• Diagnosis and management of upper gastrointestinal bleeding.

      Wilkins, Thad; Khan, Naiman; Nabh, Akash; Schade, Robert R.; Department of Family Medicine; Department of Medicine (2012-03-01)
      Upper gastrointestinal bleeding causes significant morbidity and mortality in the United States, and has been associated with increasing nonsteroidal anti-inflammatory drug use and the high prevalence of Helicobacter pylori infection in patients with peptic ulcer bleeding. Rapid assessment and resuscitation should precede the diagnostic evaluation in unstable patients with severe bleeding. Risk stratification is based on clinical assessment and endoscopic findings. Early upper endoscopy (within 24 hours of presentation) is recommended in most patients because it confirms the diagnosis and allows for targeted endoscopic treatment, including epinephrine injection, thermocoagulation, application of clips, and banding. Endoscopic therapy results in reduced morbidity, hospital stays, risk of recurrent bleeding, and need for surgery. Although administration of proton pump inhibitors does not decrease mortality, risk of rebleeding, or need for surgery, it reduces stigmata of recent hemorrhage and the need for endoscopic therapy. Despite successful endoscopic therapy, rebleeding can occur in 10 to 20 percent of patients; a second attempt at endoscopic therapy is recommended in these patients. Arteriography with embolization or surgery may be needed if there is persistent and severe bleeding.
    • Hydrogen peroxide improves the visibility of ulcer bases in acute non-variceal upper gastrointestinal bleeding: a single-center prospective study.

      Sridhar, Subbaramiah; Chamberlain, Sherman; Thiruvaiyaru, Dharma; Sethuraman, Sankara; Patel, Jigneshkumar; Schubert, Moonkyung; Cuartas-Hoyos, Francisco; Schade, Robert R.; Department of Medicine (2009-10-19)
      BACKGROUND: Acute non-variceal upper gastrointestinal bleeding (ANVB) or hemorrhage (used interchangeably) is an emergency. Endoscopically applied hydrogen peroxide (H2O2) has been shown to improve visualization of the ulcer base. AIMS: To test the hypothesis that ulcer base clot clearance with 3% H2O2 improves the visualization of ANVB lesions compared to water alone. METHODS: In this single-center prospective study, 320 patients with ANVB were examined, of which 81 met the entry criteria for evaluation. All patients with ANVB underwent urgent endoscopy. Those with adherent clots on the ulcer base were sprayed with 250 ml of water, followed by up to 100 ml of 3% H2O2. The main outcome measurement was Kalloo"s Visual Scores of the ulcer base before and after water and H2O2. RESULTS: Eighty-one patients with gastric ulcers (GU; 34) and duodenal ulcers (DU; 47) met the entry criteria. The mean improvement in grade from water to H2O2 was 2.04 (95% confidence interval [CI] (1.86, 2.23)). The mean volume of H2O2 used to clear clots was higher (70 ml) in patients who were negative for both Helicobacter pylori and non-steroidal anti-inflammatory drug (NSAID) use than in those who were positive for both (31 ml) (P = 0.00). More DU patients (72%) had visible vessels than GU patients (44%) (P = 0.01). CONCLUSIONS: H2O2 improved the visualization of ulcer bases in ANVB. A smaller volume of H2O2 was required to clear clots in patients who used NSAIDs and had H. pylori infection. H2O2 identified more DU vessels. The use of H2O2 should be considered as a standard therapy in the management of clots in ANVB.
    • Salmonella newport bacteremia in a 12-day-old infant.

      Singh, Abhijit; Wilkins, Thad; Schade, Robert R.; Department of Family Medicine (2011-03)
      In the United States, Salmonella infections (salmonellosis) cause multiple medical problems. Although the most common presenting symptom is diarrhea, bacteremia can also occur. An estimated 1.4 million cases of salmonellosis occur annually in the United States. We present a case of Salmonella bacteremia in a 12-day old infant. We discuss the presenting signs, symptoms, and management strategies for a patient younger than 28 days old (neonate) presenting with fever and diarrhea.