the surgical management of bleeding peptic ulcer disease include Immediate operation for (1) patients with rapidly exsanguinating ulcer hemorrhage and (2) patients with active bleeding and failure of endoscopic hemostasis to control the bleeding. Early elective operation after initial endoscopic hemostasis for (1) elderly patients with comorbid disease and/or hemodynamic instability who have active arterial ulcer hemorrhage (Forrest Ia) controlled with endoscopic hemostasis; (2) elderly patients with comorbid disease and/or hemodynamic instability who have a visible vessel in an ulcer crater (Forrest IIa) treated with endoscopic hemostasis: surgery is particularly advised in this circumstance for those with a positive arterial Doppler signal in the ulcer crater or a large posterior duodenal ulcer or a large lesser-curvature gastric ulcer; and (3) elderly patients with comorbid disease and/or hemodynamic instability who develop recurrent ulcer bleeding while hospitalized or with a total blood transfusion requirement exceeding 5 U.

Endoscopic injection therapy of Forrest II and III gastroduodenal ulcers guided by endoscopic Doppler ultrasound

Endoscopic Doppler ultrasound enables the reliable identification of vessels in the base of gastroduodenal ulcers. In a prospective study including 114 patients with acute ulcer bleeding, pulsed Doppler ultrasound was able to demonstrate superficial blood vessels in the ulcer base in 62% of 106 cases where complete Doppler assessment was possible (93%). Agreement between the endoscopic pattern of visible vessels and the Doppler ultrasound findings was attained in only 52% of the cases. Doppler positive ulcers (n = 66) were treated with injection therapy (if necessary, repeated), irrespective of their Forrest classification. Using such an approach, the rebleeding rate in this group decreased to less than 8% and none of the patients died of causes related to the hemorrhage. All Doppler negative ulcers (n = 40) healed without complications or the need for endoscopic treatment; among these were 11 cases with Forrest IIa and b. We conclude that endoscopic Doppler appears to be a valuable diagnostic procedure in the assessment of bleeding ulcers, thus modifying the Forrest classification. Our concept is that Doppler positive ulcers require local endoscopic treatment, whereas Doppler negative ulcers can be treated conservatively.

[Significance of the ulcer vessel in acute ulcer hemorrhage--value of local endoscopic therapy in combination with endoscopic Doppler ultrasound]

The acute ulcer hemorrhage is one of the most frequent diagnoses in Gastroenterology. In addition to the active hemorrhage the visible ulcer vessel, even if not bleeding at present, is one of the most important prognostic criteria. Numerous controlled studies have shown that with this sign recurrent hemorrhages will occur in up to 81%, resulting in emergency surgery in up to 56% with an associated mortality of up to 21%. By a meta-analysis we could show that prophylactic endoscopic therapy can significantly reduce both the rate of recurrent hemorrhage as well as emergency surgery. If the endoscopic doppler is used as well, as diagnostic as well as follow-up examination, the effectiveness of endoscopic treatment is greatly improved. The numbers we present show that active local endoscopic therapy should be undertaken in a visible ulcer vessel.

[Endoscopic Doppler ultrasound in gastroduodenal ulcer hemorrhage]

AIMS

Investigation of the information value of endoscopic Doppler ultrasonography of the base of the ulcer in comparison with visual endoscopic assessment of bleeding gastroduodenal ulcers using the Forrest classification.

STUDY DESIGN

Open prospective comparative study involving 30 patients with acutely bleeding gastroduodenal ulcers. Where Doppler ultrasonography revealed an artery in the base of the ulcer, injection with epinephrine and polidocanol was administered. Follow-up examinations were performed on day 2 and after 4 weeks.

RESULTS

Endoscopic Doppler ultrasonography reliably identifies the vessels responsible for bleeding from gastroduodenal ulcers, in particular in lesions with stigmata of recent bleeding (Forrest II), but also in ulcers with no such stigmata but a history of bleeding (Forrest III). In addition, Doppler ultrasonography also allows the results of injection therapy to be determined.

CONCLUSION

Endoscopic Doppler ultrasonography makes possible the rapid and efficient identification of invisible vessels in the ulcer floor responsible for bleeding.

Chronic duodenal ulcer in children and response to highly selective vagotomy

The effectiveness of highly selective vagotomy (HSV) in adult duodenal ulcer surgery is confirmed by absence of peroperative mortality or postoperative morbidity and by ulcer healing in the majority of cases. Whether it could be used in children with the same result was the subject of our study in 13 successive cases of complicated duodenal ulcer treated between 1974 and 1987. There was complete ulcer healing in 4 cases. Pain relapsed in 5 cases and there was recurrence of hemorrhage in 2 cases. Although immediate good results lasted for at least 3 years, 2 patients were lost to follow-up. Still, we consider HSV as a safe procedure available for children as it does not "queer the pitch" for a subsequent treatment if it fails.