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In a lecture we had about GI bleeds, he said there's a new way to distinguish upper from lower GI tract. The way we learned it is that proximal to the ligament of Treitz is the upper GI tract and distal to the ligament of Treitz is the lower GI tract. The new way is that the lower GI tract is distal to the ileocecal valve. If someone has bright red blood per rectum (hematochezia), you must first rule out a brisk Upper GI Bleed (UGIB). So just because the blood is bright red doesn't mean it's coming from the lower GI tract--the color of the blood depends on how long it's been in the GI tract, not where it's coming from. So bright red blood could be a lower GI bleed, but it could also be an upper GI bleed that's bleeding so fast that the blood doesn't have time to stay in the GI tract and become partially digested, which changes it to a darker color.
MCC (most common cause) of UGIB is PUD (even in cirrhotic pts). Thirty to 70% of UGIBs are due to PUD. So the cause of UGIB is more commonly due to PUD (peptic ulcer disease) than it is due to esophageal varices in cirrhotic pts.
UGIB is 4x more common than LGIB, so that's why you first need to r/o UGIB in a pt presenting with hematochezia.
Orthostatic hypotension indicates 20% blood volume loss! Hemoglobin level is a poor early indicator of UGIB. You need to resuscitate UGIB pts with 2 large bore IVs (16 or 18 gauge). Get type and screen for blood transfusion; correct coagulopathy. So you don't want to miss pts with hemodynamic issues. Measure orthostatics in pts who come in with hematochezia. Then you know if you'll need to resuscitate them before it's too late.
After resuscitation, give IV PPI. Erythromycin will move blood out of GI tract for endoscopy. Octreotide is given for varices. Tx empirically with antibiotics to prophylax against spontaneous bacterial peritonitis in cirrhotic pts.
Endoscopy is done ASAP in low risk pts.
Forrest classification tells you who gets endoscopic therapt for UGIBs. It classifies pts based on risk of re-bleeding in 72 hours. A non-bleeding visible vessel has a higher chance of re-bleeding in 72 hours than does a non-adherent clot.
Banding for esophageal varices needs to be repeated every 1 to 3 weeks until the varices are eradicated.
TIPS is a shunt that goes from the hepatic portal vein to the inferior vena cava, bypassing the liver. It’s done to decrease pressure in the portal vein to stop esophageal varices from bleeding. Since you bypass the liver, you increase hepatic encephalopathy with this procedure. But it will save the person from bleeding out and dying from esophageal varices. So TIPS is only done if the pt is hemorrhaging from esophageal varices.
Intubate pts with massive UGIB to protect the airway.
MCC of LGIB is diverticulosis. Second MCC of LGIB is angiodysplasia. Again, UGIB needs to be ruled out too.
Do rapid purge to get rid of the blood and then do colonoscopy. Can give PEG (easier to give the PEG via nasogastric tube than to have the pt try to drink it all). Can give metoclopramide to purge the blood.
Painless bleeding per rectum = diverticulosis. Tx = inject epinephrine and clip it off.
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JC: Lower GI bleeding guidance. St Emlyn's
JC: Lower GI bleeding guidance. St Emlyn’s
The management of the patient with apparent lower GI (gastro-intestinal) bleeding is, in my experience at least, somewhat variable. Unlike upper GI bleeding where the standards and expectations are reasonably well known1,2, the lower GI bleed patient in the ED seems to be managed at the whim however might be on call that day. This combined with the well trodden turf wars about who admits (or…
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Also, an additional thanks to @dougrose70 and @tminx3 from your @knoxvilleicebears coming through and teaching me about hockey fights...😂 - See them this Friday night bring the mayhem to Macon AND honor our #Military & 1st Responders! - Tickets: knoxvilleicebears.com 🙌🏾🏒🥅🇺🇸 - #Knoxville #IceBears #LGIB #Hockey #Radio #OnAir #Host (at Hot 104.5) https://www.instagram.com/p/Bp70qx9jSIf/?utm_source=ig_tumblr_share&igshid=sahvuayd8kv2
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Just wanted to wish my amazing husband good luck tonight in their first game of playoffs! #beatpeoria #lgib #icebears #biggestfan #myhero #26 (at Copper Pointe)
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A Rare Cause of Gastrointestinal Bleeding: A Jejunal Dieulafoy’s Lesion- Juniper Publishers
One in a thousand people have an acute gastrointestinal (GI) hemorrhage per year [1]. There are around 300,000 hospitalizations for GI bleeds, costing an estimated $2 billion per year [2-4]. Compared to lower gastrointestinal bleeding (LGIB), upper gastrointestinal bleeding (UGIB) is associated with a much higher mortality rate, with some studies suggesting a 30-day mortality rate of up to 14% [2,3]. A majority of these UGIB (67 - 80%) are attributed to gastric erosions/ulcers 6,17,18. However, of this morbid group of bleeds, a rare (1% or less), yet more serious cause is a Dieulafoy’s lesion (DFL). DFL, is an obscure type of bleeding that can cause life threatening hemorrhages with a mortality rate ranging from 28-67% [5,6].
