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Saab MA, Jacobson E, Hanson K, Kruciak B, Miramontes D, Harper S. Prehospital Whole Blood Administration for Pediatric Gastrointestinal Hemorrhage: A Case Report. PREHOSP EMERG CARE 2024:1-4. [PMID: 38940756 DOI: 10.1080/10903127.2024.2372808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
The management of gastrointestinal (GI) hemorrhage in a prehospital setting presents significant challenges, particularly in arresting the hemorrhage and initiating resuscitation. This case report introduces a novel instance of prehospital whole blood transfusion to an 8-year-old male with severe lower GI hemorrhage, marking a shift in prehospital pediatric care. The patient, with no previous significant medical history, presented with acute rectal bleeding, severe hypotension (systolic/diastolic blood pressure [BP] 50/30 mmHg), and tachycardia (148 bpm). Early intervention by Emergency Medical Services (EMS), including the administration of 500 mL (16 mL/kg) of whole blood, led to marked improvement in vital signs (BP 97/64 mmHg and heart rate 93 bpm), physiology, and physical appearance, underscoring the potential effectiveness of prehospital whole blood transfusion in pediatric GI hemorrhage. Upon hospital admission, a Meckel's diverticulum was identified as the bleeding source, and it was successfully surgically resected. The patient's recovery was ultimately favorable, highlighting the importance of rapid, prehospital intervention and the potential role of whole blood transfusion in managing acute pediatric GI hemorrhage. This case supports the notion of advancing EMS protocols to include interventions historically reserved for the hospital setting that may significantly impact patient outcomes from the field.
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Affiliation(s)
- Mathew A Saab
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Eric Jacobson
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Kip Hanson
- San Antonio Fire Department, San Antonio, Texas
| | | | - David Miramontes
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Stephen Harper
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
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Piccirillo M, Pucinischi V, Mennini M, Strisciuglio C, Iannicelli E, Giallorenzi MA, Furio S, Ferretti A, Parisi P, Di Nardo G. Gastrointestinal bleeding in children: diagnostic approach. Ital J Pediatr 2024; 50:13. [PMID: 38263189 PMCID: PMC10807079 DOI: 10.1186/s13052-024-01592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/07/2024] [Indexed: 01/25/2024] Open
Abstract
Different conditions may underlie gastrointestinal bleeding (GIB) in children. The estimated prevalence of GIB in children is 6.4%, with spontaneous resolution in approximately 80% of cases. Nonetheless, the initial approach plays a pivotal role in determining the prognosis. The priority is the stabilization of hemodynamic status, followed by a systematic diagnostic approach. GIB can originate from either upper or lower gastrointestinal tract, leading to a broad differential diagnosis in infants and children. This includes benign and self-limiting disorders, alongside serious conditions necessitating immediate treatment. We performed a nonsystematic review of the literature, in order to describe the variety of conditions responsible for GIB in pediatric patients and to outline diagnostic pathways according to patients' age, suspected site of bleeding and type of bleeding which can help pediatricians in clinical practice. Diagnostic modalities may include esophagogastroduodenoscopy and colonoscopy, abdominal ultrasonography or computed tomography and, when necessary, magnetic resonance imaging. In this review, we critically assess these procedures, emphasizing their respective advantages and limitations concerning specific clinical scenarios.
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Affiliation(s)
- Marisa Piccirillo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Valentina Pucinischi
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Maurizio Mennini
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Elsa Iannicelli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, Radiology Unit, Rome, Italy
| | - Maria Agostina Giallorenzi
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, Radiology Unit, Rome, Italy
| | - Silvia Furio
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Alessandro Ferretti
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Pasquale Parisi
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy.
