Occult hemorrhage in Egyptian children with Immune thrombocytopenia

Background Occult hemorrhage can occur in any internal organ in ITP patients. Four sites of occult hemorrhage deserve special attention including microscopic hematuria, fecal occult blood, retinal hemorrhage, and silent intracranial hemorrhage. Aim The aim of this study was to investigate for the frequency of subclinical bleeding in Egyptian children with ITP and its relation to different clinical and laboratory parameters of the disease. Methods This cross-sectional study included 40 ITP patients recruited from the Pediatric Hematology& Oncology unit, Children Hospital, Ain Shams University. Occult blood in stools and urine analysis, fundus examination, and non-contrast brain MRI, for brain microbleed, were done. Results The total number of patients with occult bleeds was eleven. Two patients had occult blood in stool, five had microscopic hematuria, one had retinal bleeds and three patients had brain microbleeds. Nine patients with occult bleeding were chronic, one persistent and one acute ITP patients. Their mean age was 10.23 ± 4.18 and their mean initial bleeding score was 2.55 ± 0.82.There were no significant differences between patients with occult bleeding and those without as regards the platelet counts & hemoglobin level, as well as the mean platelet counts & mean hemoglobin level over the disease duration. Conclusion Our results suggest that subclinical bleeding is a potential risk in children with ITP, more commonly chronic ITP patients. We could not demonstrate a significant relation of occult bleeding to the laboratory findings; nevertheless, the significance of the routine assessment of occult bleeding in ITP and the identification of high-risk patients require additional studies.

Multi-valvular infective endocarditis from Gemella morbillorum

Gemella morbillorum is increasingly implicated in infectious endocarditis. Our patient presented with anaemia and renal failure with evidence of infarcts and embolic disease. He was found to have endocarditis with an organism that could not speciate with standard culture methods requiring matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) for identification and susceptibilities. While involvement of mitral and aortic valves can be expected with Gemella, he had rare involvement of the pulmonic valve in a structurally normal heart. Although bacteriological cure was achieved, due to the locally destructive nature of Gemella, he ultimately required valve replacements for heart failure resolution. Workup for commonly implicated pathologies associated with G. morbillorum led to suspicion of gastrointestinal malignancy with findings of occult bleeding prompting an ongoing evaluation. With improved access to advanced diagnostics, G. morbillorum has been increasingly identified in infectious endocarditis. Given its destructive nature, it is important for clinicians to consider this organism is difficult to identify isolates.

Appendiceal intussusception from endometriosis

An asymptomatic 39-year-old woman was noted to have occult bleeding by faecal immunohistochemical test. Investigations showed a 3 cm×2 cm caecal lesion by colonoscopy that was consistent with abdominal CT scan findings of a 1.6 cm×1.9 cm×2.3 cm enhancing focus in the medial caecal wall. The patient underwent laparoscopic right hemicolectomy after diagnostic laparoscopy and intraoperative colonoscopy revealed an intussuscepted appendix. The final histopathology was an appendiceal intussusception secondary to endometriosis.

Management of patients with occult gastrointestinal bleeding

The majority of cases of occult bleeding are found in the course of colorectal cancer screening or during the evaluation of iron deficiency anemia. In up to half of all patients with occult GI bleeding, the source will not be found on initial endoscopic evaluation. Occult gastrointestinal bleeding is an issue with difficulties in diagnosis and treatment. It may come to the clinic as asymptomatic, detected in routine screenings or as iron deficiency of unknown etiology. In recent years, there have been great advances in the diagnosis and treatment. Capsule endoscopy and enteroscopy have provided these advances. However, the problem is not fully resolved. Additional developments are needed in this regard. In this review, the management of patients with occult gastrointestinal bleeding is explained in the light of the latest literature findings.

A delayed diagnosis of Blue rubber bleb nevus syndrome: characterized by refractory iron deficient anemia

Refractory IDA and chronic occult bleeding from GI tract could happen due to BRBNS. Clinicians should keep in mind to detect the underlying diseases from GI tract by endoscopy. Precision diagnosis and appropriate intervention could booster to upgrade the quality of life for patients.

The Spectrum of Small Intestinal Lesions in Patients with Unexplained Iron Deficiency Anemia Detected by Video Capsule Endoscopy

Background and objectives: Video-capsule endoscopy (VCE) has shown a large range (38–83%) of diagnostic yield in unexplained iron deficiency anemia (IDA) and obscure-occult bleeding. Therefore, we retrospectively investigated the VCE-detected spectrum and the prevalence of small bowel injuries and associated risk factors in inpatients with both of the above reported conditions. Methods: We selected inpatients with IDA (hemoglobin <12 g/dL in women, <13 g/dL in men) and obscure-occult bleeding. We excluded VCE indications other than IDA. Complete medical histories and laboratory tests were collected. All subjects underwent PillCam SB2/SB3. The VCE feature Lewis score was calculated when appropriate. We used the t-test and Fisher’s exact test for continuous and categorical variables, respectively, in univariate analysis. For multivariate analysis, we used binomial logistic regression. Results: We retrieved 109 patients (female:male ratio of 53:56; age 63.4 ± 18.9 years). Eighty patients (73.4%) showed ≥1 small bowel lesions. The Lewis score was calculated in 41 patients: 13 (31.7%) showed a mild (<135) and 28 (68.3%) a moderate-severe (135–790 and >790, respectively) score. In univariate analysis, the small bowel transit time (6.2 ± 2.9 versus 5.2 ± 2.1 h; p = 0.049) and non-steroidal anti-inflammatory drug use for at least two weeks (17.5% versus 0%; p = 0.01) were significantly higher in subjects with injuries. These associations were not confirmed at multivariate analysis. The severity of a lesion directly correlated with proton pump inhibitor (PPI) use and duration (not confirmed in multivariate analysis). VCE can reveal the source of obscure-occult bleeding in a high percentage of unexplained IDAs. A wide spectrum of endoscopic pictures may be found. Known as well as supposed risk factors for small bowel lesions may be detected.

Gastric antral vascular ectasia: A case report and literature review

Gastric antral vascular ectasia (GAVE) is a rare but an important cause of upper gastrointestinal bleeding (UGIB) and commonly presents as occult bleeding that manifests as iron deficiency anemia (IDA). GAVE is commonly associated with chronic illnesses, most frequently liver cirrhosis and connective tissue diseases. The pathogenesis of GAVE is still obscure, and many hypotheses such as mechanical stress, hormonal factors, and autoimmune factors, have been proposed. Upper gastrointestinal endoscopy has a major role in the diagnosis and treatment of GAVE.