Recurrent Life-Threatening Gastrointestinal Bleeding From Primary Intestinal Choriocarcinoma: A Case Report

Choriocarcinoma is a highly aggressive, malignant tumor that arises from trophoblastic cells. Although choriocarcinomas usually arise in the genital organs, they can also originate in extragenital organs, but gastrointestinal tract lesions are rare. Gastrointestinal choriocarcinoma can be primary or metastatic. Most primary gastrointestinal choriocarcinomas are associated with adenocarcinomas. We report a case of jejunal choriocarcinoma presenting with acute abdominal pain and intestinal bleeding. The patient had a very high serum beta-human chorionic gonadotropin (β-HCG) level with an isolated jejunal lesion on contrast-enhanced computed tomography of the abdomen and pelvis. The patient underwent emergency surgical resection of the jejunal lesion with good recovery. The histopathological analysis of the resected specimen confirmed the diagnosis of choriocarcinoma. However, the patient suffered from life-threatening rebleeding one month after surgery and succumbed to her illness.

Successful control of intestinal bleeding from metastasis of pulmonary pleomorphic carcinoma with pembrolizumab: A case report

RATIONALE

Pulmonary pleomorphic carcinoma is a rare tumor with a poor prognosis and has no standard chemotherapy. We herein report a case of small intestinal metastasis of pulmonary pleomorphic carcinoma that resulted in intestinal bleeding and was successfully treated with pembrolizumab monotherapy.

PATIENT CONCERNS

A 54-year-old man with a history of pulmonary pleomorphic carcinoma resection was referred to our hospital due to a 1-month history of a fever and general fatigue.

DIAGNOSIS

Laboratory investigation revealed microcytic anemia. Hematochezia was also noted after admission. Computed tomography (CT) and positron emission tomography (PET)/CT at the time of this admission revealed intraperitoneal masses alongside the small intestine with no significant ascites.

INTERVENTIONS

Pembrolizumab (400 mg/body) was introduced as the first-line chemotherapy.

OUTCOMES

By the 15th day after the initial pembrolizumab administration, the fever had disappeared, and the intraperitoneal masses were markedly reduced. Hematochezia had also disappeared, and he no longer needed to receive blood transfusions.

LESSONS

To our knowledge, this is the first report in which small intestinal metastasis of pulmonary pleomorphic carcinoma was successfully controlled by pembrolizumab monotherapy. Immune checkpoint inhibitors may be promising therapeutic agents against pulmonary pleomorphic carcinoma.

Meckel's Diverticulum with Dieulafoy's Lesion: A Cause of Severe Hematochezia

BACKGROUND

Meckel's diverticulum (MD) is a remnant of the omphalomesenteric duct. Although the majority of MD are asymptomatic, it can present with severe hematochezia. Hematochezia is generally considered to result from a peptic ulcer caused by ectopic gastric mucosa in MD. However, this hypothesis has not been proved.

METHODS

10 cases of surgically resected MD initially presenting with severe hematochezia were histologically examined.

RESULTS

Ectopic gastric mucosa was present in 9 cases, two of which also contained ectopic pancreas. No ectopic tissue was found in one case, which shows that bleeding can occur in MD without ectopic gastric mucosa. In addition, a rupture of aberrant submucosal arterioles through the overlying mucosa, a vascular abnormality called Dieulafoy's lesion, was detected in all the 10 cases.

CONCLUSION

This study suggests that the actual cause of massive bleeding in MD is not a peptic ulcer, but Dieulafoy's lesion.

[Treatment of colorectal cancer complicated by intestinal bleeding in a patient with multivessel coronary artery disease and degenerative aortic valve disease]

