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Massive gastrointestinal bleeding is rarely caused by infectious etiologies especially with esophageal localization. Even if Cytomegalovirus infection (CMV) is not often encountered in the clinical practice, it has to be taken into account when the cause of GI hemorrhage is not obvious. We report a case of a 53 years old, male patient, with diabetes who is admitted in the hospital for cellulitis of the left calf and who developed massive hematemesis with no obvious source at the upper GI endoscopy. The patient was treated conservatory with PPI and blood transfusions but he repeated the hemorrhage after 5 days with severe hypotension and a drop of hemoglobin to 6 g/dl. The second endoscopy revealed massive clots in the esophagus with erythema and deep ulcers underneath while the stomach and duodenum were normal. Multiple biopsies from esophageal mucosa were taken. We suspected viral esophagitis with CMV and we started empiric treatment with valganciclovir for 21 days with favorable clinical course. The infection was then confirmed by the pathology department and the immunohistochemical studies. The control endoscopy after one month showed healed esophageal ulcers with minimal residual lesions. [ABSTRACT FROM AUTHOR]

Esophageal cancer is currently considered the third digestive cancer and among the top ten causes of cancer in the world. Due to lack of screening methods, diagnosis is usually done in advanced stages of the disease, only 60% being candidates for palliative treatment with the survival rate below 20% at 5 years. The aim of this study was to establish the immediate and late complications and the survival rate after stent placement. Methods. This was a retrospective study conducted at Clinical Emergency Hospital Bucharest, Department of Gastroenterology. The study was made on a number of 100 patients with inoperable esophageal cancer in 2012-2014. The main parameters followed were represented by: sex, age, grades of dysphagia, stent diameter and type, immediate and late complications and survival rate. Results. We introduced in the study 100 patients with esophageal cancer. The average age of developing cancer was 63.3±11.1 years with a minimum of 39 and a maximum of 84 years and male sex was the predominant one, 89%. The average survival rate was 14.89±9.3 weeks with a minimum of one week and a maximum of 48 weeks with 11 of the 100 being still alive. Conclusions. Esophageal stenting is a safe and effective procedure technically speaking, but it is limited by the late presentation to the doctor, when the disease is too advanced. The main advantage is the short-term amelioration of the dysphagia, patients benefiting from a better nutrition. [ABSTRACT FROM AUTHOR]

Ascites represents one of the most frequent reasons to present at the emergency room. Although, in 85% of cases, cirrhosis is the responsible cause, we must not ignore other non-hepatic causes of ascites. About 5% of the patients have two causes of ascites -"mixed ascites". In these situations, is mandatory for the doctor to look beyond the main cause and not to be limited just to it. The aim of this study was to present the etiological algorithm of ascites and to illustrate the diagnostic methods based of specific causes. Methods. This was a retrospective study of patients who presented with ascites between January 2012 and December 2014 in the Clinical Emergency Hospital Bucharest. These cases were reviewed retrospectively regarding clinical exam, biological examinations (common laboratory tests, diagnostic paracentesis), ultrasound, radiology and, in particular cases, computer tomography and surgery. Results. We introduced in the study 400 patients with ascites. Regarding the etiology, cirrhosis represented 64% of the total number of causes for ascites, followed by peritoneal carcinomatosis in 23% of the cases, 5% hepatocellular carcinoma and portal vein thrombosis and, in lower percentages, cardiac causes (3%), pancreatic ascites (2%), peritoneal tuberculosis (1%), Budd-Chiari syndrome (1%) and sepsis (1%). Conclusions. Although, apparently the etiological diagnosis is easy, there are situations in which the differential diagnosis is hard and is mainly based on ascitic fluid analysis, imagistic, endoscopic techniques and even laparoscopy intervention with peritoneal biopsy. [ABSTRACT FROM AUTHOR]

Dieulafoy's lesion is rare, but with life-threatening potential. It accounts for 1-2% of acute gastrointestinal (GI) bleeding, but often is under-recognised needing repeated endoscopic evaluations. It represents a dilated aberrant submucosal vessel, which erodes the overlying epithelium in the absence of a primary ulcer. Aim. The aim of this study was to identify the problems with diagnosis and difficulties of treatment in patients with Dieulafoy's lesion. Methods. This was a retrospective study of patients with GI bleeding having as cause Dieulafoy's lesion, between 1st January 2012-1st April 2014 in Clinical Emergency Hospital Bucharest. We have reviewed for localization, anticoagulant/antiplatelet use, comorbidities, number of endoscopies for establishing the diagnosis, treatment type (endoscopic or surgical) and final outcome. Results. We had a total of 3400 cases of upper and lower GI bleeding with 33 cases with Dieulafoy's lesion (prevalence of 0.97%). The localization was: 26 cases subcardial (78.7%), 4 duodenal (12,1%), 2 colonic (6%) and 1 esophageal (3%). 2 cases were misdiagnosed at initial endoscopy, being recognized at the following examinations. One case who presented initially with Dieulafoy bleeding duodenal lesion, returned after a few months with GI bleeding from gastric lesion. Treatment was initial done by endoscopic hemostasis (adrenalin injection/hemoclips/electrocoagulation), successful in 28 cases. The rest of 5 cases had surgery, but 2 cases had complications with unfavourable outcome (death). For 2 patients from the 5 surgical cases, reintervention by endoscopy with hemoclips placement was effectively managed. In one of these cases the source of bleeding wasn't diagnosed initially, the patient had surgery with gastrotomy. He rebleed and endoscopic reevaluation by a more experienced endoscopist revealed an esophageal Dieulafoy lesion which was successful treated by hemoclips and adrenalin injection. Colonic Dieulafoy's lesion are very difficult to identify in massive lower GI bleeding. In our two cases, one of them was misdiagnosed as bleeding from colonic polyps, but at reevaluation Dieulafoy's rectal lesion was treated efficacious by hemoclips. Conclusions. Managing active Dieulafoy's lesion poses a diagnostic and therapeutic challenge. Endoscopic reevaluation is necessary in uncertain cases of GI bleeding. Endoscopic therapy, mainly with hemoclips is highly effective and decreases the mortality. Endoscopist's skill and experience are the main factors for establishing the success of diagnosis and treatment. [ABSTRACT FROM AUTHOR]

