Obscure digestive bleeding

Obscure digestive bleeding is defined as recurrent bleeding for which no definite source has been identified by routine endoscopic or barium studies. Mucosal vascular abnormality or 'angioectasia' is the most common course of obscure bleeding, especially in elderly patients. Small bowel tumours are more frequent in patients younger than 50 years. However, missed or underestimated upper and lower gastrointestinal lesions at the initial endoscopic investigation may be the source of a so-called obscure intestinal bleeding. The various radiological procedures, including enteroclysis, visceral angiography and CT scan as well as radioisotope bleeding scans have limitations in the case of obscure gastrointestinal bleeding. Recent developments in magnetic resonance imaging are promising. The different methods of enteroscopy have a similar diagnostic yield, reaching approximately 40-65%. Endoscopic cauterization of small bowel angioectasias seems to be efficacious but randomized trials are needed. Efficacy of hormonal therapy is very controversial. The extent of diagnostic and therapeutic strategies must be based on a number of factors including the patient's parameters, bleeding characteristics and also the result of previous work-up.

Enteral feeding with a solution enriched with antioxidant vitamins A, C, and E enhances the resistance to oxidative stress

OBJECTIVE

To assess whether dietary supplementation with the antioxidant vitamins A, C, and E enhances parameters of oxidative stress and influences the course of critically ill patients.

DESIGN

Prospective, randomized, double-blinded, placebo-controlled study.

SETTING

Department of medicosurgical intensive care of an academic hospital.

PATIENTS

Fifty-one patients expected to require at least 7 days of enteral feeding. Thirty-seven of these patients (age, 57 +/- 7 yrs; Simplified Acute Physiology Score II, 33 +/- 6 points) completed the study.

INTERVENTIONS

Twenty patients were randomized to receive the formula supplemented with vitamins A (67 microg/dL), C (13.3 mg/ dL), and E (4.94 mg/dL), and 17 patients received an isocaloric and isonitrogenous control solution.

MEASUREMENTS AND MAIN RESULTS

Plasma levels of antioxidant vitamins, lipid peroxidation (estimated by the malonyldialdehyde assay), and low-density lipoprotein (LDL), and erythrocyte resistance to experimental oxidative stress were determined on samples drawn two consecutive days before the initiation of feeding and at the end of the 7-day period. Clinical outcome measures included documented infection and intensive care unit and 28-day survival. Administration of the supplemented solution increased significantly the concentration of plasma beta-carotene (from 0.2 +/- 0.0 microg/mL to 0.6 +/- 0.1 microg/mL; p < 0.01) and plasma and LDL-bound alpha-tocopherol (from 6.0 +/- 0.4 microg/mL and 2.9 +/- 0.9 microg/mL to 9.7 +/- 0.5 microg/mL and 4.3 +/- 1.2 microg/mL, respectively; p < 0.05), and improved LDL resistance to oxidative stress by 21 +/- 4% (p < 0.05). No such change was observed in the control group. There was no significant difference in clinical outcome between the two groups.

CONCLUSIONS

Supplemental antioxidant vitamins added to enteral feeding solutions are well absorbed. Dietary supplementation with vitamins A, C, and E is associated with an improvement in antioxidant defenses, as assessed by ex vivo tests.

Localized amyloid tumor in small bowel

We report a case of localized jejunal amyloidosis occurring in a 74-year-old man who experienced an episode of digestive bleeding while he was receiving oral anticoagulation. It illustrates a rare entity, characterized by an endoscopic aspect of polypoid, pseudotumoral formations. Histologically, submucosal connective tissues, muscularis mucosae, and blood vessel walls are massively infiltrated by amyloid, giving a typical red/green birefringence under polarized light.

Diversion of intestinal flow decreases the numbers of interleukin 4 secreting and interferon gamma secreting T lymphocytes in small bowel mucosa

BACKGROUND/AIMS

The intestinal immune system faces large amounts of antigens, and its regulation is tightly balanced by cytokines. In this study, the effect of intestinal flow diversion on spontaneous secretion of interleukin (IL)-4 and interferon (IFN)- gamma was analysed.

METHODS

Eight patients (two with Crohn's disease, four with ulcerative colitis, and two with previous colon cancer) carrying a double lumen small bowel stoma after a total colectomy procedure were included in the study. For each patient, eight biopsy samples were taken endoscopically from both the diverted and non-diverted part of the small bowel. Intraepithelial lymphocytes (IELs) and lamina propria lymphocytes (LPLs) were isolated separately and assayed for numbers of cells spontaneously secreting IL-4 and/or IFN-gamma by an ELISPOT technique.

