Hepatic larva migrans presenting with upper gastrointestinal haemorrhage: A case report

Visceral larva migrans (VLM) occurs because of a host inflammatory response to the migrating larvae of a nematode. Patients usually present with fever, hepatomegaly and abdominal pain; vascular arterial complications are uncommon. A 19-year female presented with fever, jaundice, abdominal discomfort and melena. Computed tomography (CT) revealed multiple discrete, clustered, complex hepatic cystic lesions consistent with VLM, along with an arterial pseudoaneurysm from the right hepatic artery which was managed with endovascular coil embolisation.

EP.FRI.557 A systematic review on the use of prophylactic Proton Pump Inhibitors in patients with a hip fracture and their effect on developing acute gastrointestinal haemorrhage and mortality

Hip fractures represent a significant burden to every Orthopaedic department. Acute gastrointestinal haemorrhage (AGIH) /stress ulceration is a postoperative complication associated with increased mortality. Stress ulcer prophylaxis such as the use of proton pump inhibitors (PPI) is an important measure to decrease this perioperative complication. Aims This systematic review will aim to determine whether there is any benefit for patients with hip fractures being treated with prophylactic PPI medication to prevent AGIH and whether they reduce mortality. Methods A systematic review of the literature was conducted according to PRISMA guidelines. Studies were identified according to the selection criteria and analysed using statistical software. Results A total of 3 observational studies with 3413 participants met the criteria for inclusion. Patients taking PPIs had a reduced risk of an AGIH hip fracture than those without PPI therapy (RR 0.15 (95% CI 0.04–0.57, p < 0.0001).The use of PPIs in hip fracture patients shows a reduced mortality risk (RR 0.12 (95% CI 0.01–1.06, p < 0.0001). Conclusion These results suggest that prophylactic PPI use in hip fracture patients is associated with a reduced risk of AGIH and also a reduced rate of mortality in this patient group. Orthopaedic surgeons should be aware of the risk of AGIH as a complication in hip fracture patients, knowledgeable to the factors which increase risk in their patient population and be cognisant that the prophylactic use of PPI medication is of benefit in reducing the complication of AGIH and correlates with a decreased mortality rate.

A Review on Meropenem

Meropenem is a new Carbapenem antibacterial agent with wide spectrum of activity for intravenous administration. It is synthetic derivative of Thienamycin. Three analogues of Meropenem are evaluated and active against 18 bacterial strains. Meropenem causes rapid bacterial cell death by covalently binding to penicillin binding proteins (PBS). Structural modification at C-2 position, produced double promoiety prodrug of Meropenem and increases bioavailability of oral administration. Other forms of drug such as liposome and nanoparticles are also available with enhanced absorption. 14C labelled Meropenem prepared from 14C Dimethylamine hydrochloride is used for the analysis of M. tuberculosis transpeptidase. ICI213,689 is the only metabolite of Meropenem and it is inactive. Meropenem penetrates well into the body fluids and tissues including cerebrospinal fluid. Its bioavailability is 100% on intravenous administration. Hence it is used in the treatment of meningitis, febrile neutropenia, anthrax and various other skin and skin structure infections. Dosage reduction is required in patient with reduced renal function but not in hepatic impairment. Seizures, gastrointestinal haemorrhage are observed in patients. Vabmoere is the combination of Meropenem and Vaborbactam which is active against the Carbapenem resistant Enterobacteriacea. Meropenem is an effective broad-spectrum antibacterial drug for the treatment of wide range of infection including polymicrobial infection in both children and adult.

868 The management of acute lower gastrointestinal bleeding using a Sengstaken-Blakemore tube

Introduction Acute lower gastrointestinal haemorrhage can potentially be life-threatening. We present a case of a massive rectal bleed which was managed successfully with a balloon tamponade device designed for upper gastrointestinal haemorrhage. Presentation of case A 75-year-old gentleman, with a history of human immunodeficiency virus and cirrhosis with portal hypertension, presented with bright red rectal bleeding. Investigations showed a low haemoglobin level (74 g/L) and deranged clotting. Oesophago-gastro-duodenoscopy demonstrated no fresh or altered blood. Flexible sigmoidoscopy revealed active bleeding from a varix within the anterior rectal wall 4 cm from the anal verge. Efforts to stop the bleeding, including endoscopic clips, adrenaline injection and rectal packing, were unsuccessful and the patient became haemodynamically unstable. A Sengstaken-Blakemore tube was inserted per rectum and the gastric balloon was inflated to tamponade the lower rectum. The oesophageal balloon was then inflated to hold the gastric balloon firmly in place. A computed tomography angiogram demonstrated no evidence of haemorrhage with balloon tamponade. After 36 h, the balloon was removed with no further episodes of bleeding. Discussion The application of a balloon tamponade device should be considered in the management algorithm for acute lower gastrointestinal bleed. Advantages include its rapid insertion, immediate results and ability to measure further bleeding after the catheter has been placed. Conclusions Sengstaken-Blakemore tube per rectum may effectively control massive low rectal bleeding when alternative methods have been unsuccessful.

Unusual cause of gastrointestinal bleeding in an 84-year-old woman: a miraculous survival from an aortoduodenal fistula repair

An 84-year-old woman presented acutely with dizziness, fatigue and a total of 800 mL of fresh per rectum (PR) bleeding. The significant history of abdominal aortic aneurysm repair 5 years ago included multiple episodes of endovascular leak around the stent associated with abscess of left psoas major, left abdominal wall abscess with sinus formation, appendicitis with abscess formation, and acute pancreatic and chronic cholecystitis with multiple gallstones in the 7 months prior to this presentation. During the preceding 7 months, the patient was stabilised with an intravenous proton pump inhibitor, blood transfusions and Intensive Care Unit (ICU) management for the assumed diagnosis of stress ulcers over multiple hospital admissions. Imaging with CT scan of the abdomen made the more accurate diagnosis of acute gastrointestinal haemorrhage caused by a fistula between the distal duodenum and aorta, which was later surgically confirmed. Removal of infected stents and axillobifemoral bypass were performed with a successful recovery.

