1/168. Duodenal ulceration into the cystic artery with massive hemorrhage. This is a case presentation of a unique cause of intestinal bleeding. A duodenal ulcer eroded into the superficial branch of the cystic artery, causing massive intestinal hemorrhage. The patient, a 76-year-old woman, presented with left upper abdominal and left back pain secondary to cystic lesions in the pancreas body and tail. Stress after operation and complication of leakage of pancreatic juice after distal pancreatectomy with splenectomy and diclofenac sodium administration may have caused a deep peptic ulcer to erode the cystic artery. We performed a transfixing ligation of the bleeding vessel, serosal suture of ulcer of the gallbladder, and simple closure of the duodenal ulcer with covering greater omentum. There were no serious complications after the operation, and the patient made an uneventful recovery. ( info) |
2/168. Gastric ulcer bleeding: diagnosis by computed tomography. A case of CT demonstration of a bleeding gastric ulcer is presented, in a patient with confusing clinical manifestations. Abdominal CT was performed without oral contrast medium administration, and showed extravasation of intravenous contrast into a gastric lumen distended with material of mixed attenuation. It is postulated that if radiopaque oral contrast had been given, peptic ulcer bleeding would probably have been masked. CT demonstration of gastric ulcer bleeding, may be of value in cases of differential diagnostic dilemmas. ( info) |
3/168. Acute upper gastrointestinal bleed: a case study. Upper gastrointestinal (UGI) bleeding on a presenting symptom is of major significance for nurse practitioners in any clinical setting. Bleeding in the upper gastric tract is a symptom of a disease process rather than a disease in itself. UGI bleeding accounts for 300,000 hospitalizations annually. An astute knowledge of the pathophysiology and clinical presentations of UGI bleeding enables swift intervention and a reduction in morbidity and mortality rates. This article presents a case report of a white male in his fifties diagnosed with metastatic colon cancer and acute UGI bleeding and emphasizes the need for early screening and detection, disease education, and prompt interventions to minimize associated complications. ( info) |
| Postbulbar duodenal ulceration is not common, but when present is difficult to diagnose and treat. Between January 1965 and September 1971, 1,080 patients with duodenal ulcers were treated surgically at St James Hospital. Forty-one ulcers were found at operation to lie distal to the duodenal bulb. Pain was the most common indication for surgery. In six-patients it was clinically indistinguishable from biliary pain, giving rise to diagnostic difficulty. Twelve patients (29%) presented with haemorrhage, a percentage similar to the 25% of bulbar ulcers presenting with this complication over the period of this study. This is contrary to the finding in most other series, that postbulbar ulceration is more frequently complicated by haemorrhage than is bulbar ulceration. Perforation and stenosis are uncommon complications. Postbulbar ulceration is easily overlooked in conventional barium studies. Only one-third of the patients subjected to barium meal x-ray examination had their ulcers identified in the first study. In a further third the presence of an ulcer was suspected, and the remainder required multiple investigations for undiagnosed symptoms before the condition was demonstrated. duodenoscopy was not performed in a sufficient number of patients for its value to be assessed, but other reports indicate that it should be a valuable manoeuvre. The technical difficulties and potential hazards of Polya gastrectomy are discussed and special reference is made to the surgical management of bleeding postbulbar ulcers. ( info) |
5/168. Simple hemostatic procedure for hemorrhagic duodenal ulcer: two cases of arterial hemorrhage quickly controlled by balloon compression. We utilized balloon compression in two cases of arterial hemorrhage from duodenal ulcers. The bleeding was quickly controlled in both cases. The advantages of this technique are its simplicity and ease of performance, and the fact that it does not require precise identification of the bleeding point in the duodenal bulb. No serious complications, such as perforation or stenosis, are associated with this technique. During the healing of the ulcer, balloon expansion may result in decreased duodenal bulb deformity. The following points, however, should be clarified in future studies: a) the stability of the duodenal bulb after longer-term balloon compression, and b) the optimum amount of cold water to be injected into the balloon and the optimum compression time. ( info) |
