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Protocol-based guidelines and acute upper gastrointestinal hemorrhage: DISCUSSION (Part 1)

The agreed protocol used in the study was based on the guidelines for good practice in the management of upper GI hemorrhage recommended by the joint working group of the British Society of Gastroenterology, the Research Unit of the Royal College of Physicians of London and the Audit Unit of the Royal College of Surgeons of England. Continue reading

Protocol-based guidelines and acute upper gastrointestinal hemorrhage: RESULTS (Part 3)


First phase: Two patients, both males over the age of 75 years with a risk score of more than four, required surgery. They had diagnostic and therapeutic endoscopies within 24 h of admission and were each found to have a duodenal ulcer. Both required a second therapeutic EGD for rebleed and had oversewing of the bleeding ulcer at surgery. They were admitted to the HDU. One of them had severe respiratory comorbidity and died from respiratory failure postoperatively. The second patient was successfully discharged home three weeks after surgery. Continue reading

Protocol-based guidelines and acute upper gastrointestinal hemorrhage: RESULTS (Part 2)


First phase: Eighty-six percent of all patients underwent endoscopy some time during their admission. Of the eight patients who did not have an EGD, three refused endoscopic examination, two were young and stable and had a questionable diagnosis of upper GI bleed, one had EGD planned but died of a cerebrovascular accident and two had suspected Mallory-Weiss tears and no endoscopic examination was contemplated. Thirty-four (60%) patients had an EGD within 24 h and 22% had an EGD outside of normal working hours. Eleven (33%) of the high risk group failed to have an endoscopic examination within 24 h. Consultants/staff grade carried out endoscopy in 17 patients whereas in 32 patients specialist registrars performed the endoscopy. All endoscopies were performed by a surgeon. Twenty patients had therapeutic procedures at endoscopy and there were no complications from EGD. Continue reading

Protocol-based guidelines and acute upper gastrointestinal hemorrhage: RESULTS (Part 1)

Demographic data

First phase: Fifty-seven patients had a presumptive diagnosis of upper GI hemorrhage during the study period. Their mean age was 69 years and median of 76 years, range 16 to 95 years, with a male to female ratio of 3:2.

Second phase: Fifty-two patients were admitted with a diagnosis of upper GI bleed. Their mean age was 62 years, median age 69 years and mode 81 years with a range of 15 to 92 years. Continue reading

Protocol-based guidelines and acute upper gastrointestinal hemorrhage: MATERIALS AND METHODS

All patients admitted with a presumptive diagnosis of upper GI hemorrhage or all patients who bled acutely from the upper GI tract while in hospital for treatment of some other condition at FPH between January and April 2000 and then between June to September 2000 were included in the study. All patients had historical and/or clinical evidence of hematemesis and/or melena. Upper GI hemorrhage has been defined in this study as vomit containing red blood (or coffee ground like material, observed by a doctor or a nurse), and/or the stool has been black or red-black confirmed by observation or rectal examination. Continue reading

Protocol-based guidelines and acute upper gastrointestinal hemorrhage

hemorrhageMost audits of acute upper gastrointestinal (GI) hemorrhage usually involve an initial retrospective study to determine the management and outcome, followed by a prospective analysis that attempts to ascertain the impact of specific alteration in clinical practice, making comparison complex and unreliable. A prospective audit was started at Frimley Park Hospital (FPH), United Kingdom, in January 2000. Continue reading

Brunner’s gland hamartoma: CONCLUSIONS


The present case demonstrates a benign Brunner’s gland hamartoma presenting in a middle-aged man, with evidence of both chronic gastrointestinal blood loss as well as acute upper gastrointestinal bleeding. Although in this case, the diagnosis was not known before surgical resection, the benign nature of the lesion was suspected. Because of the symptomatic nature of the lesion, therapy was indicated. In the future, given the known endosonographic characteristics of this lesion, we believe that EUS may hold promise in establishing the diagnosis of these lesions before potentially risky and unnecessary surgical resection, especially with smaller lesions, or in cases in which the patient is asymptomatic. Best quality medications: you can buy viagra super active online any time from the best pharmacy that you can fully trust, not having to doubt the decision you made at any point of your day.

Brunner’s gland hamartoma: DISCUSSION Part 4


EUS may be helpful in establishing a preliminary diagnosis by evaluating characteristics of the mass. Certain lesions tend to have reproducible characteristics on endosonography, and the Brunner’s gland hamartoma is no exception. Whereas a typical Brunner’s gland appears as a heterogeneous hyperechoic structure, the Brunner’s gland hamartoma appears as a heterogeneous hypoechoic mass marked by multiple small cystic areas within the lesion and indistinct margins. Furthermore, it characteristically arises from the second and third echolayer. The multiple small cystic areas and the heterogeneity seen on EUS are secondary to the presence of smooth muscle bundles, fibrous stoma and clusters of glands within the lesion, some of which may be dilated.

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Brunner’s gland hamartoma: DISCUSSION Part 3

Brunner’s gland

In addition, an association between chronic pancreatitis and Brunner’s gland hyperplasia may exist. As many as 76% of patients with pancreaticoduodenal resections for chronic pancreatitis show evidence of diffuse Brunner’s gland hyperplasia, and some suggest that this may be an adaptation in the setting of exocrine insufficiency of the pancreas.
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The differential diagnosis of the Brunner’s gland hamartoma includes adenomatous polyps, leiomyomas, leiomyosarcomas, gastrointestinal stromal tumours, lymphomas, pancreatic or ampullary carcinomas, carcinoid tumour or melanoma, among others.

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Brunner’s gland hamartoma: DISCUSSION Part 2

Brunner’s gland

Although the cause of Brunner’s gland hamartomas is unknown, interesting associations have been noted. Because these glands function to buffer the acid output of the stomach, it has been postulated that Brunner’s gland hyperplasia (and, by extension, Brunner’s gland hamartomas) may be due to hyperchlorhydria. Although this theory may seem plausible, gastric hyperacidity itself is thought to be an unlikely cause, given that Brunner’s gland hyperplasia is not seen in patients with Zollinger-Ellison syndrome. In addition, Spellberg and Vucelic noted that these lesions did not regress after short term cimetidine therapy. Furthermore, Kaplan and colleagues demonstrated, in 1968, that a majority of patients with documented Brunner’s gland hyperplasia did not have increased gastric acid output. Interestingly, Tottrup, et al questioned whether hyperplasia of Brunner’s glands might actually lead to gastric hyperacidity (and not the other way around). They noted that hyperplasia of these glands is associated with subsequent proliferation of duodenal gastrin cells; this may lead to increased gastrin secretion and, consequently, an increase in gastric acid output. High quality medications available at best pharmacy that will make sure you are comfortable and secure when buying cialis professional or any other medicine that you need at any point.

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