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Hayashi R, Sawada G, Ichikawa Y, Takata A, Murakami M, Fukunaga H, Kimura H, Morita S. A case of intestinal intussusception with unique hemorrhagic polyps due to AL amyloidosis and excessive anticoagulation. Clin J Gastroenterol 2024; 17:258-262. [PMID: 38270839 DOI: 10.1007/s12328-023-01915-6] [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: 05/20/2023] [Accepted: 12/19/2023] [Indexed: 01/26/2024]
Abstract
Most adult intussusceptions are secondary to various pathological conditions that serve as a lead point. Because of their serious nature, intussusceptions often require emergency surgery. We report a surgical case of amyloidosis associated with intussusception, probably due to polypoid protrusions and bleeding tendencies. An 80-year-old man with abdominal pain was suspected of having jejunal intussusception on computed tomography. He had been prescribed warfarin for atrial fibrillation, and excessive anticoagulation was observed with a prolonged prothrombin time/international normalized ratio of 5.44 at presentation. After the excessive anticoagulation was resolved, emergency surgery was performed. The intussuscepted jejunum was resected, and a 7 cm long dark-red pedunculated polyp was identified as the lead point, which was accompanied by multiple small pedunculated polyps. Histopathological examination showed that these were all hemorrhagic polyps. Amyloid depositions were observed in the muscularis mucosae, submucosa, and the walls of the blood vessels. Immunohistochemical analysis revealed immunoglobulin light chain amyloidosis. This case is informative to discuss the clinical sequelae of gastrointestinal amyloid deposition.
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Affiliation(s)
- Rie Hayashi
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan.
| | - Genta Sawada
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
| | - Yoshitoshi Ichikawa
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
| | - Akihiro Takata
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
| | - Masahiro Murakami
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
| | - Hiroki Fukunaga
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
| | - Hayato Kimura
- Department of Diagnostic Pathology, Itami City Hospital, Itami, Hyogo, Japan
| | - Shunji Morita
- Department of Surgery, Itami City Hospital, 100 Koyaike, Itami, Hyogo, 664-8540, Japan
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2
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Teng WJ, Kung CH, Cheng MM, Tsai JR, Chang CY. Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B. J Clin Med 2023; 12:jcm12093093. [PMID: 37176534 PMCID: PMC10179287 DOI: 10.3390/jcm12093093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.
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Affiliation(s)
- Wei-Jung Teng
- School of Medicine, College of Medicine, Taipei Medical University, Taipei City 110, Taiwan
| | - Ching-Huei Kung
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei City 110, Taiwan
| | - Mei-Mei Cheng
- Division of Pediatric Gastroenterology, Department of Pediatrics, Cheng Hsin General Hospital, Taipei City 112, Taiwan
| | - Jia-Ruey Tsai
- Department of Hematology and Oncology, Taipei Medical University Hospital, Taipei City 110301, Taiwan
- Hemophilia Center, Taipei Medical University Hospital, Taipei City 110301, Taiwan
| | - Chia-Yau Chang
- Hemophilia Center, Taipei Medical University Hospital, Taipei City 110301, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 110, Taiwan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Taipei Medical University Hospital, Taipei City 110301, Taiwan
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3
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Lee SA, Youn JK, Chang YR. Multiple intussusceptions after blunt abdominal trauma in a 9-year-old boy: A case report and literature review. Trauma Case Rep 2022; 38:100630. [PMID: 35274034 PMCID: PMC8902625 DOI: 10.1016/j.tcr.2022.100630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 10/26/2022] Open
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4
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Kwon SR, Ha SO, Oh YT, Sohn YD. Air reduction of intussusception after abdominal blunt trauma and a literature review. Clin Exp Emerg Med 2016; 3:59-62. [PMID: 27752618 PMCID: PMC5051623 DOI: 10.15441/ceem.15.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 10/26/2015] [Accepted: 11/01/2015] [Indexed: 11/23/2022] Open
Abstract
The typical presentation of intussusception includes intermittent severe abdominal pain, vomiting, rectal bleeding, and the presence of an abdominal mass. We present a case of intussusception after abdominal blunt trauma along with a literature review. A 4-year-old girl was admitted to the emergency department after a bicycle accident. She complained of progressively worsening abdominal pain, but there was no vomiting, fever, bloody stool, or abdominal mass. She was finally diagnosed with traumatic intussusception by ultrasonography and treated with air reduction. Because the typical symptoms are unusual in traumatic intussusception, close attention must be paid to avoid a delayed diagnosis.
