Background and study aims: Limited data exist for the use of fully covered
self-expanding metal stent (FCSEMS) as an intervention for immediate bleeds
post-endoscopic sphincterotomy (ES) after primary endoscopic intervention
failure or to reduce the number of delayed bleeding events in patient with
increased risk of bleeding post-ES.
Patients and methods: We evaluated a retrospective cohort of individuals
who had ES performed from 2011 to 2014. A total of 700 patients were identified
with 67 patients having post-ES bleeding. The FCSEMS treatment group included 23
patients and the non-FCSEMS treatment group included 44 patients. The primary
end point was rate of change of Hgb at 72 hours after ES in the FCSEMS group and
the primary endoscopic intervention-only group. A comparison also was made
between the FCSEMS and non-FCSEMS group with regards to proportion of
coagulopathy and number of delayed bleeding events.
Results: The FCSEMS treatment group had a lower bleeding rate at 72 hours
(0.66 g/dL vs 1.98 g/dL P < 0.001), increased proportion of patients
at high risk of bleeding (40 % vs 9 % P value 0.008), and increased
frequency of bleeding events that were moderately severe (52 % vs 9 %
P = 0.0002) compared to the non-FCSEMS treatment group. The FCSEMS group
included 9 patients at increased risk of bleeding and no patients with delayed
bleed compared to the non-FCSEMS group, in which all 4 patients at increased
risk of bleeding developed a delayed bleed.
Conclusion: FCSEMS can provide homeostasis after primary endoscopic
intervention failure, thus reducing the need for high-risk procedures. FCSEMS
can reduce delayed bleeding events in patients at high risk of post-ES
bleeding.
Metastatic breast cancer is typically identified in the bones, lymph nodes, lungs and liver. Rarely does metastatic breast cancer involve the common bile duct (CBD) without direct extension from liver metastasis into the CBD. We present a woman diagnosed with metastatic breast cancer in the CBD after presenting with obstructive jaundice. Patients with a history of primary breast cancer who present with obstructive jaundice secondary to CBD mass need identification of the mass in order to provide appropriate treatment.
Context. Clostridium perfringens septicemia is often associated with translocation from the gastrointestinal or gastrourinary tract and occurs in patients who have malignancy or are immunocompromised. Clostridium perfringens septicemia is usually fatal without early identification, source control, and antibiotics. Case. We present a case of a 65-year-old female with Clostridium perfringens septicemia secondary to emphysematous cholecystitis, with progression to hepatic abscesses. Conclusion. Septicemia secondary to Clostridium perfringens is generally fatal if not detected early. Source control with surgery or percutaneous drainage and early antibiotic therapy is imperative. Hyperbaric oxygen therapy may reduce mortality. Clinicians caring for patients with sepsis and intravascular hemolysis must have Clostridium perfringens septicemia on their differential diagnosis with a low threshold for starting antibiotics and pursuing source of infection.
Background and study aims: Patients with a continuous-flow left ventricular assist device (LVAD) have a 65 % incidence of bleeding events within the first year. The majority of gastrointestinal bleeding (GIB) is from gastrointestinal angiodyplasia (GIAD). The primary aim of the study was to determine whether GIAD was associated with a higher rate of significant bleeding, an increased number of bleeding events per year, and a higher rate of transfusion compared to non-GIAD sources.
Patients and methods: This retrospective cohort study included 118 individuals who received a LVAD at a tertiary medical center from 2006 through 2014. Patients were subdivided into GIB and non-GIB for comparison of patient demographics, comorbid conditions, and laboratory data. GIB was further divided into sources of GIB, GIAD, obscure, or non-GIAD to establish severity of bleeding, rate of re-bleeding, and transfusion rate.
Results: GIAD is associated with an increased number of bleeding events compared to non-GIAD sources of GIB (2.07 vs 1.23, P = 0.01) and a higher number of bleeding events per year (0.806 vs. 0.455 P = 0.001). GIAD compared to non-GIAD sources of GIB was associated with an increased incidence of major bleeding (100 % vs 60 %, P = 0.006) and increased rates of transfusion (8.8 vs 2.95 units, P = 0.0004). Cox Regression analysis between non-GIB and GIAD demonstrated increased risk with age (P = 0.001), history of chronic kidney disease (P = 0.005), and length of stay after LVAD implantation of more than 45 days (P = 0.04). History of hypertension (P = 0.045), diabetes mellitus (P = 0.016), and male gender was associated with decreased risk (P = 0.04).
Conclusion: Patients with a continuous-flow LVAD who develop a GIB secondary to GIAD have a higher rate of major bleeding, multiple bleeding events, and require more transfusions to achieve stabilization compared to patients who do not have GIAD.
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