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Postpolypectomy bleeding is the most common complication of endoscopic polypectomy, being life threatening in massive hemorrhage. It can be divided in early bleeding which occurs immediately after polypectomy and delayed bleeding which appears after hours to up to 30 days after polypectomy. The aim of this study was to identify the risk factors and the prophylactic management for developing early/delayed postpolypectomy hemorrhage. Methods. This was a retrospective study of patients who developed early or delayed hematochezia after endoscopic polypectomy, between January 2013 - March 2014 in the Clinical Emergency Hospital Bucharest. These cases were retrospectively reviewed regarding risk factors, pathological findings and prophylactic methods or treatment of bleeding. Results. We introduced in the study 71 patients with polypectomies. We had 17 cases (23,94%) with early bleeding, 12 (16,90%) cases with delayed hemorrhage and 42 cases (59,15%) in which we have used prophylactic methods. The risk factors for early bleeding were the size of polyp (median size 2,8 cm), the morphology (thick stalk, sessile). All the bleedings, even the arterial spurting ones were effectively controlled by endoscopic management. Methods included hemoclip placement in all cases and adrenalin injection or electrocoagulation. The patients with delayed bleeding presented in average on the 6th day. The main risk factors were the type of the polyp (sessile), the size (average 10 mm), the old age (more than 60 years), the use of aspirin (even if the guidelines do not contraindicate polypectomy during treatment with aspirin) and early reinitiation of antithrombotic agents. 2 of 12 patients from this group presented with massive bleeding requiring transfusions with packed red blood cells units and urgent colonoscopies. All the cases were successful managed by placing hemoclips and/or injection or thermal probes. We studied a separate group of 42 patients with pedunculated polyps >2 cm / sessile or with aspirin and clopidogrel therapy, in which we had to use prophylactic measures consisting of adrenalin submucosal injection, endoloop placed prior to polypectomy and hemoclips placed prior or after the polypectomy. Only one case of immediate bleeding occurred after endoloop detachment, but it was successfully managed by hemoclips placement. No delayed bleeding occurred after prophylactic measures. Conclusions. Most of postpolypectomy bleedings can be efficiently managed by endoscopic treatment, depending on the endoscopist's technique and availability of hemoclips. In the presence of risk factors (pedunculated polyps >2 cm, sessile polyps, aspirin/clopidogrel use, age >60 years), we recommend prophylactic measures with hemoclips. We recommend the patient to refrain from aspirin for at least 7 days prior to polypectomy if the polyp is larger than 1 cm and the indication is primary prophylaxis, despite the recommendation from the ASGE. [ABSTRACT FROM AUTHOR]

Copyright of Internal Medicine / Medicină Internă is the property of Sciendo and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction. Ingestion of foreign bodies is a common pathology seen in the emergency departments of gastroenterology and ENT, most of the times requiring upper digestive endoscopy. Even though the majority of them are aliments, non-food foreign bodies have an increased risk of perforation, upper gastrointestinal occlusion, bleeding, toxicity, requiring emergency extraction. Aim. We are proposing in this paper to present the experience of Clinical Emergency Hospital Bucharest in management of non-food foreign bodies from the upper digestive tract. Methods. We have evaluated the patients presented after foreign bodies ingestion in the period 1st of January 2010-31st of December 2013 in the Digestive Endoscopy Department of Clinical Emergency Hospital. The endoscopy service from Clinical Emergency Hospital Bucharest has a 24h shift, many patients being redirected from ENT specialized hospitals. The retrieval devices used were: polypectomy snares, alligator forceps, rat-tooth forceps, Dormia basket and overtube. Results. 660 patients with foreign bodies ingestion were analyzed in this period; in only 32 patients (5%) the foreign bodies were non-food. Although classically non-food foreign bodies are present mostly in pediatric pathology, given the hospital's profile addressability for adults, only one case has been forwarded from the pediatrics. Most cases, 50% were represented by voluntary ingestion at psychiatric patients or prisoners. 25% were patients with accidental ingestion of dental work and the rest was the involuntary ingestion of other objects with high diversity (toothbrushes, rings, toothpicks, etc.). Upper digestive endoscopy was effective in extracting foreign bodies in 100% of cases, most commonly using extraction with polypectomy snare or alligator forceps. A single case-narcotics bag showed no indication of extraction because of the associated risk. Conclusions. Endoscopic treatment is the method of choice in dealing with foreign bodies located in the upper digestive tract with a high rate of success. Most patients with foreign body ingestion of non-food need psychiatric evaluation. [ABSTRACT FROM AUTHOR]