A. Nunes

Nonvariceal upper gastrointestinal bleeding in Portugal, A multicentric retrospective study in twelve Portuguese hospitals

BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with important mortality. More information is needed in order to improve NVUGIB management. The aims of this study were: (a) characterizing Portuguese patients and clinical approaches used in NVUGIB, (b) comparing management used in Portugal with management globally used in European countries, (c) identify factors associated with management options, and (d) identify factors associated with adverse outcome. METHODS ENERGiB was an observational, retrospective cohort study, on NVUGIB with endoscopic evaluation, carried across Europe. This study focuses on Portuguese patients of the ENERGiB study. Patients were managed according to routine care. Later, data were collected from files. Multivariate/univariate analyses were conducted on predictive factors of poor outcome and clinical decisions. RESULTS Patients (n=404) were mostly men (66.8%), mean age 68, with co-morbidities (72%), frequently on NSAIDs/aspirin. Most were assisted by general medical (57.8%) or surgical team (20.6%), only 19.4% by gastroenterology/GI-bleeding team. PPI was largely used. Gastric/duodenal ulcers, erosive gastritis and esophagitis were the main bleeding causes. 10% had bleeding persistence/recurrence. Death occurred in 24 patients, 20 from a non-bleeding related cause. Poor outcomes were related with age >65, co-morbidities, fresh blood haematemesis, shock/syncope, bleeding through previous nasogastric tube, massive fluid replacement or transfusions besides erythrocytes. CONCLUSIONS This study contributed to characterization of Portuguese patients and NVUGIB episodes in real clinical setting and identified factors associated with a poor outcome. It also identified differences, especially in the organization of GI bleeding teams, which might help us to improve the management of these patients.

Obstrucción pilórica en un paciente con gastrostomía percutánea

Reportamos el caso de un varón de 44 años de edad, residente de un asilo, bajo alimentación enteral mediante gastrostomía endoscópica percutánea (PEG), desde que sufrió una embolia 2 años antes. De manera accidental se extrajo su sonda de alimentación. Para prevenir el cierre de la gastrostomía, le fue colocado de inmediato una sonda de Foley. Después de varias horas, presentó vómito. Al día siguiente, se llevó a cabo una endoscopia después de haber administrado azul de metileno mediante el catéter. Reveló que la sonda de Foley había atravesado el antro gástrico (fig. 1) con el globo migrando al duodeno (fig. 2) causando obstruccion parcial (fig. 3). El catéter fue retirado, se introdujo una sonda de PEG, 20F de Bard®, resolviendo así la obstrucción. En casos de extracción accidental de sondas de PEG, con el objeto de evitar que la gastrostomía se cierre, con frecuencia se utilizan sondas de Foley, ya que son fáciles de pasar mediante la gastrostomía y se encuentran disponibles en la mayoría de las instituciones de salud. Sin embargo, no cuentan con un borde externo y la peristalsis podría arrastrar el globo al duodeno originando obstrucción pilórica. En lugar de proceder con la inserción de una sonda de Foley, se debe referir rápidamente a los pacientes a algún centropresented with vomiting. The next day, after the administration of methylene blue through the catheter, the patient underwent an endoscopy, which revealed that the Foley catheter had passed into the pyloric antrum (fig. 1), with the balloon migrating into the duodenum (fig. 2), causing partial obstruction (fig. 3). The catheter was removed, a 20 F Bard PEG tube was inserted, and the obstruction was resolved. In cases of accidental PEG tube extraction, Foley catheters are frequently used to prevent gastrostomy closure because they are easily passed through the gastrostomy and they are available at the majority of health facilities. However, they do not have an external bumper and peristalsis can pull the balloon into the duodenum, causing gastric outlet obstruction. Rather than

Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding

CONTEXT Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. OBJECTIVES The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. METHODS From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake. RESULTS From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. CONCLUSIONS Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.

Diagnóstico endoscópico de un hematoma intramural que se presentó como íleo por anticoagulantes

A 73-year-old man with hypertension and atrial fibrillation under warfarin was admitted with abdominal pain, distension, and dark blood hematemesis. He presented with anemia (Hb-8.4 g/dL), prolonged prothrombin time and partial thromboplastin time with an INR >15. An endoscopy was performed. No lesions were identified, reporting only blood in the duodenum. A 150 cm long pediatric colonoscope was introduced disclosing purple mucosa with ulcerations in the distal duodenum with spontaneous bleeding (Fig. 1a). As the endoscope passed into the jejunum, large and deeper ulcers were observed (Fig. 1b). Approximately 15 cm distal to the

Dr. Max Winternitz. (1900-1952)

Dr. Max Winternitz. (1900-1952) Sad news reached us from Czechoslovakia about the death of Dr. Max Winternitz on September 20th, 1952. He had been suffering from coronary insufficiency and died rather suddenly during a vacation in his beloved Tatra mountains. Max Winternitz was born in Prague on June 11th, 1900, a son of Moritz Winternitz who was well known for his research in Sanskrit literature. He graduated from the Medical School of the German University in Prague and soon became first assistant at the First Medical University Clinic where he developed an outstanding department of electrocardiography. He spent World War II in England and later returned to Czechoslovakia where he became chief of a large department of internal medicine