We report a rare case of upper gastrointestinal bleeding in a 55-year-old man with monoclonal gammopathy of unknown significance presenting with abdominal pain, weight loss and melaena. Gastroscopy was unremarkable, but melaena persisted, with the development of symptomatic anaemia. While colonoscopy excluded a lower gastrointestinal aetiology, CT revealed jejunitis, confirmed at capsule endoscopy. Histopathological examination of specimens obtained at single balloon enteroscopy revealed an unusual aetiology: small bowel AL-amyloidosis. We review his clinical presentation, radiological, endoscopic and histological findings and review the literature of this unusual condition.
The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.
IntroductionAdenomas detected at Bowel Scope are classified based on the BSG guideline on adenoma follow up. Subjects with high or intermediate risk adenomas are referred for colonoscopy to clear the whole colon of polyps. Subjects with low risk adenomas (one or two sub 1 cm adenomas) undergo polypectomy and are discharged. However, in deviation to the guideline, if adenomas have villous component – tubulovillous adenoma (TVA) or villous adenoma (VA), they are upstaged to intermediate risk and subjects are referred for colonoscopy. We audit the outcome of the colonoscopies in subjects who have been upstaged.MethodInterrogating the Northamptonshire Bowel Scope database, subjects with upstaged adenomas were identified. Colonoscopy and histology reports were reviewed, data collated and analysed. This covered a time period from July 2014 to February 2017 (6000+ Bowel Scope procedures have been performed).Results• 64 subjects (~1% of Bowel Scope subjects) had upstaged adenomas.• 47 males (73.4%) and 17 females (26.6%), 60 TVAs and 4 VAs.• 58 subjects had 1 adenoma, six had 2 adenomas.• Two subjects had 2 adenomas with villous component (1 had two TVAs with high grade dysplasia).• 66 TVAs/VAs in total, mean and median size=6 mm.• 24 in rectum (36.4%), 35 in sigmoid colon (53.0%), 7 in descending colon (10.6%).• 6 subjects have not had colonoscopy (9.4%) - 4 (male) subjects declined, 2 subjects awaiting colonoscopy.• 36 (56.3%) had no further adenomas seen at colonoscopy (2 hyperplastic polyps).• 22/64 (34.4%) subjects had further adenomas – 17 males (81.0%), 4 females (19.0%).• 14 single adenomas, 3 multiple, 1 serrated adenoma (SSA) and 4 non-retrieved.• 27 adenomas resected, 23 diminutive (sub 5 mm, 20 TAs, 2 TVAs, 1 SSA).• 4 larger adenomas; 9 mm, 9 mm, 12 mm and 20 mm (all TVAs).• After colonoscopy, 54/58 (93.1%) patients classed as low risk, 1 (1.7%) as intermediate risk and 3 (5.2%) as high risk.Conclusion66 subjects with low risk adenomas at Bowel Scope upstaged due to villous component yielded 58 colonoscopies thus far (90.6% of eligible) with an overall polyp detection rate of 39.7% and adenoma detection rate of 31.0%. There is a male predominance, 56.3% yielded no adenomas. 85.2% of adenomas resected are diminutive. Only 4 (male) subjects remain upstaged after colonoscopy to intermediate or high risk groups (6.1%).This data opens up a debate to whether upstaging subjects found to have low risk adenomas with villous component is an effective strategy. 93.9% of subjects end up classed as low risk after colonoscopy and the vast majority of adenomas resected at colonoscopy are diminutive. The number needed to colonoscope to remain upstaged is 14.5.Reference. SR Cairns, JH Scholefield, RJ Steele, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut2010;59:666–690.Disclosure of InterestNone Declared
The present letter to editor is related to Bohra A et al Prognostic significance of hepatic encephalopathy in patients with cirrhosis treated with current standards of care. World J Gastroenterol 2020; 26(18): 2221-2231. Hepatic encephalopathy (HE) is a significant and frequent major decompensating event in cirrhosis. However clinical studies examining the clinical outcome of HE are lacking despite its high prevalence.
IntroductionAcute gastrointestinal bleeding is a medical emergency. Some 44% of bleeds are caused by peptic ulcer disease but the most severe haemorrhage and highest mortality is seen amongst those with bleeding oesophageal or gastric varices.1 Competent triage and assessment are cornerstones of its initial management, with emphasis on identifying sick patients with life threatening haemodynamic compromise, and then initiating appropriate and timely resuscitation being of paramount importance in the patient’s outcome. In a national audit, variceal bleeding accounted for just over 10% of all UK admissions, with just fewer than 50% presenting outside normal working hours.2 The average mortality for a variceal bleed is reported to be up to 20%, with studies confirming a 2–3 fold increase in mortality amongst inpatients.2 Therefore it is paramount that all junior are able to recognise and manage suspected variceal bleeds appropriately.MethodsAn initial questionnaire was distributed and completed by 67 junior doctors (FY1-FY2) at the University Hospitals of Leicester in November 2015, all with jobs involving the acute medical take and providing ward cover. Junior doctors perceived confidence and knowledge was sampled in a range of key areas i.e. management pre and post endoscopy, senior support and escalation, blood transfusion targets and use of risk stratification tools such as the Blatchford score. Following evaluation of the initial questionnaire a dedicated teaching programme was delivered to 65 junior doctors, whom were subsequently re-surveyed.ResultsFollowing introduction of the teaching session all junior doctors expressed improved confidence in managing variceal UGIB’s- improved from 8% to 41% of junior doctors feeling confident. Additionally there were significant improvements identified in all areas. Notably; correct pre-endoscopic management improved to 94% (from 36%), appropriate transfusion targets improved from 45% to 76%, knowledge and use of risk stratification scores improved to 88% (from 3%). With inappropriate pre-endoscopic use of proton pump inhibitors falling from 25% to 0%.ConclusionAdopting a focused teaching programme for junior doctors on the management of acute variceal bleeds designed around pre-identified areas of weakness has proven to increase both knowledge and confidence in its specific management. Junior doctor teaching on core medical emergencies such as UGIB’s should perhaps be incorporated into trust induction programmes to ensure junior doctors are as prepared as possible on their first day in clinical practice.References1 Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. SIGN. September 2009.2 UK comparartive audit of upper gastrointestinal bleeding and the use of blood. British.Disclosure of InterestNone Declared
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