6/168. Ulcer perforation in gastric urinary conduit: never use a gastric segment in the urinary tract if there are other options available. A male patient, who had had a conservatively treated hemorrhagic peptic ulcer 12 years earlier, underwent gastrocystoplasty after radical cystoprostatectomy for carcinoma of the urinary bladder. After operation the patient suffered urinary incontinence and dysuria which he found so bothersome that the gastric bladder was converted to diversion using the same gastric segment as a tube. Postoperatively there were clots of blood in stomal urine and after the kidneys had been drained intestinal fluid oozed from the stoma. On the 14th postoperative day the patient died of pulmonary embolism. The autopsy showed a perforated peptic ulcer in the gastric segment resulting in a closed fistula to the small bowel. Most probably the reason for development of the peptic ulcer was stress caused by the operation and it might have been avoided by using hydrogen-blocking agents. This case seriously questions whether a gastric segment should be used in the urinary tract at all, and at least it should never be used as a conduit. ( info) |
7/168. life-threatening intraabdominal arterial embolization after histoacryl injection for bleeding gastric ulcer. N-butyl-cyanoacrylate (Histoacryl) injection has become the treatment of choice for acutely bleeding esophagogastric varices, and is the only effective option for endoscopic treatment of gastric varices. Recent reports confirm the ability of Histoacryl injection therapy to achieve immediate hemostasis in cases of gastric ulcer bleeding or Dieulafoy ulcer, where conventional endoscopic hemostatic treatment had failed. Although the overall safety record of Histoacryl injection has been relatively good, there have been scattered cases of serious complications. Here, we present two patients showing life-threatening intraabdominal arterial embolization after Histoacryl injection. They had chronic gastric ulcers with active arterial bleeding. In spite of attempts at hemostatic treatment, complete hemostasis was not achieved. We injected Histoacryl, diluted with Lipiodol, into bleeding gastric ulcers, resulting in successful hemostasis. Soon after the procedure, intraabdominal arterial embolization developed in both patients. One patient survived and the other died. Based on these experiences, we would like to warn gastrointestinal endoscopists to be alert to these fatal complications, and we propose that less diluted Histoacryl seems to be preferable in cases of bleeding peptic ulcers. ( info) |
8/168. Endoscopic removal of an embedded biliary Wallstent by piecemeal extraction. Expandable metal biliary stents are reserved for patients with unresectable malignant biliary obstruction. Occasionally, these stents may cause complications necessitating removal. We describe successful endoscopic removal of a biliary Wallstent one year after insertion in a patient who initially underwent placement of an expandable metal biliary stent for presumed biliary malignancy. The stent was removed after a stent related bleeding duodenal ulcer formed. ( info) |
9/168. Endoscopic band ligation for gastric ulcer bleeding. Endoscopic band ligation is used commonly to treat variceal bleeding. The use of band ligation has been described in selected cases of nonvariceal bleeding. The successful use of endoscopic band ligation, after the failure of standard techniques, to arrest bleeding in two cases of gastric ulcer hemorrhage is reported. prospective studies are indicated to further evaluate this technique. ( info) |
10/168. blindness following gastrointestinal haemorrhage. Loss of vision is a rare but well known complication of distant and recurrent haemorrhage. It shares a poor prognosis, with only 10-14% of cases likely to make a complete recovery. Visual symptoms, due to ischaemic anterior optic neuropathy, vary from blurred vision to complete loss of vision in one or both eyes. The pathogenesis of such ischaemia remains unclear. Gastrointestinal bleeding seems to be the leading cause of loss of vision secondary to haemorrhage. However, complete and permanent blindness following gastrointestinal bleeding has rarely been reported. We report the case of a 51 -year-old woman who complained of complete blindness following blood loss, secondary to peptic ulcer, and discuss the pathogenesis of such a complication. ( info) |