RESULTS

Compared with the non-diverted mucosa, a significant decrease in the number of spontaneously IFN-gamma secreting CD3 lymphocytes was observed in the diverted small bowel mucosa among both IELs (p = 0.008) and LPLs (p = 0.007). The same results, although less significant, were obtained for IL-4, especially in LPLs (p = 0.01).

CONCLUSION

The intestinal content influences the spontaneous secretion of IFN-gamma and IL-4 by intestinal lymphocytes. These results could help to elucidate the anti-inflammatory role of split ileostomy in patients suffering from inflammatory bowel diseases.

"Missed" upper gastrointestinal tract lesions may explain "occult" bleeding

BACKGROUND AND STUDY AIMS

Enteroscopy has been shown to be an effective diagnostic method in patients with obscure gastrointestinal bleeding. Arteriovenous malformations (AVMs) of the small bowel are the most common lesions discovered at enteroscopy. However, bleeding lesions may still be detected in the upper gastrointestinal tract even in patients who have previously undergone esophagogastroduodenoscopy. The aim of this study was to focus on these "missed" upper gastrointestinal lesions.

PATIENTS AND METHODS

A retrospective review was conducted of all enteroscopic examinations carried out in patients with suspected gastrointestinal bleeding or overt gastrointestinal bleeding treated at our institution between 1993 and 1997. All patients had previously undergone an esophagogastroduodenoscopy. The push enteroscope (Olympus XSIF-100) was used in all of them.

RESULTS

Push enteroscopy was performed in 233 patients (124 men and 109 women; mean age 63). A suspected bleeding lesion was observed in 53 % of the cases. AVMs represented 63% of the detected lesions. "Missed" upper gastrointestinal lesions were described in 25 patients (10.2 %). In half of these cases, the lesion was located in the upper part of the fundus. Wirsungorrhagia was the cause of bleeding in two cases.

CONCLUSIONS

The study confirmed that push enteroscopy is an effective method of detecting lesions responsible for occult gastrointestinal bleeding. In this study, the overall diagnostic yield was 53%. In 10% of the patients, the lesion was located in the upper gastrointestinal tract, despite an initial esophagogastroduodenoscopy. The lesions were mainly located in the fundus. Although it is a rare condition, Wirsungorrhagia must be considered in patients with occult gastrointestinal bleeding.

Home parenteral nutrition in adults: the current use of an experienced method

Home parenteral nutrition (HPN) is now commonly used in industrialized countries. In Europe, the mean incidence of newly enrolled cases is about 3 patients per 10(6) inhabitants, per year. The use of HPN is much larger in North America. Cancer has become the largest single indication of HPN over the world. The complications are either related to the central catheter (sepsis, thrombosis, migration) or metabolic (liver abnormalities, bone disorder, deficiencies). Complications rate may be lowered by an adequate nutritional regimen, a good teaching of the patients and the presence of a nutritional team in specialized centres. The survival probability for patients with benign diseases is about 65% at 5 years. The mortality rate related to HPN itself is less than 10%. For patients with benign diseases, weaning of HPN is observed in 40 to 70% of the cases. Sixty percent of the patients have a very good quality of life. HPN must be used selectively in cancer patients.

Management of nutrition in European intensive care units: results of a questionnaire. Working Group on Metabolism and Nutrition of the European Society of Intensive Care Medicine

OBJECTIVE

To describe the practical aspects of nutritional management in intensive care units (ICUs).

DESIGN

A 49-item questionnaire was sent to the physician members of the European Society for Intensive Care Medicine. The issues addressed included: medical environment, assessment of nutritional status and current practice for enteral and parenteral nutrition.

SETTING

1608 questionnaires were sent in 35 European countries.

ANALYSIS

The answers were pooled and stratified by country.

RESULTS

271 questionnaires were answered (response rate 17%). Assessment of nutritional status was generally based on clinical (99%) and biochemical (82%) parameters rather than on functional (24%), anthropometric (23%), immunological (18%) or questionnaire-based (11%) data. Two thirds of 2774 patients hospitalised in the corresponding ICUs at the time the questionnaire was answered were receiving nutritional support; 58% of those were fed by the enteral route, 23% by the parenteral route and 19% by combined enteral and parenteral. The preferred modality was enteral nutrition, instituted before the 48th h after admission, at a rate based on estimated caloric requirements. Specific and modified solutions were rarely used. Parenteral nutrition was less commonly used than enteral, although the practices differed between countries. It was mainly administered as hospital-made all-in-one solutions, at a rate based on calculated caloric requirements.

CONCLUSIONS

European intensivists are concerned by the nutritional management of their patients. The use of nutritional support is common, essentially as early enteral feeding.