Perceived Benefits and Risk of NSAIDs in Relation to Its Association with Cancer: A Comprehensive Review

Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat fever and pain. Apart from its medicinal benefits, it is also well known for its numerous side effects, including myocardial infarction, gastrointestinal haemorrhage, renal failure, etc. Even beside these side effects NSAIDs are believed to play a major role in cancer. Though there are contrary of being inducing or preventive reason for cancer. Many studies shows NSAIDs are associated with the increasing risk of cancer. While as in various studies these drugs also have been investigated for their anti-cancer property as chronic inflammation has direct association with carcinogenesis. This review enlights the role of NSAIDs in cancer promotion and cancer prevention, connection between chronic inflammation and cancer, and some of the potentially lethal side effects of these drugs.

Rivaroxaban Causing Thrombocytopenia in a Case of Deep Vein Thrombosis (DVT)

Novel oral anticoagulants (NOACs) are used as alternative to intravenous anticoagulants. It includes apixaban, dabigatran, rivaroxaban and edoxaban.1 Some of the complications induced by these drugs are gastrointestinal haemorrhage, cerebral haemorrhage and rarely thrombocytopenia. We present a rare case report of a selective factor Xa inhibitor rivaroxaban, which induced thrombocytopenia in a case of deep vein thrombosis (DVT) of right lower limb. Drugs commonly used to prevent embolization of systemic circulation are warfarin and novel oral anticoagulants, such as rivaroxaban and dabigatran.

A rare anomaly: duodenal Dieulafoy’s lesion in a preterm baby

Neonatal Dieulafoy’s lesion is a rare but serious condition that can be life-threatening if not diagnosed and intervened in a timely manner. It presents with episodes of sudden acute gastrointestinal haemorrhage in the form of blood in vomit and/or blood in stool. In general, most of the lesions are successfully treated with endoscopic or angiographic intervention. Surgery is usually reserved for cases that fail endoscopic or angiographic intervention. We present a neonatal case of duodenal Dieulafoy’s lesion that occurred in a 29-week-old male baby with birth weight of 1.2 kg. He developed melena and haematemesis at 4 weeks of life. He required normal saline boluses and transfusion of blood products for acute blood loss. The lesion was successfully treated with endoscopic intervention.

Critical presentation and management of an acute gastrointestinal haemorrhage as a result of an arterioenteric fistula secondary to a failed pancreatic allograft

We present a case of a 60-year-old woman status post failed pancreatic transplant, presenting with right lower extremity pain and large volume rectal bleeding. The team initiated a massive transfusion protocol. Investigations revealed an arterioenteric (AE) fistula between the right external iliac artery and terminal ileum. The patient was then emergently sent for right iliac artery stent placement, successfully stopping the active arterial haemorrhage. Afterwards, the surgical team transected the pancreatic jejunal anastomosis, subsequently resecting 7 cm of jejunum. On postoperative day 1, the patient became unstable, going into disseminated intravascular coagulation evidenced by low platelet count, elevated prothrombin time and bloody output from multiple sites. Resuscitation with pressors and blood product transfusion was unsuccessful. She was made comfort measures only and expired shortly after extubation. Although a rare aetiology, it is important to consider AE fistulas in patients presenting with vascular and gastrointestinal symptoms in the setting of a failed allograft.

Splenic artery pseudoaneurysm complicated by haemorrhage into pancreatic pseudocyst: a clinical case

Background. Splenic artery pseudoaneurysm is a rare complication of acute and chronic pancreatitis caused by an arterial wall lesion with aggressive pancreatic enzymes and followed by arrosive bleeding into pseudocyst lumen and the formation of a dense fibrous capsule prone to growth.Clinical Case Description. Patient M., 61 yo, was emergently admitted to Territorial Clinical Hospital No. 2 with a preliminary diagnosis: Chronic pancreatitis, incomplete remission. Pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting. Gastrointestinal haemorrhage. The patient complained of moderate persistent belting upper abdominal and left subcostal pain, nausea, general weakness, black liquid stool over last five days. Pancreonecrosis in history. Pseudocyst formation in two months, endoscopic papillosphincterotomy and pancreatic stenting in hospital, the aforementioned complaints appeared past three months. Moderate anaemia (haemoglobin 73 g/L, erythrocyte count 2.8 x 1012), hyperamylasaemia (amylase 170 U/L), no other pathology in general and biochemic blood panels. The patient was rendered urgent oesophagogastroduodenoscopy for large duodenal papilla, with no evident bleeding detected. Abdominal CT angiography revealed a haemorrhagic mass connected with splenic artery lumen in the projection of pancreatic tail. The patient was transferred to an interventional radiology room for coil embolisation of splenic artery. The postoperative period was benign, and the patient discharged on day 3 after surgery for outpatient surgical patronage. Definite clinical diagnosis: Chronic pancreatitis, incomplete remission. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting.Conclusion. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst is reluctant to early diagnosis due to a lacking definite clinical picture and tractable only at an interdisciplinary institution disposing with a rich diagnostic toolkit and sufficiently qualified medical personnel. Endovascular treatment is overall most effective and enables a reliable aneurysm isolation from the splenic artery basin.