Clinical Case Summary

Introduction: Hemorrhoid disorders are a frequent reason for attending a gastroenterology clinic. A large number of drugs, procedures, and surgical interventions are used in hemorrhoid therapy, but their efficacy is only moderate with frequent side effects and complications. Sclerotherapy with polidocanol foam injection is an effective treatment modality, with a low complication rate of 2,5% (prostatitis, hemorrhage, abscess).
Case: A 73-year-old male with multiple cardiovascular risk factors and previous history of sigmoidectomy due to complicated diverticular disease and of symptomatic internal hemorrhoids grade IV, submitted to two sessions of polidocanol foam injection with three-week interval. A few hours after the second session, the patient was admitted in the emergency department due to abdominal pain and hematochezia. The colonoscopy showed a violaceous rectal mucosa, ulcerated, suggestive of ischemia, without apparent extramural complication in computed tomography. Conservative management with antibiotics was started, but due to clinical deterioration and endoscopic progression, the patient was referred for hyperbaric oxygen therapy and completed 20 sessions. The endoscopic reavaluation one month after hyperbaric therapy revealed complete mucosal healing. However, it has resulted in stenosis of the colorectal anastomosis, and dilation with through-the-scope balloon resulted in clinical improvement.
Discussion: In our experience, polidocanol foam injected into the hemorrhoids is very effective, reducing bleeding in 98% of patients even in a complex population having grade III and IV, as well as patients under anticoagulation/antiplatelet therapy. In this patient, the previous history of sigmoidectomy with consequent surgical amputation of superior rectal artery was therefore essential in the pathogenesis of the rectal ischemia, suggesting more frequent complications of polidocanol foam injection in patients with previous history of colorectal surgery.

References

Fernandes V, Fonseca J. Polidocanol Foam Injected at High Doses with Intravenous Needle: The (Almost) Perfect Treatment of Symptomatic Internal Hemorrhoids. GE Port J Gastroenterol. 2019 May;26(3):169-175. doi: 10.1159/000492202. Epub 2018 Aug 31. PMID: 31192285; PMCID: PMC6528101.

Introduction

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies managed by gastroenterologists. Despite advances in pharmacological/endoscopic therapy, this condition is still associated with considerable morbidity/mortality.

Aims & Methods

We aimed to characterize Portuguese patients and clinical approaches in UGIB, as well as factors associated with adverse outcomes. We conducted a retrospective multicentric cohort study which included adult patients consecutively presenting UGIB at 6 participating centers over a 6-month period. Data relevant to the initial UGIB episode and for up to 30 days afterwards were collected from patient medical records. Patients’ clinical information was presented using descriptive statistics. Continuous variables were described by mean ± standard deviation. Categorical data were presented as absolute numbers and percentages. Qualitative variables were compared with Chi-square and Fisher's tests. Non-normal distribution quantitative variables were compared with Mann-Whitney test. A p value < 0,05 was considered statistically significant.

Results

600 patients presenting with UGIB were included, mostly men (58,2%, n=349) with a mean age of 71 (18-100), with multiple comorbidities and a mean Charlson comorbidity index of 5 (0-16). Antiplatelet/Anticoagulant/NSAID consumption was present in 53,5% (n=321). The primary symptoms were melena (47,2%, n=283) and hematemesis (27,3%, n=164). The median Rockall score (RS) and Glasgow-Blatchford score were 5 (0-10) and 12 (0-21), respectively. A higher RS was associated with prolonged hospitalization (p=0,03). At least one cause for UGIB was documented in 499 patients (83%). Peptic ulcer disease (PUD, 37,8%, n=192), erosive gastroduodenitis (10,0%, n=51) and gastric/duodenal angiodysplasia (6,7%, n=34) were the main bleeding causes of nonvariceal UGIB (n=507). In patients with chronic liver disease (n=93), variceal bleeding (46,2%, n=43) was the main bleeding cause, followed by PUD (19,4%, n=18). Endoscopic hemostasis was performed in 257 patients (42,8%). Combination therapy (injection therapy + thermal/mechanical therapy) was used in 122 cases. Median hospitalization time was 11 days (0-168) and admission in intensive care unit (ICU) was needed in 9,8% (n=59). Surgery for severe UGIB was performed in 2% (n=12). In-hospital rebleeding occurred in 13,3%, more frequently in chronic liver disease (p=0,02). Death occurred in 90 patients (15%), 73 from a non-bleeding related cause. Logistic regression showed that age≥65 years (p=0,02), chronic liver disease (p=0,049) and ICU admission (p=0,045) were associated with in-hospital mortality.

Conclusion

This study contributed to characterization of Portuguese patients admitted with UGIB in real clinical setting. Gastroenterologists are facing a progressively older population, with multiple comorbidities and on therapies potentially causing UGIB. Although PUD still remains the most common cause of UGIB, other conditions such as angiodysplasia are becoming more frequent in clinical practice. Chronic liver disease is a risk factor for rebleeding and in-hospital mortality. The high mortality observed in this research was mainly due to decompensation of comorbid conditions rather than exsanguination, which reflects the complexity of the elderly. These patients require early risk assessment, adequate resuscitation and an attempt to identify and treat the bleeding source, which might help us to improve the management of UGIB in Portugal.

References

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