Gastrointestinal Endoscopy in High-Risk Patients

Valeshabad

Case Reports in Obstetrics and Gynecology

2013

The incidence of colorectal cancer (CRC) during pregnancy is so rare. Herein we present a case of colorectal cancer that was missed by pregnancy all over the pregnancy period. The patient was a 37-year-old woman (gravid 4, para 2) referred with the complaints of vaginal discharge and suspicious rupture of membrane (ROM). The patient was pale and the initial physical examination revealed dilation of two fingers, effacement about 30%. She underwent emergent cesarean section which showed adhesions surrounding the uterus, the bladder, and the abdominal wall. Forty days postoperatively, the patient presented with abdominal pain in the left upper quadrant (LUQ). Imaging confirmed a mass in LUQ. Partial colectomy of transverse colon (20 cm) was performed. Postoperative histopathologic study revealed a 7 ∗ 6 ∗ 5 cm mass in transverse colon compatible to stage IIa of the Duck class (T3, N0, Mx). Adjuvant chemotherapy was applied and the patient showed improvements during 7 months followup after surgery. Colorectal cancer in pregnancy is associated with diagnostic and therapeutic challenges which mostly lead to late diagnosis in advanced stages and poor prognosis. A targeted program to improve the general population knowledge and the establishment of a national consultant and screening program particularly for women with a planned pregnancy in the high risk group might be beneficial.

Section: Discussionmentioning

confidence: 99%

A Case of Colorectal Cancer during Pregnancy: A Brief Review of the Literature

Valeshabad

Case Reports in Obstetrics and Gynecology

2013

Case Reports in Surgery

“…Maternal oxygen therapy, blood pressure monitoring, and foetal cardiac monitoring are recommended to identify any signs of foetal distress [7]. Complications include placental abruption from mechanical pressure applied to uterus and foetal injury secondary to maternal hypoxia or hypotension during the procedure [8]. …”

Section: Discussionmentioning

confidence: 99%

Virilisation during Pregnancy in a Patient with Metastatic Colorectal Cancer

Conway

Jarvis

Thornton

2012

This paper describes the case of a 25-year-old woman with virilisation occurring during pregnancy in the presence of metastatic colorectal cancer. Virilisation during pregnancy is rare. The potential causes include adrenal, foetal, or ovarian pathologies. The most common causes during pregnancy are pregnancy luteoma and hyperreactio luteinalis. The incidence of cancer during pregnancy is rare and the incidence of colorectal cancer (CRC) in pregnancy is even rarer. The presenting signs and symptoms of CRC can be confused with symptoms commonly encountered during pregnancy, thereby delaying diagnosis and commencement of treatment. Diagnosis and staging also proves more problematic in the pregnant patient as the usual modalities of colonoscopy with biopsy and imaging with CT are relatively contraindicated. Treatment is dependent on gestational age of the foetus. There is currently no agreed best practice as to the role of prophylactic oophorectomy in the prevention of metachronous ovarian metastases. Surgical and adjuvant treatments have implications for females of child-bearing age.

“…In patients with GI bleeding related to a severe coagulopathy (e.g., heparin overdose), the coagulopathy should be reversed before NG intubation to avoid hemorrhage during intubation. Patients may require medication to control arrhythmias or angina and mechanically assisted ventilation before NG intubation (10). NG intubation is best performed in an intensive care or other monitored unit in sick patients with recent MI.…”

Section: Discussionmentioning

confidence: 99%

“…In addition to the usual complications of NG tubes (6)(7)(8), patients status post-MI may be more susceptible to cardiopulmonary complications, particularly myocardial ischemia or cardiac arrhythmias, from anxiety or discomfort during the intubation (9). Yet the data provided by NG intubation on bleeding severity, acuity, and location may be particularly valuable in these patients: (1) in difficult decisions on the timing of endoscopy (i.e., urgent versus elective) because of the increased endoscopic risks soon after an MI (10,11); (2) in avoidance or deferment of nonessential endoscopic tests (e.g., colonoscopy in a patient with melena when the NG aspirate is bloody); (3) in avoidance of recurrent MI secondary to hypovolemia with further GI bleeding (12)(13)(14)(15); and (4) in decisions concerning cardiovascular prophylaxis after MI with aspirin or anticoagulants because of the attendant risks of GI bleeding (16,17).…”

mentioning

confidence: 99%

Safety and Efficacy of Nasogastric Intubation for Gastrointestinal Bleeding After Myocardial Infarction: An Analysis of 125 Patients at Two Tertiary Cardiac Referral Hospitals

Cappell

2005

Dig Dis Sci

Self Cite

Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4-103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55-78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.