DFL was first described by MT Gallard [7] in 1884 as a type of aneurysm and later clarified by P. G. Dieulafoy in 1898 who believed this was an early stage of ulceration [7-9]. DFL’s are a collection of large tortuous arterioles of the gastrointestinal vessels. These are often compared to aneurysms, however, DFL’s are caused by genetic malformations rather than degeneration. While the exact mechanism of rupture and subsequent hemorrhage is still poorly understood, several studies have suggested mucosal erosion and ischemic injury, related to aging and/or cardiovascular disease, as possible causes [10]. DFLs are predominantly seen in elderly patients (mean age 69.7 years) though they can be seen in younger patients as well. A vast majority of patients also will have underlying comorbidities such as renal failure, diabetes, or coronary artery disease. Additionally, there have been a few isolated cases associated with chronic immunosuppression whether from underlying malignancies or medication induced [11].
More than 70% of these rare lesions are found in the stomach, usually near the lesser curvature. The discovery of extragastric DFL’s are infrequent, with the duodenum (14%) and colon (5%) being the most common locations [12-14]. The most unusual site is the jejunum, which accounts for 1% of all DFL’s [12-14]. Historically, there have been a few case reports worldwide of jejunal DFL’s, however, of these reported cases, the lesions were found by advanced imaging (CT angiogram or Bleeding scan). We present a case of a jejunal DFL that was unable to be found by advanced imaging but was diagnosed on push enteroscopy.
Assessment
The patient was a 79-year-old African American female with a known history of end stage renal disease and large granular lymphocytic leukemia. Over the course of 8 months, the patient had 3 admissions for gastrointestinal bleeds. She received a total of 16 units of blood with 4 EGDs, 2 colonoscopies, 1 bleeding scan and 1 CT angiogram. Of the listed procedures performed, all were negative for active bleeding and there was no solid evidence of a bleeding source. She was presumed to have bled twice from erosive gastritis and the most recent admission was from an unknown etiology. An outpatient small bowel capsule study was done after these admissions showing no findings.
She subsequently presented to the ER 24 days after her most recent admission for melena and orthostasis, where she was found to have a hemoglobin of 4.4 g/dL (previous hemoglobin was 10.2 g/dL). EGD and colonoscopy did not show any findings or source of bleeding. The patient continued to have melena and required 8 units of blood. A CT angiogram and bleeding scan were again inconclusive. A push enteroscopy was performed on day 6 of admission, showing an actively oozing area in the jejunum with no surrounding ulceration or malformations (Figure 1). Bipolar cauterization and 2 hemoclips were placed ceasing the actively bleeding Dieulafoy’s lesion. The patient’s hemoglobin stabilized, and the melena resolved 1 day after the enteroscopy.
Management
Our patient had a history of large granulocytic lymphocytic leukemia (LGL) and end stage renal disease. Though the usual course of LGL presents with neutropenia and anemia, thrombocytopenia can be seen in up to 20% of cases [15]. Thrombocytopenia combined with immunosuppression from underlying malignancy and ESRD put this patient at an increased risk of developing hemorrhagic complications such as DFLs. On multiple admissions, our patient was found to pancytopenia, likely as a result of her bleeding and immunosuppression. To date, there have been a few case reports citing immunosuppression, immunotherapy, and thrombocytopenia all being associated with GI bleeds due to a DFL [16,17]. While the mechanism is not yet established, it is thought to be related to impaired tissue remodeling and repair.
