Successful surgical treatment of intractable post-radiation rectal bleeding

Patients will typically present symptoms of chronic post-radiation colitis and proctitis 8-12 months after finishing their treatment. Endoscopic methods play the main role the treatment of bleeding caused by post-radiation colitis and proctitis. Surgical treatment is required for remained approximately 10% of patients. Here we present a 64 year old female with metastatic breast cancer, who was referred to us for intractable rectal bleeding. Total colonoscopy and rigid rectosigmoidoscopy revealed proctitis, rectal and sigmoidal telangiectasis, multiple necrotic ulcers between 15 to 30 cm from the anal verge, and also huge ishemic ulcer with patchy necrotic areas about 10 cm from the anal verge. This abnormal irradiated part was resected and then mucosectomy of the remnant rectum, both transabdominally and transanally was done. We performed pull-through technique of normal proximal colon to anal region through the remnant rectal wall and finally did coloanal anastomosis. Diverting stoma was not made because of anastomosis in anal region. With this technique we can achieve benefits such as avoidance of harsh dissection in a frozen pelvis and its consequences, we can avoid intra-abdominal anastomosis, there is no need to a diverting stoma and, most important of all, definite bleeding control.

The indications for performing colonoscopy in Iranian children – a cross-sectional study

Background: Colonoscopy is the gold standard dia­gnostic method for colon diseases providing an excellent view of the mucosal surface of the colon and terminal ileum. Colonoscopy in children is indicated for dia­gnosis and treatment of gastrointestinal diseases. In this study, we evaluated the reasons for performing colonoscopy in children. Methods: This was a descriptive cross-sectional study including all children referred for colonoscopy to the Gastroenterology clinic affiliated with the Shiraz University of Medical Sciences. The children were selected by a convenient sampling method. Statistical analysis was conducted in the SPSS 22 software. Results: From 389 children referred for colonoscopy, 203 were boys and 186 were girls. The mean age was 8.36 ±4.8 years. The most common reason for colonoscopy was rectal bleeding (63.5%) with the most prevalent dia­gnoses being juvenile polyp and inflammatory bowel disease, each accounting for 11.3% patients. Conclusions: The most common findings of colonoscopy were polyp, IBD and colon inflammation, and the most prevalent symptoms leading to colonoscopy were rectal bleeding, chronic diarrhea, IBD treatment follow-up, suspected IBD and abdominal pain. The high prevalence of pediatric patients presenting with these symptoms indicates the increasing importance of colonoscopy in these patients. Keywords colonoscopy, gastrointestinal bleeding, inflammatory bowel disease, gastrointestinální onemocnění

Rectal gastric heteroptopia in a child. Case-report of casuistic pathology

Heterotopy of gastric mucosa in the rectum in children is a rare malformation to keep in mind when examining a child with a rectal bleeding. About 5 such clinical cases in children were described in the literature over the past 10 years. This condition is congenital, due to impaired tissue differentiation during embriogenesis. This case-report demonstrates the diagnostics and treatment of a child with rectal gastric heteroptopia.

Neutrophils prevent rectal bleeding in ulcerative colitis by peptidyl-arginine deiminase-4-dependent immunothrombosis

ObjectiveBleeding ulcers and erosions are hallmarks of active ulcerative colitis (UC). However, the mechanisms controlling bleeding and mucosal haemostasis remain elusive.DesignWe used high-resolution endoscopy and colon tissue samples of active UC (n = 36) as well as experimental models of physical and chemical mucosal damage in mice deficient for peptidyl-arginine deiminase-4 (PAD4), gnotobiotic mice and controls. We employed endoscopy, histochemistry, live-cell microscopy and flow cytometry to study eroded mucosal surfaces during mucosal haemostasis.ResultsErosions and ulcerations in UC were covered by fresh blood, haematin or fibrin visible by endoscopy. Fibrin layers rather than fresh blood or haematin on erosions were inversely correlated with rectal bleeding in UC. Fibrin layers contained ample amounts of neutrophils coaggregated with neutrophil extracellular traps (NETs) with detectable activity of PAD. Transcriptome analyses showed significantly elevated PAD4 expression in active UC. In experimentally inflicted wounds, we found that neutrophils underwent NET formation in a PAD4-dependent manner hours after formation of primary blood clots, and remodelled clots to immunothrombi containing citrullinated histones, even in the absence of microbiota. PAD4-deficient mice experienced an exacerbated course of dextrane sodium sulfate-induced colitis with markedly increased rectal bleeding (96 % vs 10 %) as compared with controls. PAD4-deficient mice failed to remodel blood clots on mucosal wounds eliciting impaired healing. Thus, NET-associated immunothrombi are protective in acute colitis, while insufficient immunothrombosis is associated with rectal bleeding.ConclusionOur findings uncover that neutrophils induce secondary immunothrombosis by PAD4-dependent mechanisms. Insufficient immunothrombosis may favour rectal bleeding in UC.

Caecal duplication, a case report

The caecum is one of the rarest sites of intestinal duplication cysts. The most common symptomatology includes vomiting, abdominal pain, abdominal distention, palpable mass and rectal bleeding. Most of the duplications are diagnosed within the first two years of life, including prenatal diagnosis. Only few cases of caecal duplication have been reported in the literature up to the present day. We are going to present a case of a five-years old girl with caecum duplication who reached our ward due to abdominal distension with no other symptoms.

Case report: fatal bleeding from a duodenal ulcer—Dieulafoy’s lesion?

A 46-year-old man was admitted to the hospital by ambulance due to syncope. A standard blood screening showed a normal Hb value. The man had known hemorrhoids and a single fresh rectal bleeding earlier at home. On the following morning, the patient suddenly required resuscitation within a few minutes and subsequently died. Autopsy revealed a fatal hemorrhage with blood loss in the stomach and small and large intestines and a mucosal defect of the duodenum. After autopsy, the question arose whether the cause of death might have been a rare Dieulafoy’s lesion—aim of this case report was to clarify the diagnosis.

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records

BackgroundClinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.MethodsWe used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014–2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.Results48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18–24 vs 55–64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.ConclusionsGuideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.