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Quitadamo P, Anselmi F, Mantegazza C, Tambucci R, Campanozzi A, Malamisura M, Raucci U, Tipo V, Dolce P, Saccomani MD, Chiaro A, Mancini V, Felici E, Orizio P, Parma B, Salvatore S, Borrelli O. Hematemesis in Infants: The First Evidence-Based Score to Predict the Need for Timely Endoscopy. Pediatr Emerg Care 2022; 38:e1245-e1250. [PMID: 35482500 DOI: 10.1097/pec.0000000000002579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Infantile acute upper gastrointestinal bleeding involves a decision for therapeutic intervention that most pediatricians first coming into contact with the patient are, not unreasonably, unable to objectively provide. Therefore, some objective tools of individual risk assessment would seem to be crucial. The principal aim of the present study was to investigate the anamnestic and clinical parameters of infants with hematemesis, together with laboratory and instrumental findings, to create a scoring system that may help identify those infants requiring an appropriate and timely application of upper gastrointestinal (GI) endoscopy. METHODS Clinical data of infants admitted for hematemesis to the participating centers over the study period were systematically collected. According to the outcome dealing with rebleeding, need for blood transfusion, mortality, finding of GI bleeding lesions, or need for surgical intervention, patients were blindly divided into a group with major clinical severity and a group with minor clinical severity. Univariate and multivariate logistic regressions were conducted to investigate significant prognostic factors for clinical severity. RESULTS According to our findings, we drafted a practical diagnostic algorithm and a clinical score able to predict the need for timely upper GI endoscopy (BLOVO infant score). Our clinical scoring system was created by incorporating anamnestic factors, clinical parameters, and laboratory findings that emerged as predictors of a worst outcome. CONCLUSIONS We provided the first objective tool of individual risk assessment for infants with hematemesis, which could be very useful for pediatricians first coming into contact with the patient in the emergency department.
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Affiliation(s)
- Paolo Quitadamo
- From the Department of Pediatrics, Santobono-Pausilipon Children's Hospital
| | - Federica Anselmi
- Department of Translational Medical Science, Section of Pediatrics, "Federico II" University of Naples, Naples
| | - Cecilia Mantegazza
- Department of Pediatrics, University of Milan, Buzzi Children's Hospital, Milan
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Angelo Campanozzi
- Department of Medical and Surgical Sciences, University Hospital of Foggia, Foggia
| | - Monica Malamisura
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Vincenzo Tipo
- Emergency Pediatric Department, Santobono-Pausilipon Children's Hospital, Naples
| | - Pasquale Dolce
- Department of Public Health, University of Naples Federico II, Naples
| | | | - Andrea Chiaro
- Paediatric Gastroenterology and Digestive Endoscopy Unit, Giannina Gaslini Institute, Genoa
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, San Carlo Borromeo Hospital, Milan
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, "Umberto Bosio" Center for Digestive Diseases, The Children Hospital, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria
| | - Paolo Orizio
- Department of Pediatric Surgery, Spedali Civili Children's Hospital, Brescia
| | - Barbara Parma
- Paediatric Department, ASST-Lariana, Sant'Anna General Hospital, Como
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte," University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
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Choi YJ, Cho YH, Kim SH, Kim HY. Clinical implication of spontaneous gastrointestinal perforation in pediatric patients: its difference according to age group. Ann Surg Treat Res 2018; 95:141-146. [PMID: 30182020 PMCID: PMC6121166 DOI: 10.4174/astr.2018.95.3.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose Spontaneous gastrointestinal perforations (SGIPs; not associated with injury or disease) occur rarely in pediatric patients. This study aimed to define age-specific features associated with SGIPs in pediatric patients. Methods Retrospectively reviewed the clinical data of children (before adolescence) who received surgery due to a SGIP at a single institution. Thirty-nine patients were enrolled. Characteristics were compared between the 2 age groups: neonates (group A) and beyond neonates (group B). Results Group A included 24 patients (61.5%) an group B included 15 patients (38.5%). Thirteen perforations occurred in the stomach (33.3%), 12 in the small intestine (30.8%), and 14 in the large intestine (35.9%). A significantly higher proportion of perforations occurred in the stomach and small intestine in group A, while more perforations occurred in the large intestine in group B (P = 0.01). Several associated conditions during the preoperative period were identified in both groups. The overall mortality rate was 15.4% (6 of 39). Mortality was relatively high in group A (5 of 24, 20.8%) and for perforations of stomach (3 of 13, 23.1%) and small intestine (3 of 12, 25.0%); however, there were no significant differences with regard to age or perforation site (P = 0.244, P = 0.122, respectively). Conclusion SGIPs in pediatric patients had diverse clinical features and different perforation patterns according to age group. However, no significant group differences in mortality were found. Thus, favorable results regardless of age can be expected with prompt recognition, medical resuscitation, and adequate surgical management.
