Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding

The pancreaticoduodenal arteries are rare sites for true aneurysm formation, but these may develop in association with occlusion of the coeliac circulation, degenerative conditions or inflammatory vascular disorders. These have a high risk of rupture regardless of size or other factors. One identified cause is polyarteritis nodosa (PAN), which is an autoimmune necrotising vascular condition that affects small-sized and medium-sized arteries. We report a case of a 40-year-old man with massive gastrointestinal tract bleeding from a ruptured pancreaticoduodenal artery aneurysm secondary to PAN. This was managed with emergent open aneurysm ligation followed by high-dose corticosteroids and cyclophosphamide pulse therapy. Only three other cases of PAN-associated pancreaticoduodenal artery aneurysms have been reported in the literature.

The use of prognostic scales in upper gastrointestinal tract bleeding.

IntroductionIn order to select high-risk patients, many prognostic scales have been invented. Among them, Rockall, Glasgow-Blatchford and AIMS 65 scales were considered the most useful.Material and methodsPatients with upper GI tract bleeding, treated between 2017 and 2018 were retrospectively enrolled to the study. Every patient had a Rockall, Glasgow-Blatchford and AIMS 65 score calculated retrospectively. Data on hospitalization as blood transfusions, length of hospital stay, rebleeding, intensive care unit (ICU) admission, mortality was included into data-base.ResultsUnivariate logistic regression revealed that only the AIMS65 scale was a prognostic factor for in-hospital mortality (OR 11.028; 95% CI: [2.271, 53.563], p=0.001). The AIMS 65 score >2 was the only factor predicting the need of >4 blood units transfusion during hospitalization (OR 3.977; 95% CI: [1.305, 12.122], p=0.015), whereas Glasgow-Blatchford scale >5 was the only risk factor for the need of fresh frozen plasma transfusion (OR 3.657; 95% CI: [1.010-13.242], p=0.048). The area under a curve (AUC) in the ROC analysis revealed that the AIMS 65 scale was the most accurate in mortality prediction (AUC=0.859, p=0.002), whereas Rockall score and Glasgow-Blatchford were not significant (AUC=0.614, p=0.093 and AUC=0.504, p=0.97, respectively).ConclusionsBased on our results, we recommend using AIMS 65 scoring system. It’s simple and requires few of parameters to be counted. Also, it proved to be the most efficient in predicting in-hospital mortality.

Lower Gastrointestinal Bleeding

Bleeding from the lower part of the digestive system that appears as hematochezia (fresh blood, clot or cherry-coloured stool) or melena (dark-coloured tarry stool) is called lower gastrointestinal tract bleeding (lower GI bleeding) (or colonic bleeding). In the traditional definition, lower GI bleeding was generally classified as bleeding distal to the Treitz ligament (duodenojejunal junction) as the border. In the last decade, GI bleeding has adopted three categories in some recent publications: Upper, middle, and lower. According to this category, bleeding from a source between the Treitz ligament and the ileocecal valve is classified as middle GI bleeding, bleeding from the distal of the ileocecal valve is classified lower GI bleeding. Lower GI bleeding and hospitalization rates increase with ageing. Currently, physicians managing lower GI bleeding have many different diagnostics and therapeutic options ranging from colonoscopy and flexible sigmoidoscopy to radiographic interventions such as scintigraphy or angiography. Lower GI bleeding often stops spontaneously and less common than upper GI bleeding. Even though no modality has emerged as the gold standard in the treatment of lower GI bleeding, colonoscopy has several advantages and is generally considered as the preferred initial test in most of the cases.

Bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients: a hospital-based study

Background The presence of bacteremia as a complication of variceal bleeding in patients with liver cirrhosis had been investigated by many studies. The aim of this study was to assess the bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients. A cross-sectional study was conducted on 99 patients with chronic liver disease divided into three groups: group I included 35 patients presented with first attack of variceal bleeding, group II included 35 patients presented with recurrent attacks of variceal bleeding, and group III included 29 patients with no history of previous variceal bleeding as a control group. Routine laboratory tests were done, upper GI endoscopy, blood culture, and measurement of procalcitonin level in blood. Results Patients with recurrent variceal bleeding had statistically (p < 0.05) the highest percentage of positive blood culture followed by patients with first variceal bleeding and the control (60% vs 45.7% vs 24.1%) respectively. In addition to procalcitonin results, patients with recurrent variceal bleeding had statistically the highest values of PCT followed by patients with first variceal bleeding and the control (1.92 vs 0.325 vs 0.22 ng/ml) respectively. Multivariate regression analysis showed that procalcitonin and hemoglobin only was the significant predictors for variceal bleeding. Hemoglobin at cutoff value of ≤ 9.6 and procalcitonin (ng/dl) at cutoff value of > 1.76 is the most specific in predicting bleeding 86.21%, 86.21% (CI 95%) respectively. Conclusion Bacteremia and procalcitonin are risk factor for variceal bleeding in cirrhotic patients. Procalcitonin can be used as easily measurable and surrogate biomarker for bacteremia and variceal bleeding.

Rivaroxaban versus warfarin in Chinese elder diabetic patients with non-valvular atrial fibrillation: A retrospective study on the effectiveness and associated risks (EAR) analysis

Purpose: To evaluate the effectiveness and associated risks of rivaroxaban against warfarin in Chinese elderly diabetic patients with non-valvular atrial fibrillation.Methods: Data regarding demographical characteristics, clinical conditions, ischemic stroke, intracranial bleeding, gastrointestinal tract bleeding, myocardial infractions, hip/pelvic fracture, asthma, breast/prostate cancer, and death during 3-years of treatment of 584 Chinese diabetic patients with confirmed non-valvular atrial fibrillation who were placed on rivaroxaban (RX Cohort, n = 201) or warfarin (WF Cohort, n = 383) were collected from hospital records and analyzed. Multivariate analysis was performed for the prediction of the incidence of the treatment-emergent event(s).Results: During the 3-year treatment period, higher numbers of patients were reported for intracranial bleeding (p = 0.042), ischemic stroke (p = 0.042), gastrointestinal bleeding (p = 0.0006), hip/pelvic fracture (p = 0.042), and asthma (p = 0.0007) in WF cohort than RX cohort. Also, higher mortality was reported in WF cohort than for RX cohort (24 vs. 4, p = 0.024). Female sex (p = 0.031), age (p = 0.035), and comorbidities (p = 0.021) were associated with incidence of treatment-emergent event(s).Conclusion: With rivaroxaban, a significant and safe risk-reduction of thromboembolic events are found in elderly diabetic patients with non-valvular atrial fibrillation. Keywords: Anticoagulant, Diabetes, Non-valvular atrial fibrillation, Rivaroxaban, Warfarin