Howard K. Gogel

Colonoscopy after golytely preparation in acute rectal bleeding

Thirty-five consecutive patients with acute hematochezia, negative gastric aspirates, and negative sigmoidoscopy underwent urgent colonoscopy after Golytely purgation. Mucosal visualization was excellent. Colonic bleeding lesions were identified in 24 of 35 patients, and hemorrhage originating proximal to the ileoceal valve was documented in three of these 35 patients. Therapeutic endoscopic electrocautery, employed in 12 of 35 patients, was effective in 11. The peroral preparation was well tolerated, and there were no complications of the preparation or of colonoscopy. The data suggest that urgent colonoscopy following Golytely purgation is a safe, sensitive, and specific diagnostic procedure that provides an opportunity for early nonoperative treatment of acute colonic hemorrhage.

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.

Substances that interfere with guaiac card tests: Implications for gastric aspirate testing

Previous studies have shown that acidic pH and several ingestible substances can cause misleading guaiac tests of gastric aspirates. In this in vitro study, over 100 foods, beverages, and drugs were diluted to concentrations potentially present in the stomachs of outpatients being evaluated for gastrointestinal bleeding. These were mixed with known concentrations of blood and tested with different brands of guaiac cards. Decreased guaiac test sensitivity was associated with activated charcoal, dimethylaminoethanol, red chile, N-acetylcysteine, rifampin, red Jell-O (General Foods Corp, White Plains, NY), orange juice, Pepto-Bismol (Norwich Eaton Pharmaceuticals, Norwich, NY), simethicone, spaghetti sauce, and several red wines. Chlorophyll and methylene blue-containing tablets produced false-positive results, but other blue and blue-green colored tablets did not, except at high concentrations. Previously described false-negative results with vitamin C, bile, and certain antacids were confirmed, as were false-positive results with iodide, bromide, cupric sulfate, iron salts, and hypochlorite. Physicians should exercise caution when interpreting guaiac card tests of gastric aspirates, especially in the outpatient setting.

Scrotal and abdominal skin necrosis complicating intravenous vasopressin therapy for bleeding esophageal varices

Two patients with severe liver disease developed scrotal necrosis after intravenous vasopressin infusion for bleeding esophageal varices. One of these patients also developed anterior abdominal wall skin necrosis. Although ischemic complications secondary to vasopressin are probably not totally avoidable, attention to hypovolemia, concomitantly administered pressor drugs, patient position, and points of local pressure may decrease the likelihood of these previously unreported complications.

Emergency management of upper gastrointestinal hemorrhage

In the United States, upper gastrointestinal (UGI) hemorrhage is a common medical emergency resulting in 250,000 admissions/year or SO-150 episodes/ 100,000 population/yeari-3 at an annual cost of nearly one billion dollars.4 It accounts for approximately 15% of admissions to the Medical Intensive Care Unit at The University of New Mexico Hospital. Men are more likely to suffer UGI hemorrhage than women, and bleeding becomes more frequent among both sexes with advancing age.” Despite significant advances in pre-hospital care, patient monitoring, blood banking, endoscopic diagnosis, anesthesia, and surgery, the overall mortality rate for this condition has remained constant at approximately 10% over the past four decades.5 This may be related to the slowly rising average age of patients (currently 59 years)(i.j-9) and to an increasing percentage of patients hemorrhaging within the context of serious underlying disease. Prompt, careful evaluation and management may improve the outcome in individual patients.9 This review explores issues in the care of patients with UGI hemorrhage in the temporal order in which they are confronted by the emergency physician: initial management, clinical evaluation, empirical emergency therapy, specific diagnostic tests, prognosis, prevention of UGI bleeding, and, finally, future trends. Like many other emergent conditions, decisions made early in the clinical course of UGI hemorrhage are the most important in reducing avoidable morbidity and mortality.