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Affiliation(s)
- Young-Jin Choi
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong-Hoon Cho
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo-Hong Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hae-Young Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
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Gultekingil A, Teksam O, Gulsen HH, Ates BB, Saltık-Temizel İN, Demir H. Risk factors associated with clinically significant gastrointestinal bleeding in pediatric ED. Am J Emerg Med 2018; 36:665-668. [PMID: 29305021 DOI: 10.1016/j.ajem.2017.12.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Gastrointestinal bleeding is a common problem in pediatric emergency department (PED). Some of these patients can lose significant amount of blood which may lead to shock. The aim of this study is to determine the risk factors predicting clinically significant gastrointestinal (GIS) bleeding in patients presenting to PED. METHODS This study was performed prospectively from January 1st 2013 to December 31th 2013 in patients with upper or lower GIS bleeding. Clinically significant GIS bleeding was defined as >2g/dL hemoglobin decrease at any time during observation in PED, need for erythrocyte transfusion or need for rapid endoscopic evaluation. RESULTS 105 patients were enrolled, 81 of which were eligible for the study. Twenty two patients (26,8%) had clinically significant GIS bleeding. These patients have significantly more commonly have upper GI bleeding and symptoms of melena, pallor and tachycardia. Initial laboratory findings revealed lower hemoglobin, RBC and albumin levels with higher WBC and BUN levels. They need significantly more nasogastric tube placement and PPI and H2 blocker treatment. Final diagnosis included more gastritis and peptic ulcers. These patients have less hematochezia, less lower gastrointestinal bleeding and less commonly diagnosed as acute gastroenteritis or Mallory Weiss tear as a final diagnosis. CONCLUSIONS Pediatric emergency physicians should be aware of clinical and laboratory parameters of patients with clinically significant GIS bleeding to predict which patients are under risk of life threatening blood loss. Patients who have melena, pallor, tachycardia, anemia and uremia at presentation are more prone to have significant GIS bleeding.
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Affiliation(s)
- Ayse Gultekingil
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, Ankara, Turkey.
| | - Ozlem Teksam
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, Ankara, Turkey
| | - Hayriye Hızarcıoğlu Gulsen
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Ankara, Turkey
| | - Burcu Berberoğlu Ates
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Ankara, Turkey
| | - İnci Nur Saltık-Temizel
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Ankara, Turkey
| | - Hülya Demir
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Ankara, Turkey
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Zviedre A, Engelis A, Tretjakovs P, Jurka A, Zile I, Petersons A. Role of serum cytokines in acute appendicitis and acute mesenteric lymphadenitis among children. MEDICINA-LITHUANIA 2016; 52:291-297. [PMID: 27793542 DOI: 10.1016/j.medici.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 10/10/2016] [Accepted: 10/10/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE The diagnostic role of serum cytokines depends on the etiology and pathogenesis of acute appendicitis (AA) and acute mesenteric lymphadenitis (AML). The aim of this study was to evaluate differences in cytokine levels between AA and AML. MATERIALS AND METHODS Data of 7- to 18-year-old children were collected prospectively from October 2010 to October 2013. There were 31 patients with AA (AA group), 26 with AML (AML group), and 17 with elective non-inflammatory surgical disease (control group). Serum levels of IL-10, IL-12(p70), IL-1β, IL-4, IL-6, IL-8, IL-17, MCP-1, EGF, TNF-α and white blood count (WBC) were measured three times consecutively in each group. RESULTS The level of IL-6 and IL-10 was significantly higher in the AA group than the AML group at the first measurement (8pg/mL vs. 3.2pg/mL, P=0.000; 6.1pg/mL vs. 3.2pg/mL, P=0.005, respectively). There was a significant difference observed in time dynamics of concentration of IL-6 and MCP-1 for AA and AML. The area under the curve (AUC) was 0.77 (95% CI 0.64-0.89; P=0.001) for IL-6 with a cut-off value of 4.3pg/mL (67.7% sensitivity and 76.9% specificity) for AA 1h before surgery. The AUC for WBC was 0.72 (95% CI 0.58.4-0.85; P=0.005) with a cut-off value of 10.7×103/μL (sensitivity 71.0% and specificity 46.2%). CONCLUSIONS Serum IL-6 with a cut-off value of 4.3pg/mL and WBC with a cut-off value of 10.7×103/μL assessed together will yield more sensitivity for AA.
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Affiliation(s)
- Astra Zviedre
- Department of Pediatric Surgery, University Children's Hospital, Riga, Latvia.