Trace element deficiency and toxicity

Trace elements are involved in enzymatic activities, immunological reactions, physiological mechanisms and carcinogenesis. Deficiency in some trace elements, such as iron and iodine, is still an important health problem, especially in developing countries. Some groups of individuals are more likely to develop trace element deficiency. The role of trace elements deficiency is suspected in various clinical situations and is now confirmed by well designed supplementation studies. Although toxicity of trace elements with clinical manifestations is rare, it has been observed that manganese toxicity may occur in patients receiving parenteral nutrition. Recent data about trace elements deficiency and toxicity are indicated in this review.

Role of the double-contrast barium enema in rectal stenosis due to suppositories containing paracetamol and acetylsalicylic acid

Self-treatment of chronic headache with suppositories containing paracetamol and acetylsalicylic acid may lead to serious complications. We report the radiological features of five cases of rectal stenosis following the use of such suppositories. The role of the double-contrast barium enema in suggesting the diagnosis of this complication of a chronic and often unrecognized self-treatment is emphasized.

The wirsungorrhagies: causes and management in 14 patients

BACKGROUND AND STUDY AIMS

Wirsungorrhagy is an extremely rare cause of upper gastrointestinal bleeding. The present study describes 14 cases observed over a seven-year period.

MATERIAL AND METHODS

Among 10,000 endoscopic retrograde cholangiopancreatographies performed between 1989 and 1996 we have identified 14 wirsungorrhagies, which were reviewed retrospectively. They occurred in patients with chronic and acute pancreatitis, and primary and metastatic pancreatic cancer.

RESULTS

Clinical signs of bleeding were present in six patients; three other patients had occult blood loss, and in five patients wirsungorrhagy was caused by endoscopic manipulation (n=3) or extracorporeal shock-wave lithotripsy (n=2) without clinical or hemodynamic effects. In six patients, wirsungorrhagy was managed by endoscopic methods. Five patients in unstable clinical conditions had an arteriography which allowed identification and treatment of the source of bleeding in three cases. Two patients with bleeding from a communicating cyst in chronic pancreatitis underwent surgery.

CONCLUSIONS

Wirsungorrhagy can be responsible for massive bleeding in certain patients, especially those with chronic pancreatitis and pseudoaneurysm. In these cases, arteriography is most useful for identification and treatment of the bleeding. When it occurs during endoscopic manipulations, it can usually be managed endoscopically and/or stops spontaneously with appropriate main pancreatic duct drainage. When it occurs in patients with pancreatic tumors, optimal treatment is surgical resection; this is, unfortunately, usually not feasible.

Spontaneous secretion of interferon gamma and interleukin 4 by human intraepithelial and lamina propria gut lymphocytes

BACKGROUND

Cytokines secreted by intestinal T lymphocytes probably play a critical role in regulation of the gut associated immune responses.

AIMS

To quantify interferon gamma (IFN-gamma) and interleukin 4 (IL-4) secreting cells (SC) among human intraepithelial (IEL) and lamina propria (LPL) lymphocytes from the duodenum and right colon in non-pathological situations and in the absence of in vitro stimulation.

PATIENTS

Duodenal and right colonic biopsy specimens were obtained from patients with no inflammation of the intestinal mucosa.

METHODS

Intraepithelial and lamina propria cell suspensions were assayed for numbers of cells spontaneously secreting IFN-gamma and IL-4 by a two site reverse enzyme linked immunospot technique (ELISPOT).

RESULTS

The relatively high proportion of duodenal lymphocytes spontaneously secreting IFN-gamma (IEL 3.6%; LPL 1.9%) and IL-4 (IEL 1.3%; LPL 0.7%) contrasted with the very low numbers of spontaneously IFN-gamma SC and the absence of spontaneously IL-4 SC among peripheral blood mononuclear cells. In the basal state, both IFN-gamma and IL-4 were mainly produced by CD4+ cells. Within the colon, only 0.2% of IEL and LPL secreted IFN-gamma in the basal state, and 0.1% secreted IL-4.

CONCLUSIONS

Compared with peripheral lymphocytes substantial proportions of intestinal epithelial and lamina propria lymphocytes spontaneously secrete IFN-gamma and/or IL-4. These cytokines are probably involved in the normal homoeostasis of the human intestinal mucosa. Disturbances in their secretion could play a role in the pathogenesis of gastrointestinal diseases.

Oral budesonide for lymphocytic colitis

Lymphocytic colitis is a rare inflammatory colonic disease of unknown etiology accompanied by watery diarrhea. Diagnosis is based upon pathological examination of colonic biopsies. Treatment essentially involves antiinflammatory agents such as sulfasalazine/5-ASA or corticosteroids if necessary. We report the case of a female patient suffering from severe lymphocytic colitis who remained unresponsive after 5-ASA therapy but who improved dramatically after oral budesonide administration.

