74 - Causes of Upper and Lower Gastrointestinal Bleeding

Causes of Upper GI bleeding

1. Ulcers

2. Varices

3. Mallory-Weiss tears

4. Gastroduodenal erosions

5. Erosive esophagitis

6. Neoplasm

7. Vascular ectasias

8. Erosive duodenitis

9. Aortoenteric fistulas

10. Vascular lesions (including Hereditary Haemorrhagic Telangiectasias {Osler-Weber-Rendu Syndrome} and Gastric antral vascular ectasia {Watermelon Stomach}).

11. Dieulafoy's lesion (An aberrant vessel in the mucosa bleeds from a pin-point mucosal defect).

12. Prolapse gastropathy (Prolapse of proximal stomach into esophagus with retching, especially in alcoholics).

13. Hemobilia or Hemosuccus pancreaticus (Bleeding from the bile duct or pancreatic duct).

Causes of Lower GI bleeding :

A. Small Intestinal Causes : 

                                                        1. Vascular ectasias 

                                                        2. Tumors (Adenocarcinoma,
                                                             Leiomyoma, Lymphoma,
                                                             Benign polyps,
                                                             Carcinoid, Metastases and Lipoma)

                                                        3. NSAID induced Erosions and Ulcers

                                                        4. Crohn's disease

                                                        5. Infection

                                                        6. Ischemia

                                                        7. Vasculitis

                                                        8. Small bowel varices

                                                        9. Diverticula

                                                       10. Meckel's diverticulum (children)

                                                       11. Duplication cysts

                                                       12. Intussusception

B. Colonic sources of bleeding :

                                                        1. Hemorrhoids

                                                        2. Anal fissures

                                                        3. Diverticula

                                                        4. Vascular ectasias (Proximal colon;
                                                             more than 70 y age)

                                                        5. Neoplasms (Primary adenocarcinoma)

                                                        6. Colitis (Infectious, Idiopathic IBD,
                                                            Ischemic or Radiation)

                                                        7. Postpolypectomy bleeding

                                                        8. Solitary rectal ulcer syndrome

                                                        9. NSAID induced ulcers or colitis

                                                       10. Trauma

                                                       11. Varices (Most commmonly rectal)

                                                       12. Lymphoid nodular hyperplasia

                                                       13. Vasculitis

                                                       14. Aortocolic fistulas

                                                       15. IBD (Children and adolescents)

                                                       16. Juvenile polyps (Children
                                                             and adolescents)

                                                       

73 - Wilms' Tumor Staging

*Usually any tumor is staged before surgery, but Wilms' tumor is staged after surgery.

*Based on the stage of the tumor after surgery, the decision whether to give adjuvant chemotherapy or not is usually taken. (This is the typical practice in North America).

*In europe, oncologists first take a biopsy before surgery and confirm the tumor. Then before attempting surgery they try to shrink the tumor (the tumors are usually very large at presentation) by giving chemotherapy to the patient.

*In both the cases the tumor is staged only after surgery.

*It has to be noted that because the European oncologists use chemotherapy and markedly shrink the tumor before surgery, the postoperative staging is more of Stage I and Stage II variety in this case. The prognosis is excellent in both approaches and the overall relapse free survival is also almost the same with both approaches.

*So simply put the Pathologist decides the stage rather than the radiologist or the surgeon.

*STAGING OF WILMS' TUMOR :

- StageI : The tumor is confined to the kidney with capsular or vascular invasion.

- Stage II : The tumor has extended beyond the renal capsule, infiltration of vessels. The cases where biopsy has been performed before surgery are grade II, as well as those cases where the tumor has ruptured intraoperatively.

- Stage III : Positive Lymph nodes in the abdomen or pelvis, peritoneal invasion, or residual tumor at surgical margins.

- Stage IV : Metastatic disease outside the abdomen or pelvis.

- Stage V : Bilateral tumors at original diagnosis.

* Below is a beautiful video (Contrast Enhanced CT Scan) of Wilms' tumor in the right kidney of a 13 month old patient.
- Note the large size and poor heterogenous enhancement of the tumor in a Pediatric patient that is typical of Wilms' tumor.