| | - Arnis Engelis
- Department of Pediatric Surgery, University Children's Hospital, Riga, Latvia; Department of Pediatric Surgery, Riga Stradiņš University, Riga, Latvia
| | - Peteris Tretjakovs
- Department of Physiology and Biochemistry, Riga Stradiņš University, Riga, Latvia
| | - Antra Jurka
- Department of Physiology and Biochemistry, Riga Stradiņš University, Riga, Latvia
| | - Irisa Zile
- Department of Research, Statistics and Health Promotion, Centre for Disease Prevention and Control of Latvia, Riga, Latvia; Department of Public Health and Epidemiology, Riga Stradiņš University, Riga, Latvia
| | - Aigars Petersons
- Department of Pediatric Surgery, University Children's Hospital, Riga, Latvia; Department of Pediatric Surgery, Riga Stradiņš University, Riga, Latvia
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Adamou H, Magagi IA, Habou O, Magagi A, Maazou H, Adamou M, Harouna Y. [Etiology and prognosis of acute mechanical intestinal obstructions at the National Hospital of Zinder: Cross-sectional study of 171 patients]. Pan Afr Med J 2016; 24:248. [PMID: 27800103 PMCID: PMC5075469 DOI: 10.11604/pamj.2016.24.248.8372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 06/19/2016] [Indexed: 11/11/2022] Open
Abstract
Acute mechanical intestinal obstruction (AIO) is one of the most frequent pathologies in emergency digestive surgery. The objective of this study was to describe the etiologic and prognostic features of acute mechanical intestinal obstruction at the National Hospital of Zinder (HNZ), Niger. We conducted a cross-sectional study including all the patients operated for AIO over a period of 24 months (January 2013 - December 2014) Mechanical intestinal obstructions represent 24.50% (n=171) of digestive surgical emergencies (n=622). The median age was 25 years (range: 1 day-95 years). The sex ratio was 3.5 in favour of men. Children accounted for 38.60% (n=66). The seat of the obstacle was at the level of the small bowel in 60.82% (n=104), colonic in 21.63% (n=37) and mixed in 17.54% (n=30). The mechanism of strangulation accounted for 88,89% (n=152), among these strangulated hernias were detected in 49,70% (n=85) of patients and acute intestinal invaginations in 19,88% (n=34) of patients. Anorectal malformations and tumors were the main cause of obstruction in 7.02% (n=12) and 3.51% (n=6) of cases respectively. Intestinal resection was performed in 52 cases (30.41%). Septic complications prevailed (n=39/53); among these parietal suppuration (n=23). The average length of stay in hospital was 7.82 days. The overall mortality rate was 11.70% (n=20). This was statistically correlated to intestinal necrosis (p=0.01) and to delayed hospital admission (p=0.04). There are many causes of AIO which are dominated by strangulated hernia. The high morbidity and mortality rate from AIO might be prevented by early treatment performed before intestinal necrosis occurs.
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Affiliation(s)
- Harissou Adamou
- Service de Chirurgie Générale et Digestive B, Hôpital National de Zinder, Niger
| | | | - Oumarou Habou
- Service de Chirurgie Pédiatrique, Assistant à la Faculté des Sciences de la Santé de Zinder, Niger
| | - Amadou Magagi
- Service d'Anesthésie-Réanimation, Hôpital National de Zinder, Niger
| | | | - Mansour Adamou
- Service de Chirurgie Générale et Digestive B, Hôpital National de Zinder, Niger
| | - Yacouba Harouna
- Service de Chirurgie Viscérale C, Hôpital National de Niamey, Niger
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Withdrawn: Risk factors associated with clinically significant gastrointestinal bleeding in pediatric emergency department. Am J Emerg Med 2015. [DOI: 10.1016/j.ajem.2015.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gattai R, Pantalone D, Migliaccio ML, Bonizzoli M, Peris A, Bechi P. Upper G.I. hemorrhage from glass fragments' ingestion in a patient with jejunal diverticula - Case report. Int J Surg Case Rep 2014; 6C:191-3. [PMID: 25543882 PMCID: PMC4334954 DOI: 10.1016/j.ijscr.2014.11.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/21/2014] [Accepted: 11/21/2014] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Acute upper gastrointestinal bleeding is a common emergency. The ingestion of foreign bodies represents a less frequent cause of bleeding, but it is equally life-threatening, especially if the patient does not report the incident. PRESENTATION OF CASE We are reporting the case of a 77-year-old patient with a bleeding caused by ingestion of glass fragments with co-existing jejunal diverticula. DISCUSSION The ingestion of foreign bodies is a rare, mostly accidental event. Another possible source of upper G.I. bleeding is jejunal diverticula; in this case, the examination of the specimens showed evidence of glass ingestion fragments as the likely cause of bleeding. CONCLUSION Surgeons should be aware that patients may fail to report correctly on the possible causes of bleeding, misleading the diagnosis, and delaying the diagnostic routes.
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Affiliation(s)
- Riccardo Gattai
- Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134 Florence Italy.
| | - Desire' Pantalone
- Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134 Florence Italy.
| | - Maria Luisa Migliaccio
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Manuela Bonizzoli
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Adriano Peris
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Paolo Bechi
- Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134 Florence Italy.
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