The current endoscopic modalities to manage a DFL include mechanical treatment (with endoclips or band ligators), injection therapy (with diluted epinephrine), thermal coagulation therapy, or in some cases, a combination of different modalities. Two controlled trials suggested that mechanical hemostasis with endoclips can control acute bleeding and may reduce recurrent bleeds compared to injection therapy alone [18]. There have been no studies comparing the efficacy of thermal coagulation alone or in combination with other methods. A second trial comparing endoclips to injection therapy with epinephrine showed equal rates of initial hemostasis but significantly lower rates of rebreeding in the endoclip arm (0%) vs epinephrine arm (35%) [19].
Post endoscopic management depends on whether the patient is at high risk or low risk for rebleeding. One method used to calculate risk of recurrence is the Glasgow - Blatchford bleeding score (GBS score). A GBS score of 0-1 is considered low risk for rebleeding, and in this case the patient may be discharged from inpatient care with plans for outpatient endoscopic intervention. Inpatient treatment is recommended for patients with GBS scores of 2 or greater [20]. The rate of recurrence of bleed for a Dieulafoy’s lesion ranges from 9-40% [21]. There is a higher rate of recurrence with endoscopic monotherapy compared to combined endoscopic interventions [22]. The rate of rebleeding is not associated with gender or location of DFL or past medical history [23]. Inpatient treatment recommendation is to treat with IV pantoprazole for 72 hours in order to keep gastric pH above 6 in order to maintain intact coagulation process, followed by oral pantoprazole therapy. While mortality is lowest in patients with no significant medical history or comorbidities, overall longterm prognosis of a DFL is favorable once primary hemostasis is achieved [24]. Following push enteroscopy our patient did well without any further complications or signs of rebleeding [25-30].
Conflict of Interest
All authors have read and approved the submission of this manuscript. The manuscript has not been published and is not being considered for publication elsewhere, in whole or in part. The authors declare that there is no conflict of interests regarding the publication of this paper
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THINGS YOU NEED TO KNOW BEFORE UNDERGOING BARIATRIC SURGERY -
Bariatric surgery is necessary to induce long lasting weight loss in those suffering from severe obesity and to induce long term remission from diabetes in those suffering from uncontrolled type 2 diabetes.
You become more healthy. You will stop the medications needed for diabetes, high BP, high blood fats, and joint pains.
But before surgery, you should be physically and mentally prepared for what your life is going to be after surgery.
HEALTHY DIET & PHYSICAL EXERCISE:
You need to be committed to change to a healthy lifestyle. Surgery is the strongest tool that helps you to lose significant amount of weight, which you couldn't have dreamed to achieve otherwise. But to maintain the lost weight you need to stick onto lifelong healthy diet and physical exercise.
SKIN LOOSENING:
Significant and rapid weight loss will make your skin look wrinkled and you may have a weak look. It will take some time for the skin to get tightened completely and to get back the tight skin and healthy look.
You can get massages done once in a week or two, exercise daily to hasten skin tightening.
HAIR LOSS:
You notice hair loss after surgery. This is because of significant weight loss. But this is temporary. Whatever hair you lose will come back once weight loss is stabilised. You need to take sufficient protein, and vitamins to reduce hair loss.
GALL BLADDER STONES:
Weight loss can result in formation of gall bladder stones. You need to hydrate well and avoid oil foods to reduce this risk. Your doctor prescribes you 'Ursodeoxy cholic acid' tablets during weight loss period to reduce this risk.
LOSS OF APPETITE & FOOD AVERSIONS:
Weight loss and diabetes remission after bariatric surgery are mainly due to changes in the hormones that control body fat. Because of these hormonal changes, your hunger comes down. And you will develop a lot of food aversions. Your taste alters. You start hating smells of foods. You don't feel like eating at all. And your stomach capacity is low. It will be full even after eating little quantity. In order to meet minimum daily requirements of nutrients and fiber, you have to plan a schedule and take food at regular intervals. Eat and drink small quantities more frequently to meet daily requirements.
DUMPING SYNDROME:
Eating sugar and refined carbohydrates lead to sweating, weakness, palpitations and dizziness especially after gastric bypass surgeries (Roux-En-Y Gastric Bypass and Mini Gastric Bypass). This problem is significantly less after Sleeve Gastrectomy or Sleeve + Bypass combination surgeries (SLDS, SADI-S, SG LDJB, SG LGIB). You have to avoid simple and refined carbohydrates to prevent dumping.
