Treatment In case 1, the visible vessel was ablated at single-balloon enteroscopy by injection of dilute epinephrine and by heater probe thermocoagulation. She had been taking non-steroidal anti-inflammatory drugs NSAIDs about two days per month for several months, but was not taking proton pump inhibitors PPIs. Gastroscopy is usually the initial treatment for suspected GI bleeding. Published online May Normally this condition is diagnosed and treated by side-viewing modalities such as duodenoscope 3 5 but can also be managed using push endoscopy. In case 1, a year-old woman with prior Roux-en-Y gastric bypass RYGB 11 years earlier for morbid obesity presented with melena, weakness, and orthostatic dizziness for 1 wk.
Use of these specialized endoscopes enteroscopes permitted the diagnosis of the etiology of the acute upper GI bleeding as peptic ulcers, permitted identification of high-risk stigmata of recent hemorrhage SRH consisting of either a visible vessel or active oozing of blood, and permitted performance of therapeutic endoscopy for hemostasis. United States, Through Normally this condition is diagnosed and treated by side-viewing modalities such as duodenoscope 3 5 but can also be managed using push endoscopy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the evaluation of acute UGI bleeding in patients status post RYGB surgery when EGD was non-diagnostic because of failure to intubate these excluded segments. Laparoscopic Roux-en-Y gastric bypass with remnant gastrectomy for focal intestinal metaplasia of the gastric antrum. The patient was readmitted 3 d later for recurrent melena with a hemoglobin level of 5. Percutaneous endoscopic gastrostomy has been successfully used to endoscopically access the excluded segments[ 1 ].
Perforated duodenal ulcer after gastric bypass surgery. Single balloon enteroscopy performed in a year-old woman, status post Roux-en-Y gastric bypass Studt surgery 11 years earlier for morbid obesity, who presented with acute melena and a hemoglobin decline to 5.
Endoscopic shuffling, infection control, and the clinical practice of push enteroscopy. Term explanations RYGB is an acronym for Roux-en-Y gastric bypass surgery, a popular form of bariatric surgery, in which a large part of the stomach and the ugb is surgically excluded from the normal stream of food.
Two patients with UGI bleeding status post RYGB surgery are reported who had non-diagnostic EGDs because of this technical difficulty, but then had 4-cm-wide or 5-mm-wide bulbar ulcers diagnosed and endoscopically treated after successfully intubating the proximal duodenum by push enteroscopy or single balloon enteroscopy.
MLL treated the patient and analysed the manuscript critically.
The symptoms of weakness and orthostatic dizziness suggest that the bleeding caused hypovolemia and was therefore physiologically significant and severe. World J Gastrointest Endosc. Investigations Gastroscopy is usually the initial treatment for suspected GI bleeding.
Ann R Coll Surg Engl ; Colonoscopy did not reveal any etiology of lower GI bleeding. Some authors have even suggested placing a gastrostomy tube within a radiopaque silastic ring during primary RYGB surgery to facilitate subsequent percutaneous endoscopic access to the excluded stomach[ 1 ].
The visible vessel was ablated by injection of 10 mL of dilute epinephrine 1: Gastrointest Endosc ; Surgical reconstruction of a small proximal gastric pouch promotes weight loss by causing early satiety due to limited proximal gastric pouch capacity, and by causing decreased appetite by reducing ghrelin synthesis.
An acidic environment within the excluded segment[ 1415 ], deprivation of the buffering effect of ingested food in the excluded segment[ 16 ], bile acid reflux into the excluded stomach and duodenal bulb, excessive alcohol consumption, frequent NSAID use, and H. This work points out the need for a prospective, large study comparing the diagnostic yield of enteroscopy vs EGD in patients with upper GI bleeding status post RYGB surgery. The patient is doing well at 3 mo follow-up, with no further GI bleeding.
Case of GI Bleeding
Some authorities even suggest resection of the excluded stomach, which can be performed during the initial bypass surgery[ 21 ]. The symptoms of dyspnea, fatigue, and syncope all suggest severe GI bleeding that is causing symptoms of end-organ injury or insufficiency from hypovolemia: Case 2 A year-old woman with prior RYGB for morbid obesity 10 years earlier presented acutely with melena and hematochezia, associated with dyspnea, fatigue, and syncope.
The results of this study require confirmation by a large study that is preferentially prospective, randomized, and controlled. Clin Imaging ; The most important aspect is to control the bleeding, and if this can be achieved by endoscopy and radiological procedures, the physiological stress and potential complications in terms of morbidity and mortality 12 when performing an emergency laparotomy can be avoided.
The patient had one further, self-limited, episode of melena, after which the bleeding resolved, and the patient was discharged.
In case 1, the history of prior RYGB surgery in a patient presenting with melena suggests possible bleeding from an anastomotic marginal ulcer, but other common causes of upper GI bleeding are in the differential diagnosis, including ordinary peptic ulcer disease, hemorrhagic gastritis, hemorrhagic reflux gastritis, as well as relatively uncommon lesions. EGD performed 5 d earlier for melena had revealed no upper gastrointestinal lesions, but the afferent limb of the Roux-en-Y, including the excluded proximal duodenum and stomach, had not been intubated and visualized because of technical difficulties at EGD; B: N Engl J Med.
Elective surgery to save my life: Evaluation of gastrointestinal bleeding by red blood cells labeled in vivo with technetium m.
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Abstract The successful management of upper gastrointestinal GI bleeding requires identification of the source of bleeding and when this is achieved the bleeding can often wtudy treated endoscopically. Correspondence to Dr Michael Wilhelmsen, moc. Normally this condition is diagnosed and treated by side-viewing modalities such as duodenoscope 3 5 but can also be managed using push endoscopy.
The visible vessel was ablated by injection of 10 mL of dilute epinephrine 1: Single balloon enteroscopy showing the etudy bulbar ulcer after dual therapy of dilute epinephrine injection and heater probe thermocoagulation.
Single balloon enteroscopy, with intubation of the afferent limb, revealed a non-bleeding, 4-cm-wide bulbar ulcer with a non-bleeding visible vessel in the afferent limb and no other lesions.