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Affiliation(s)
- So Ra Kwon
- Department of Emergency Medicine, Hallym University Medical Center, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Medical Center, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young Taeck Oh
- Department of Emergency Medicine, Hallym University Medical Center, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - You Dong Sohn
- Department of Emergency Medicine, Hallym University Medical Center, Hallym University Sacred Heart Hospital, Anyang, Korea
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5
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Lu SJ, Goh PS. Traumatic intussusception with intramural haematoma. Pediatr Radiol 2009; 39:403-5. [PMID: 19214494 DOI: 10.1007/s00247-009-1158-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 12/15/2008] [Accepted: 01/03/2009] [Indexed: 11/26/2022]
Abstract
Traumatic intussusception due to intramural haematoma as the lead point is rare. We present the CT findings of a large duodenojejunal intramural haematoma acting as the lead point of a jejunojejunal intussusception in a 12-year-old boy.
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Affiliation(s)
- Suat-Jin Lu
- Department of Diagnostic Imaging, National University Hospital, Singapore.
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6
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Kwak JH, Jang HJ, Kim JH, Ahn JH, Eom DW, Han MS. Intramural and Intraluminal Hematoma of the Small Bowel as the Lead Point of Intussusception in an Adult Patient with Warfarinization. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.77.suppl.s13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jin Ho Kwak
- Department of Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Hyuk Jai Jang
- Department of Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Ji Hoon Kim
- Department of Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Je Hong Ahn
- Department of Radiology, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Dae Woon Eom
- Department of Pathology, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Myeng Sik Han
- Department of Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
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7
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Howard JM, Hanly AM, Stephens RB. Conservative management resulting in complete resolution of a double intussusception in an adult haemophiliac. Colorectal Dis 2008; 10:197-8. [PMID: 17711500 DOI: 10.1111/j.1463-1318.2007.01315.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute abdominal pain in haemophiliacs should be approached as haemorrhage until proven otherwise. With advancements in factor repletion and coagulopathic management a conservative approach should be considered. We describe a case of double colo-colonic intussusception lead by an intramural haematoma occurring spontaneously and resolving with conservative management in a young haemophiliac. This demonstrates that intussusception in these cases may be transient, and does not require surgical intervention.
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Affiliation(s)
- J M Howard
- Department of Colorectal Surgery, St James's Hospital, Dublin, Ireland
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8
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Uzun MA, Koksal N, Gunerhan Y, Sahin UY, Onur E, Ozkan OF. Intestinal obstruction due to spontaneous intramural hematoma of the small intestine during warfarin use: a report of two cases. Eur J Emerg Med 2008; 14:272-3. [PMID: 17823563 DOI: 10.1097/mej.0b013e3282703633] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Warfarin-dependent spontaneous intramural hematoma of the small intestine is a rare complication. The first symptom is usually abdominal pain, frequently accompanied by nausea and vomiting. In some cases, concomitant gastrointestinal bleeding might be seen. Ultrasonography and computed tomography are the most useful radiographic methods for the diagnosis of an intramural hematoma of the intestines. Although it is usually treated conservatively, surgical intervention is required in cases involving active bleeding, intestinal obstruction, or acute abdominal symptoms. Here we present two patients who were treated surgically. Both patients had intestinal obstruction and ischemia, and one had concomitant gastrointestinal bleeding and intussusception due to an intramural hematoma.
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Affiliation(s)
- Mehmet Ali Uzun
- General Surgery Department, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.
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9
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Jarry J, Biscay D, Lepront D, Rullier A, Midy D. Spontaneous intramural haematoma of the sigmoid colon causing acute intestinal obstruction in a haemophiliac: report of a case. Haemophilia 2007; 14:383-4. [PMID: 18179573 DOI: 10.1111/j.1365-2516.2007.01627.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Small bowel intussusception after blunt abdominal trauma in a 6-year-old boy: case report and review of 6 cases reported in the literature. J Pediatr Surg 2006; 41:1930-2. [PMID: 17101374 DOI: 10.1016/j.jpedsurg.2006.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although intussusception is a well-known cause of acute abdomen in the pediatric population, traumatic intussusception is exceedingly rare and has been reported previously only 6 times in a preadolescent child. We present a case of ileoileal intussusception in a previously healthy 6-year-old boy after blunt trauma to the abdomen and review the English language literature on the subject.
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11
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Katsumi A, Matsushita T, Hirashima K, Iwasaki T, Adachi T, Yamamoto K, Kojima T, Takamatsu J, Saito H, Naoe T. Recurrent intramural hematoma of the small intestine in a severe hemophilia A patient with a high titer of factor VIII inhibitor: a case report and review of the literature. Int J Hematol 2006; 84:166-9. [PMID: 16926140 DOI: 10.1532/ijh97.06053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 17-year-old man with severe hemophilia A (factor VIII <1%) developed intermittent left upper quadrant pain. He had a high titer of factor VIII inhibitor (1024 Bethesda units/mL) and was diagnosed with intramural hematoma of the jejunum. He was managed conservatively with activated prothrombin complex concentrate (APCC), resulting in the resolution of symptoms. He developed recurrent intramural hematoma of the small intestine over the next 54 months, and was successfully treated with APCC. This case highlights a rare clinical manifestation in hemophilia patients, and also indicates the effectiveness of APCC instead of exploratory surgery for intramural hematoma. Cases of intramural hematoma of the gastrointestinal tract among hemophilia patients are also reviewed.