ESOPHAGEAL REFLUX:
Some surgeries can increase acid reflux into your food pipe. To prevent this reflux, you need to avoid chilly, spice and oil. You need to take small quantity of foods each time. And you may have to use medications to control reflux.
If you are mentally prepared for the new lifestyle, your weight loss and weight maintenence journey will be smooth and happy.
BOOK APPOINTMENT NOW..
Dr. AMAR VENNAPUSA
Chief Consultant Bariatric & Metabolic Surgeon
Dr. Amar Bariatric & Metabolic Center,
Hyderabad, India
www.drvamar.com
+91 9676675646
[email protected]
#obesity #obesityawareness #diabetes #diabetesawareness #jointpain #highbloodpressure #highbloodsugar #weightloss #healthydiet #physicalexercise #medication #skin #hairloss #foodaversions #protein #fitnesslifestyle #weightlosscenter #weightlosssurgeon #weightlossjourney #bariatriccommunity #bestbariatricsurgeon #drvamar #bariatricprocedures
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Eu! #ootd #ootdfashion #ootdmen #pastelcolors #melissaoficial #melissaulitsasneaker #fairykei #fairykeiboy (em República, São Paulo) https://www.instagram.com/p/B9Atpm-lgIb/?igshid=4c787n6ntorx
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Princess Lindsey, a study in yellow. 💛 (at Alamo Square) https://www.instagram.com/p/B0bMvc-lgIB/?igshid=1frqh98qrchih
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A Role for First-Line Surgical Treatment Of Lower GI Bleeding
“Traditionally, and at my hospital, patients with LGIB go first to the medical ICU; then other disciplines, like gastroenterology and surgery, get consulted ...
from Google Alert - Gastroenterology http://bit.ly/2Y5Wozu
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#flower #flowers #floweroftheday #flowerporn #flowerp #blooms #buterfly #flowermagic #bloom #petal #petals #nature #beautiful #love #pretty #plants #blossom #sopretty #spring #summer #flowerstagram #flowersofinstagram #flowerstyles_gf #amazing #macri #day #green #beauty #photooftheday #nature_seekers (em Cruz, Ceara, Brazil) https://www.instagram.com/p/BzAgu_-lgiB/?igshid=1ebueond9nx9
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An upper gastrointestinal bleed (UGIB) is defined as one with a source proximal to the ligament of Treitz (esophagus, stomach, first part of the duodenum [D1]). Causes include peptic ulcer disease, esophageal varices or tears, and esophagitis. They tend to present with hematemesis (vomited blood) and/or melena (black tarry stools) unless they are very large and brisk, at which point they may cause hematochezia (aka bright red blood per rectum, BRBPR). Swallowed blood from the naso-oropharynx may also be thrown up. Blood coughed up from the lungs = hemoptysis. A lower gastrointestinal bleed (LGIB) is defined as one with a source distal to the ligament of Treitz (second-fourth parts of the duodenum [D2-4], ileum, large intestine, rectum). Causes include colorectal cancer, angiodysplasia, and diverticula (Meckel's or otherwise). A high or slow bleed presents with melena, while a low or fast bleed causes hematochezia. Blood from beyond the ligament of Treitz very rarely backs up to cause hematemesis. Image: Colorized version of "Suspensory muscle of the duodenum or muscle of Treitz," Henry Gray's Anatomy: Descriptive and Applied (Philadelphia: Lea & Febiger, 1913). #TeachingRounds, #FOAMed, #anatomy, #GI, #gastroenterology
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Love making new friends especially when it feels like you have known them forever. #knoxville #icebears #LGIB #girlsnight (at Knoxville, Tennessee)
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A Rare Cause of Gastrointestinal Bleeding: A Jejunal Dieulafoy’s Lesion- Juniper Publishers
One in a thousand people have an acute gastrointestinal (GI) hemorrhage per year [1]. There are around 300,000 hospitalizations for GI bleeds, costing an estimated $2 billion per year [2-4]. Compared to lower gastrointestinal bleeding (LGIB), upper gastrointestinal bleeding (UGIB) is associated with a much higher mortality rate, with some studies suggesting a 30-day mortality rate of up to 14% [2,3]. A majority of these UGIB (67 - 80%) are attributed to gastric erosions/ulcers 6,17,18. However, of this morbid group of bleeds, a rare (1% or less), yet more serious cause is a Dieulafoy’s lesion (DFL). DFL, is an obscure type of bleeding that can cause life threatening hemorrhages with a mortality rate ranging from 28-67% [5,6].
