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Review
. 2009 Sep;23(9):625-31.
doi: 10.1155/2009/862816.

Recurrent obscure gastrointestinal bleeding: dilemmas and success with pharmacological therapies. Case series and review

Majid Almadi  1 , Peter M Ghali, Andre Constantin, Jacques Galipeau, Andrew Szilagyi
Affiliations
Review

Recurrent obscure gastrointestinal bleeding: dilemmas and success with pharmacological therapies. Case series and review

Majid Almadi et al. Can J Gastroenterol. 2009 Sep.

Abstract
in English, French

The present article describes three difficult cases of recurrent bleeding from obscure causes, followed by a review of the pitfalls and pharmacological management of obscure gastrointestinal bleeding. All three patients underwent multiple investigations. An intervening complicating diagnosis or antiplatelet drugs may have compounded longterm bleeding in two of the cases. A bleeding angiodysplasia was confirmed in one case but was aggravated by the need for anticoagulation. After multiple transfusions and several attempts at endoscopic management in some cases, long-acting octreotide was associated with decreased transfusion requirements and increased hemoglobin levels in all three cases, although other factors may have contributed in some. In the third case, however, the addition of low-dose thalidomide stopped bleeding for a period of at least 23 months.

Le présent article décrit trois cas difficiles de saignements récurrents pour des raisons incertaines, suivis d’une analyse des écueils et de la prise en charge pharmacologique de ce type de saignements. Les trois patients ont subi de multiples explorations. Dans deux cas, un diagnostic interposé compliqué ou des antiplaquettaires ont pu aggraver le saignement à long terme. Une angiodysplasie hémorragique a été confirmée dans un cas mais empirée par la nécessité d’administrer des anticoagulants. Après de multiples transfusions et plusieurs tentatives de prise en charge endoscopique dans certains cas, l’administration d’octréotides à action prolongée s’est associée à une diminution des besoins de transfusion et à une augmentation des taux d’hémoglobine dans les trois cas, même si d’autres facteurs ont pu y contribuer dans certains cas. Dans le troisième cas, cependant, l’ajout d’une faible dose de thalidomide a permis d’interrompre le saignement pendant une période d’au moins 23 mois.

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Figures

Figure 1)
Figure 1)
Case 1. Distribution of transfusions of packed red blood cells (PRBC) and hemoglobin requirements on and off long-acting octreotide
Figure 2)
Figure 2)
Case 2. Distribution of transfusions of packed red blood cells (PRBC) and hemoglobin on and off long-acting octreotide. Transfusions and hemoglobin are displayed for the period of one year off treatment. Acetylsalicylic acid (ASA) was continued for several years until mid March 2003. The patient underwent concomitant octreotide and ASA therapy for three months
Figure 3)
Figure 3)
Case 3. Distribution of transfusions of packed red blood cells (PRBC) and hemoglobin on and off long-acting octreotide up to and including March 2004
Figure 4)
Figure 4)
Angiogram of the superior mesenteric artery. A Extravasations of contrast into the jejunum from an area of hypervascularity approximately 10 cm long, with a prominent vessel in the proximal jejunum. B The placement of three 1 cm microcoils via a 3.2 Fr microcatheter. The extravasations of contrast stopped. Double-line effects are due to motion artefact
Figure 5)
Figure 5)
Distribution of transfusions of packed red blood cells (PRBCs) and hemoglobin with addition of tranexamic acid 1 g four times daily is shown. Subcutaneous (sc) octreotide was added two months later. However, because of further bleeding, thalidomide was also added in November 2006. Transfusion requirements were reduced, then completely eliminated. Hemoglobin level was maintained thereafter
See this image and copyright information in PMC

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