The aim of the presented clinical observation is to demonstrate a multidisciplinary approach in the treatment of a comorbid patient with complicated colorectal cancer, multivessel coronary artery disease, degenerative aortic valve disease and chronic heart failure. The authors presented a clinical case of treatment of a patient with ischemic heart disease, postinfarction cardiosclerosis (acute myocardial infarction from 1990), hemodynamically significant intestinal bleeding, the source of which was cancer of the descending colon. Comprehensive examination revealed moderately differentiated (G2) adenocarcinoma of the descending colon cT3N1M0, stage IIIB, in combination with multivessel coronary artery disease and degenerative aortic heart disease with a predominance of stenosis (pressure gradient: Pg max - 94 mm Hg, Pg mean - 68 mm Hg) and the development of aortic valve insufficiency. Taking into account the results of the examinations, the patient is indicated for myocardial revascularization and aortic valve replacement, which implied the subsequent long-term use of anticoagulants, but this increased the risk of recurrence of fatal colonic bleeding. At the same time, performing the operation to remove the source of recurrent bleeding according to all oncological principles had high risks of cardiovascular complications intraoperatively and in the immediate postoperative period. In this regard, after an objective assessment of all perioperative risks, it was decided to simultaneously perform direct myocardial revascularization, aortic valve replacement and extended left-sided hemicolectomy with extended lymphadenectomy. The patient is monitored at the Moscow State Clinical Hospital named after S.S. Yudin after the operation for 2 years, there is no data for the progression of the oncological process. Thus, a favorable outcome in this patient was determined by a multidisciplinary approach - performing a simultaneous operation on a comorbid patient.

[Pancreatic mucinous cystadenoma complicated by intestinal bleeding]

Mucinous cystadenoma is a cystic tumor of the pancreas absolutely requiring surgical intervention. The authors report successful surgical treatment of a patient with mucinous pancreatic cystadenoma complicated by severe intestinal bleeding.

[Metastasis of clear cell renal cell carcinoma into small bowel in 5 years after nephrectomy]

Small bowel tumor causes gastrointestinal bleeding in 1-4% of cases. Gastrointestinal bleeding from metastases of renal cell carcinoma is a rare and little-known manifestation of this disease. We report a rare clinical case of a solitary metastasis of clear cell renal cell carcinoma into small bowel in 5 years after nephrectomy. The first symptom was intestinal bleeding. This example emphasizes the need for more thorough examination of patients with symptoms of latent and anamnestic blood loss.

Anisakiasis in the Small Intestine with Excessive Bleeding That Was Difficult to Diagnose Endoscopically

Anisakiasis involves the stomach in most cases and occurs rarely in the small intestine. Anisakiasis in the small intestine is associated with abdominal pain and obstruction and is rarely associated with intestinal bleeding. Unlike in the stomach, anisakiasis in the small intestine is difficult to diagnose anatomically. The patient in this case study developed hypovolemic shock due to excessive bleeding and underwent emergency surgery. With the recent increase in the consumption of raw fish around the world, this report provides an important finding of bleeding in the small intestine due to an unknown cause.

Pathophysiology of NSAID-Associated Intestinal Lesions in the Rat: Luminal Bacteria and Mucosal Inflammation as Targets for Prevention

Non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine, mainly through an involvement of enteric bacteria. This study examined the pathophysiology of NSAID-associated intestinal lesions in a rat model of diclofenac-enteropathy and evaluated the effect of rifaximin on small bowel damage. Enteropathy was induced in 40-week old male rats by intragastric diclofenac (4 mg/kg BID, 14 days). Rifaximin (delayed release formulation) was administered (50 mg/kg BID) 1 h before the NSAID. At the end of treatments, parameters dealing with ileal damage, inflammation, barrier integrity, microbiota composition, and TLR-NF-κB-inflammasome pathway were evaluated. In addition, the modulating effect of rifaximin on NLRP3 inflammasome was tested in an in vitro cell system. Diclofenac induced intestinal damage and inflammation, triggering an increase in tissue concentrations of tumor necrosis factor and interleukin-1β, higher expression of TLR-2 and TLR-4, MyD88, NF-κB and activation of caspase-1. In addition, the NSAID decreased ileal occludin expression and provoked a shift of bacterial phyla toward an increase in Proteobacteria and Bacteroidetes abundance. All these changes were counterbalanced by rifaximin co-administration. This drug was also capable of increasing the proportion of Lactobacilli, a genus depleted by the NSAID. In LPS-primed THP-1 cells stimulated by nigericin (a model to study the NLRP3 inflammasome), rifaximin reduced IL-1β production in a concentration-dependent fashion, this effect being associated with inhibition of the up-stream caspase-1 activation. In conclusion, diclofenac induced ileal mucosal lesions, driving inflammatory pathways and microbiota changes. In conclusion, rifaximin prevents diclofenac-induced enteropathy through both anti-bacterial and anti-inflammatory activities.

