Gastrointestinal Bleeding in the Cancer Patient

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Etiology

The major causes of UGIB in both cancer and noncancer patients are summarized in Box 1. Less commonly, cancer from various primary sources can metastasize to the esophagus, stomach, or duodenum and may be present with GIB ranging from an occult bleed to a significant hemorrhage. Lymph node disease from either primary GI lymphoma or metastatic disease can also erode through overlying mucosa and become a source of significant bleeding. In addition, mucositis related to chemotherapy can lead to

Lower gastrointestinal bleeding

Acute LGIB is one of the most common GI indications for hospitalization, increasing dramatically with age.49 Colorectal cancer, commonly presenting with LGIB, is the fourth most commonly diagnosed cancer and second leading cause of cancer-related deaths in the United States.50 Approximately 147,000 cases are diagnosed annually with over 57,000 deaths.50 Depending on patient population, somewhere between 1% and 17% of acute LGIB is due to colonic neoplasms.51 Postpolypectomy bleeding accounts

Summary

UGIB has a relatively high mortality rate despite advances in treatment and detection. Although cancer is a less likely primary cause of upper GI bleeding, hematologic and anatomic cancer-related changes complicate the work-up and management of UGIB. Additionally, cancer treatments can have a variety of consequences that can lead to occult or massive hemorrhage. Initial management for GI bleeding is similar in patients with and without cancer; however, special consideration must be given to

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References (96)

  • M. Contreras

    Diagnosis and treatment of patients refractory to platelet transfusions

    Blood Rev

    (1998)
  • G.M. Eisen et al.

    An annotated algorithmic approach to upper gastrointestinal bleeding

    Gastrointest Endosc

    (2001)
  • F.W. Green et al.

    Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor prolonged gastroduodenal mucosal hemorrhage

    Gastroenterology

    (1978)
  • J.L. Frossard et al.

    Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial

    Gastroenterology

    (2002)
  • W. Qureshi et al.

    ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005

    Gastrointest Endosc

    (2005)
  • L. Amitrano et al.

    MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

    J Hepatol

    (2005)
  • W.C. Chen et al.

    Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial

    Gastrointest Endosc

    (2001)
  • A.R. Soylu et al.

    Overt gastrointestinal bleeding in haematologic neoplasms

    Dig Liver Dis

    (2005)
  • A. Okano et al.

    Predictors of bleeding after endoscopic mucosal resection of gastric tumors

    Gastrointest Endosc

    (2003)
  • R.E. Davila et al.

    ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer

    Gastrointest Endosc

    (2005)
  • R.E. Davila et al.

    ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding

    Gastrointest Endosc

    (2005)
  • G.R. Zuckerman et al.

    Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes

    Gastrointest Endosc

    (1999)
  • G. Zuccaro

    Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee

    Am J Gastroenterol

    (1998)
  • J.M. Hunter et al.

    Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding

    Am J Surg

    (1990)
  • F.H. Miller et al.

    An initial experience: using helical CT imaging to detect obscure gastrointestinal bleeding

    Clin Imaging

    (2004)
  • M. Cuffy et al.

    Colorectal cancer presenting as surgical emergencies

    Surg Oncol

    (2004)
  • J.S. Gady et al.

    Selective arterial embolization for control of lower gastrointestinal bleeding: recommendations for a clinical management pathway

    Curr Surg

    (2003)
  • J.M. Schwartz et al.

    Severe gastrointestinal bleeding after hematopoietic cell transplantation, 1987-1997: incidence, causes, and outcome

    Am J Gastroenterol

    (2001)
  • D.J. Weisdorf et al.

    Acute upper gastrointestinal graft-versus-host disease: clinical significance and response to immunosuppressive therapy

    Blood

    (1990)
  • T. Akimoto et al.

    Rectal bleeding after high-dose-rate brachytherapy combined with hypofractionated external-beam radiotherapy for localized prostate cancer: impact of rectal dose in high-dose-rate brachytherapy on occurrence of grade 2 or worse rectal bleeding

    Int J Radiat Oncol Biol Phys

    (2006)
  • C. Cozzarini et al.

    Significant correlation between rectal DVH and late bleeding in patients treated after radical prostatectomy with conformal or conventional radiotherapy (66.6-70.2 Gy)

    Int J Radiat Oncol Biol Phys

    (2003)
  • P.C. Koper et al.

    Impact of volume and location of irradiated rectum wall on rectal blood loss after radiotherapy of prostate cancer

    Int J Radiat Oncol Biol Phys

    (2004)
  • T. Akimoto et al.

    Rectal bleeding after hypofractionated radiotherapy for prostate cancer: correlation between clinical and dosimetric parameters and the incidence of grade 2 or worse rectal bleeding

    Int J Radiat Oncol Biol Phys

    (2004)
  • M. Chun et al.

    Rectal bleeding and its management after irradiation for uterine cervical cancer

    Int J Radiat Oncol Biol Phys

    (2004)
  • G. Rotondano et al.

    Long-term outcome of argon plasma coagulation therapy for bleeding caused by chronic radiation proctopathy

    Dig Liver Dis

    (2003)
  • T.J. Maatman et al.

    Simplified management of post-prostate biopsy rectal bleeding

    Urology

    (2002)
  • S.J. Teach et al.

    Rectal bleeding in the pediatric emergency department

    Ann Emerg Med

    (1994)
  • J.J. Imbesi et al.

    A multidisciplinary approach to gastrointestinal bleeding in cancer patients

    J Support Oncol

    (2005)
  • R. Enns

    Acute lower gastrointestinal bleeding: part 1

    Can J Gastroenterol

    (2001)
  • D.A. Gilbert et al.

    The national ASGE survey on upper gastrointestinal bleeding. III. Endoscopy in upper gastrointestinal bleeding

    Gastrointest Endosc

    (1981)
  • M.S. Cappell

    Common hepatic emergencies. Preface

    Med Clin North Am

    (2008)
  • N.M. Blijlevens

    Cytotoxic treatment-induced gastrointestinal symptoms

    Curr Opin Support Palliat Care

    (2007)
  • P.A. Salem et al.

    Histiocytic lymphoma presenting with portal hypertension and bleeding esophageal varices: a case report

    J Surg Oncol

    (1982)
  • D.O. Faigel et al.

    Chronic lymphocytic leukemia: an unusual cause of upper gastrointestinal hemorrhage

    Am J Gastroenterol

    (1995)
  • R.E. Schwarz et al.

    Successful management and outcome of a postoperative aortogastric fistula in a patient with recurrent gastric cancer: report of a case

    Surg Today

    (2002)
  • S. Shuangshoti

    Fatal hemorrhage from additional primary esophageal squamous cell carcinoma in a patient previously having primary bronchogenic adenocarcinoma

    J Med Assoc Thai

    (1995)
  • R.E. Cuellar et al.

    Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate

    Arch Intern Med

    (1990)
  • J.M. Duggan

    Personal view: crystalloid transfusion in acute gastrointestinal haemorrhage: is it beneficial? An historical perspective

    Aliment Pharmacol Ther

    (2006)
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