DFL was first described by MT Gallard [7] in 1884 as a type of aneurysm and later clarified by P. G. Dieulafoy in 1898 who believed this was an early stage of ulceration [7-9]. DFL’s are a collection of large tortuous arterioles of the gastrointestinal vessels. These are often compared to aneurysms, however, DFL’s are caused by genetic malformations rather than degeneration. While the exact mechanism of rupture and subsequent hemorrhage is still poorly understood, several studies have suggested mucosal erosion and ischemic injury, related to aging and/or cardiovascular disease, as possible causes [10]. DFLs are predominantly seen in elderly patients (mean age 69.7 years) though they can be seen in younger patients as well. A vast majority of patients also will have underlying comorbidities such as renal failure, diabetes, or coronary artery disease. Additionally, there have been a few isolated cases associated with chronic immunosuppression whether from underlying malignancies or medication induced [11].
More than 70% of these rare lesions are found in the stomach, usually near the lesser curvature. The discovery of extragastric DFL’s are infrequent, with the duodenum (14%) and colon (5%) being the most common locations [12-14]. The most unusual site is the jejunum, which accounts for 1% of all DFL’s [12-14]. Historically, there have been a few case reports worldwide of jejunal DFL’s, however, of these reported cases, the lesions were found by advanced imaging (CT angiogram or Bleeding scan). We present a case of a jejunal DFL that was unable to be found by advanced imaging but was diagnosed on push enteroscopy.
Assessment
The patient was a 79-year-old African American female with a known history of end stage renal disease and large granular lymphocytic leukemia. Over the course of 8 months, the patient had 3 admissions for gastrointestinal bleeds. She received a total of 16 units of blood with 4 EGDs, 2 colonoscopies, 1 bleeding scan and 1 CT angiogram. Of the listed procedures performed, all were negative for active bleeding and there was no solid evidence of a bleeding source. She was presumed to have bled twice from erosive gastritis and the most recent admission was from an unknown etiology. An outpatient small bowel capsule study was done after these admissions showing no findings.
She subsequently presented to the ER 24 days after her most recent admission for melena and orthostasis, where she was found to have a hemoglobin of 4.4 g/dL (previous hemoglobin was 10.2 g/dL). EGD and colonoscopy did not show any findings or source of bleeding. The patient continued to have melena and required 8 units of blood. A CT angiogram and bleeding scan were again inconclusive. A push enteroscopy was performed on day 6 of admission, showing an actively oozing area in the jejunum with no surrounding ulceration or malformations (Figure 1). Bipolar cauterization and 2 hemoclips were placed ceasing the actively bleeding Dieulafoy’s lesion. The patient’s hemoglobin stabilized, and the melena resolved 1 day after the enteroscopy.
Management
Our patient had a history of large granulocytic lymphocytic leukemia (LGL) and end stage renal disease. Though the usual course of LGL presents with neutropenia and anemia, thrombocytopenia can be seen in up to 20% of cases [15]. Thrombocytopenia combined with immunosuppression from underlying malignancy and ESRD put this patient at an increased risk of developing hemorrhagic complications such as DFLs. On multiple admissions, our patient was found to pancytopenia, likely as a result of her bleeding and immunosuppression. To date, there have been a few case reports citing immunosuppression, immunotherapy, and thrombocytopenia all being associated with GI bleeds due to a DFL [16,17]. While the mechanism is not yet established, it is thought to be related to impaired tissue remodeling and repair.
The current endoscopic modalities to manage a DFL include mechanical treatment (with endoclips or band ligators), injection therapy (with diluted epinephrine), thermal coagulation therapy, or in some cases, a combination of different modalities. Two controlled trials suggested that mechanical hemostasis with endoclips can control acute bleeding and may reduce recurrent bleeds compared to injection therapy alone [18]. There have been no studies comparing the efficacy of thermal coagulation alone or in combination with other methods. A second trial comparing endoclips to injection therapy with epinephrine showed equal rates of initial hemostasis but significantly lower rates of rebreeding in the endoclip arm (0%) vs epinephrine arm (35%) [19].