Ectopic variceal bleeding due to portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein : case report and literature review of ectopic varices

Ectopic varices are dilated portosystemic venous collaterals located outside of the gastro-esophageal region. Whereas they are common endoscopic findings in patients with portal hypertension, ectopic variceal bleeding is rather rare and accounts for only 1 to 5 % of all variceal bleedings. The rectum and the duodenum are the most common sites for ectopic varices, but they can be present along the whole intestinal tract and neighborhood. At present, there is no consensus well established on diagnostic workup for ectopic variceal bleeding and their therapeutic strategies. Further investigation of large series or randomized-controlled trials is needed because nowadays most of the data available are based on case reports. We report here an unusual case of an ectopic variceal bleeding, presented as an acute small intestine bleeding, due to a portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein in a patient with alcoholic cirrhosis. The involvement of an ovarian vein in ectopic variceal bleeding is rarely described.

Persistent intestinal bleeding due to severe CMV-related thrombocytopenia in a preterm newborn

The optimal threshold for neonatal platelet transfusions in sick newborns is still uncertain. We report a congenital cytomegalovirus (CMV) infection in a premature neonate with severe thrombocytopenia who subsequently presented with necrotizing enterocolitis and intestinal bleeding. The baby recovered after platelet transfusions were discontinued and the therapy was switched from intravenous ganciclovir to oral valganciclovir. We discuss both measures, speculating on the key role of platelet transfusions.

Angiopoietin-1 prevents severe bleeding complications induced by heparin-like drugs and fibroblast growth factor-2 in mice

Critically ill children can develop bleeding complications when treated with heparin-like drugs. These events are usually attributed to the anticoagulant activity of these drugs. However, previous studies showed that fibroblast growth factor-2 (FGF-2), a heparin-binding growth factor released in the circulation of these patients, could precipitate intestinal hemorrhages in mice treated with the heparin-like drug pentosan polysulfate (PPS). Yet very little is known about how FGF-2 induces bleeding complications in combination with heparin-like drugs. Here, we examined the mechanisms by which circulating FGF-2 induces intestinal hemorrhages in mice treated with PPS. We used a well-characterized mouse model of intestinal hemorrhages induced by FGF-2 plus PPS. Adult FVB/N mice were infected with adenovirus carrying Lac-Z or a secreted form of recombinant human FGF-2, and injected with PPS, at doses that do not induce bleeding complications per se. Mice treated with FGF-2 in combination with PPS developed an intestinal inflammatory reaction that increased the permeability and disrupted the integrity of submucosal intestinal vessels. These changes, together with the anticoagulant activity of PPS, induced lethal hemorrhages. Moreover, a genetically modified form of the endothelial ligand angiopoietin-1 (Ang-1*), which has powerful antipermeability and anti-inflammatory activity, prevented the lethal bleeding complications without correcting the anticoagulant status of these mice. These findings define new mechanisms through which FGF-2 and Ang-1* modulate the outcome of intestinal bleeding complications induced by PPS in mice and may have wider clinical implications for critically ill children treated with heparin-like drugs.

The capsule endoscopy "suspected blood indicator" (SBI) for detection of active small bowel bleeding: no active bleeding in case of negative SBI

OBJECTIVE

Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The "suspected blood indicator" (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding.

METHODS

This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC).

RESULTS

In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%).

CONCLUSION

The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

Thalidomide for treatment of severe intestinal bleeding

Apart from its anti-inflammatory activity, which has been used for the treatment of active Crohn's disease, thalidomide is also a potent inhibitor of angiogenesis. We therefore studied the effect of thalidomide in six patients with severe recurrent intestinal bleeding refractory to standard treatment (three patients with Crohn's disease (CD), three patients with obscure intestinal bleeding; mean of 56 blood transfusions within the last 24 months). Bleeding stopped within two weeks after the start of thalidomide in all patients. Haemoglobin normalised without further transfusions for the whole observation period (mean follow up 33 months) while patients needed a mean of 2.2 (CD) and 3.1 (obscure bleeding) blood units/month in the 12 months before treatment. After three months of thalidomide therapy, serum levels of vascular endothelial growth factor were strongly suppressed compared with pretreatment levels. (CD 818 (82) v 129 (86) pg/ml; obscure bleeding 264 (68) v 50 (25) pg/ml). All six patients reported transient fatigue. Peripheral neuropathy was observed in one patient with CD after nine months and was reversible after lowering the dose to 100 mg daily. These results indicate that thalidomide might be useful for patients with otherwise refractory intestinal bleeding.