The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity

In industrialized countries, surgical gastroplasty is performed more and more frequently in patients with morbid obesity. The aims of this prospective study were to determine the incidence of upper gastrointestinal lesions in obese patients and to assess the place of digestive endoscopy in symptomatic patients after gastroplasty. A consecutive group of 159 obese patients were studied before and after vertical banded gastroplasty. In the preoperative evaluation, reflux esophagitis and gastroduodenal lesions were endoscopically observed in 31% and 37% of the patients, respectively. Interestingly, the majority of the obese patients with upper gastrointestinal lesions were asymptomatic. In the postoperative follow-up period, 55 of the 159 patients complained of upper gastrointestinal symptoms such as vomiting (72%), esophageal reflux (17%), and epigastric pain (3%). Stenosis of the outlet of the gastric pouch was described in 40 of the 55 symptomatic patients. Esophagitis was observed in 60% of these patients. Endoscopic dilation using Savary bougies or TTS balloon was successfully performed in all the patients with symptomatic stenosis of the gastric outlet. Food impaction was endoscopically removed in four patients. Thus, we recommend performing an upper gastrointestinal endoscopy in obese patients who are candidates for surgical gastroplasty because of the high incidence of upper gastrointestinal peptic lesions. Endoscopy is also helpful in patients with digestive disorders occurring after gastroplasty in order to define and to treat the lesions.

Short- and long-term efficacy of cyclosporin administration in patients with acute severe ulcerative colitis. Belgian IBD Group

Cyclosporin (CsA) has been proposed in the management of patients with acute ulcerative colitis (UC) in whom standard therapy failed and who were candidates for colectomy. Seven academic hospitals contributed to this retrospective study that included 29 patients (median age: 33 y. (15-74 y.); 12 females and 17 males). The median duration of the disease was 4 y. (0.3 to 33 y.). Before initiating CsA, patients were unresponsive to treatment including i.v. corticosteroids (n = 29), 5-ASA or salazopyrine (n = 19), azathioprine (n = 3), antibiotics (n = 14). The i.v. mean dose was 4 mg/kg/day and was adapted to blood level. Concomitant treatment included corticosteroids (n = 27). The median duration of i.v. CsA administration was 10 days (4 to 41 days). At the end of CsA administration, a global improvement was described in 20 patients while a surgery had to be performed immediately in 8 patients because of exacerbation of symptoms (n = 7) or perforation (n = 1). One other patient (74 y.) died because of Pneumocystis carinii infection. For the responders, maintenance therapy included: tapering dose of steroids (n = 12), azathioprine (n = 12), 5-ASA or salazopyrine (n = 10), methotrexate (n = 1) or oral CsA (n = II). The median duration of follow-up was 12 months (4 to 48 months). Among the 20 responders, 7 were subsequently referred for colectomy either electively (n = 3) or because of recurrence of the disease (n = 4). Among the 12 patients treated by azathioprine as a maintenance therapy, only 3 had to be referred for surgery (25%). Among the 8 patients who did not receive azathioprine, 4 were subsequently referred for a colectomy (50%) (NS). In patients with acute refractory UC who received CsA, the short-term efficacy (avoidance of immediate colectomy) was obtained in 20 out of 29 patients (69%). However, after a median follow-up of 12 months, only 13 patients were colectomy free (45%).

Detection of fastidious mycobacteria in human intestines by the polymerase chain reaction

The aim of this study was to determine whether difficult-to-grow mycobacteria are present in human intestines. Intestinal tissue samples were subjected to both mycobacterial culture and a polymerase chain reaction (PCR) assay. After detection by PCR, species identity was determined by hybridizing the amplified 16S rRNA gene fragments with species-specific oligonucleotides. Intestinal biopsies from 63 patients with noninflammatory bowel diseases (n = 22), Crohn's disease (n = 31), or ulcerative colitis (n = 10) were analyzed. Culture and PCR revealed mycobacteria in four (6%) and 25 (40%) samples, respectively. Samples positive by PCR were negative with all probes specific to nine common cultivable species but were positive with Mycobacterium genavense-specific probe in 68% of cases. Mycobacterial isolates were identified as Mycobacterium gordonae and Mycobacterium chelonae. Findings were similar in Crohn's disease samples compared to non-Chron's disease samples. This study shows that difficult-to-grow mycobacteria can be detected by PCR in large and similar proportions of inflamed intestinal tissue from patients with inflammatory bowel disease and intestinal tissue that appears normal from patients with noninflammatory bowel disease.