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Affiliation(s)
- Akira Katsumi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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12
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Stockinger ZT, McSwain N. Intussusception Caused by Abdominal Trauma: Case Report and Review of 91 Cases Reported in the Literature. ACTA ACUST UNITED AC 2005; 58:187-8. [PMID: 15674172 DOI: 10.1097/01.ta.0000063405.53305.df] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Zsolt T Stockinger
- Department of Surgery, Tulane University Health Sciences Center, New Orleans, Louisiana 70112-2699, USA.
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13
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Ko SF, Shieh CS, Ng SH, Tiao MM, Lee TY, Wan YL. Posttraumatic retrograde jejunojejunal intussusception involving a Roux-en-Y loop. J Pediatr Gastroenterol Nutr 1999; 29:604-6. [PMID: 10554133 DOI: 10.1097/00005176-199911000-00026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- S F Ko
- Department of Radiology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan
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14
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Brooks A, Bebington BD, Lucas S, Oettle GJ. Intussusception caused by blunt abdominal trauma. THE JOURNAL OF TRAUMA 1999; 47:156-7. [PMID: 10421204 DOI: 10.1097/00005373-199907000-00032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A Brooks
- Department of Surgery, Helen Joseph Hospital and the University of the Witwatersrand, Johannesburg, South Africa
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15
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Abstract
Serious abdominal injury as a result of a fall in a baby walker has not been previously reported. We present the case of a 13-month-old boy who developed intussusception following a fall down five stairs in a baby walker. Attempted hydrostatic reduction was unsuccessful. At operation, a bowel wall hematoma, serving as a lead point, was identified. This case adds another type of injury to the list of those previously associated with baby walker use.
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Affiliation(s)
- G P Conners
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, New York, USA
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16
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Affiliation(s)
- P C Ferrera
- Department of Emergency Medicine, Albany Medical Center, NY 12208, USA
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17
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Affiliation(s)
- R Komadina
- Department of Trauma Surgery, General Hospital Celje, Slovenia
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18
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Abstract
Intussusception is a rare cause of intestinal obstruction in adults. When seen most cases have identifiable pathology. Intussusception following blunt abdominal trauma is extremely rare. This report presents a case of double jejuno-jejunal intussusception in a patient who sustained such an injury. There was no other intra-abdominal abnormality and manual reduction resulted in a complete recovery. The coincidental discovery of Q-fever may be etiologically relevant.
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Affiliation(s)
- M O Bashir
- James Connolly Memorial Hospital, Blanchardstown, Dublin
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Pauly MP, Watson-Williams E, Trudeau WL. Intussusception presenting with lower gastrointestinal hemorrhage in a hemophiliac. Gastrointest Endosc 1987; 33:115-8. [PMID: 3494646 DOI: 10.1016/s0016-5107(87)71526-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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20
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Mittal R, Spero JA, Lewis JH, Taylor F, Ragni MV, Bontempo FA, Van Thiel DH. Patterns of gastrointestinal hemorrhage in hemophilia. Gastroenterology 1985; 88:515-22. [PMID: 3917418 DOI: 10.1016/0016-5085(85)90515-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Peptic ulcer has been reported to be the cause of bleeding in 53%-85% of hemophiliacs with gastrointestinal hemorrhage (GIH). The management of GIH in hemophiliacs during the past decade has been affected by the availability of plasma concentrates, an increasing occurrence of chronic liver disease, and widespread use of endoscopic procedures. To determine the present patterns of GIH, we reviewed our experience at the Hemophilia Center of Western Pennsylvania during the last 10 yr. Twenty-five (10.3%) of 243 hemophiliacs experienced 41 episodes of GIH. The severity of hemophilia and a history of retroperitoneal hemorrhage were significant risk factors for GIH. Duodenal ulcer (22%), unknown site (22%), and gastritis (14%) were the three most common diagnoses. The use of fiberoptic endoscopy resulted in the recognition of diagnoses such as gastritis, esophagitis, Mallory--Weiss syndrome, and esophageal varices. Red cell transfusion requirements of hemophiliacs with GIH were no different than those of nonhemophiliacs with GIH (p greater than 0.05). The amount of factor VIII replacement used by hemophiliacs with GIH correlated with the severity of gastrointestinal bleeding (p less than 0.01), but not with the cause of gastrointestinal bleeding (p greater than 0.05). In conclusion, hemophiliacs develop GIH secondary to a variety of causes as do nonhemophiliacs. Fiberoptic endoscopy, after correction of factor VIII level to 0.40 U/ml, is a safe and valuable diagnostic procedure in hemophiliacs. The specific etiology of GIH in hemophiliacs should be aggressively sought and appropriate specific therapy provided.
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