Post endoscopic management depends on whether the patient is at high risk or low risk for rebleeding. One method used to calculate risk of recurrence is the Glasgow - Blatchford bleeding score (GBS score). A GBS score of 0-1 is considered low risk for rebleeding, and in this case the patient may be discharged from inpatient care with plans for outpatient endoscopic intervention. Inpatient treatment is recommended for patients with GBS scores of 2 or greater [20]. The rate of recurrence of bleed for a Dieulafoy’s lesion ranges from 9-40% [21]. There is a higher rate of recurrence with endoscopic monotherapy compared to combined endoscopic interventions [22]. The rate of rebleeding is not associated with gender or location of DFL or past medical history [23]. Inpatient treatment recommendation is to treat with IV pantoprazole for 72 hours in order to keep gastric pH above 6 in order to maintain intact coagulation process, followed by oral pantoprazole therapy. While mortality is lowest in patients with no significant medical history or comorbidities, overall longterm prognosis of a DFL is favorable once primary hemostasis is achieved [24]. Following push enteroscopy our patient did well without any further complications or signs of rebleeding [25-30].
Conflict of Interest
All authors have read and approved the submission of this manuscript. The manuscript has not been published and is not being considered for publication elsewhere, in whole or in part. The authors declare that there is no conflict of interests regarding the publication of this paper
To read more articles in
Journal of Surgery
Please Click on:
https://juniperpublishers.com/oajs/index.php
For More
Open Access Journals
in
Juniper Publishers
Click on: https://juniperpublishers.com/journals.php
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I am Syam Kumar. I am a farmer from Kamalapuram. My weight was 114 kg and I had uncontrolled type 2 diabetes with HbA1C 12.6% and uncontrolled blood pressure. My sister underwent Bariatric surgery by Dr. Amar 4 years back. She lost 83.5 kg (From 137.5 to 54 kg) and doing pretty well. Though I hesitated initially, after seeing her I decided to undergo surgery. Dr. Amar performed Metabolic surgery - Sleeve Gastrectomy with Loop Gastroileal Bypass (SG LGIB) on 28th May 2020. It has been 6 months since I underwent surgery, I lost 23 kg in these 6 months, still losing weight! My blood sugar is under control without medications. HbA1C came down to 5.3%. Blood pressure became normal without medications. I am free from both diabetes and hypertension! I am able to eat well and I don't have any weakness. In fact my energy levels increased, I am able to to my work very well which involves lot of physical activity. Dr. Amar is in regular touch with us. Whenever we call he responds and clarifies our doubts. I am very happy that I underwent surgery, that too by Dr. Amar. He is the best.
If you want to talk to me, you can get my number from Dr. Amar. I am happy to clear your doubts.
Regards
Syam Kumar
For more videos please subscribe to this Youtube channel - www.youtube.com/drVamar
Please find the contact details of Dr. Amar below
Dr. V. AMAR
Chief Consultant Bariatric & Metabolic Surgeon
Dr. Amar Bariatric & Metabolic Center,
Jubilee Hills,
Hyderabad
🌏 www.drvamar.com
📱+91 9676675646
#weightlossmotivation #ObesityFreeIndia #drvamar #Type2diabetes #bariatriccommunity #obesitysurgery #hyderabad #bariatriclife #weightloss #diabetes #health #healthylifestyle #fitness #weightlossjourney #nutrition #interview #diabetestype #healthy #overweight #weightlosstransformation #bariatricsurgery #obese #severediabetes #obesity #lifestylechange #weightlosssurgery #weightlossstory #review #bariatricreview #happysmiles
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In CAD With GI Bleeding, Higher Mortality With Triple Therapy
20 in the Journal of Gastroenterology and Hepatology. Parita Patel, M.D., from the University of Chicago Medical Center, and colleagues conducted a retrospective cohort study involving 716 patients hospitalized with LGIB and CAD while on aspirin. Patients were identified using a validated algorithm ...
from Google Alert - Gastroenterology http://ift.tt/2iX2e6Q
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starting night float in a world that doesn’t give a fuck about my suffering
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