Hemorragia digestiva cronica hd oculta
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Este documento presenta el caso de un paciente de 73 años con anemia y hemorragia digestiva oculta crónica. Se realizaron exámenes que mostraron anemia leve con Thevenon positivo. La colonoscopia no identificó la fuente de sangrado. El documento provee información general sobre la hemorragia digestiva oculta, su fisiopatología, etiología, investigación clínica e implicancias diagnósticas.
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Hemorragia digestiva cronica hd oculta
- 1. Encuentra las videosclases en: http:// www.youtube.com/channel/UCgZGxUTlxGuZV3MYDcLWEBg?feature=watch
- 2. HEMORRAGIAHEMORRAGIA DIGESTIVA CRONICADIGESTIVA CRONICA HEMORRAGIA OCULTA DEL TGIHEMORRAGIA OCULTA DEL TGI DR HECTOR PAUCAR SOTOMAYORDR HECTOR PAUCAR SOTOMAYOR CATEDRA DECATEDRA DE GASTROENTEROLOGIAGASTROENTEROLOGIA FMH - UNSAACFMH - UNSAAC
- 3. CASO CLINICOCASO CLINICO Paciente varon de 73 años de edad,Paciente varon de 73 años de edad, derivado del CE de Cardiologia porderivado del CE de Cardiologia por presentar palidez de piel y mucosas,presentar palidez de piel y mucosas, con un resultado de Hto=24%.con un resultado de Hto=24%. La PA es 130/90 mmHg, FC: 78 x minLa PA es 130/90 mmHg, FC: 78 x min Se evidencia palidez de piel ySe evidencia palidez de piel y mucosas, resto del examen fisico esmucosas, resto del examen fisico es normal.normal.
- 4. CASO CLINICOCASO CLINICO Examenes auxiliares:Examenes auxiliares: Hb: 8 gr/dl, Hto: 25%Hb: 8 gr/dl, Hto: 25% Hemograma normalHemograma normal Glucosa, urea y creatinina normalesGlucosa, urea y creatinina normales Ecografia abdominal normalEcografia abdominal normal Thevenon: +++Thevenon: +++
- 6. CONCEPTOS GENERALESCONCEPTOS GENERALES DEFINICION:DEFINICION: ““Hemorragia del TGI que no se pone deHemorragia del TGI que no se pone de manifiesto en las heces”manifiesto en las heces” PREVALENCIA:PREVALENCIA: ““5% en la poblacion general adulta”5% en la poblacion general adulta”
- 8. CONCEPTOS GENERALESCONCEPTOS GENERALES ““Para que se produzca melena es necesarioPara que se produzca melena es necesario una perdida de 100 – 150 ml/dia deuna perdida de 100 – 150 ml/dia de sangre en el TGI”sangre en el TGI” ““Puede existir sangrado de < 100 ml/dia sinPuede existir sangrado de < 100 ml/dia sin sintomas aparentes de sangrado en elsintomas aparentes de sangrado en el TGI”TGI”
- 11. TUMORES Y NEOPLASIASTUMORES Y NEOPLASIAS • Adenocarcinoma primarioAdenocarcinoma primario • MetastasisMetastasis • Polipos GIPolipos GI • LinfomaLinfoma • LeiomiomaLeiomioma • LeiomiosarcomaLeiomiosarcoma • LipomaLipoma
- 12. CAUSAS INFECCIOSASCAUSAS INFECCIOSAS • UncinariasUncinarias • StrongiloidiasisStrongiloidiasis • AscaridiasisAscaridiasis • Enterocolitis TBCEnterocolitis TBC • AmebiasisAmebiasis CAUSAS DIVERSASCAUSAS DIVERSAS • Uso de AINEsUso de AINEs • Correr grandes distanciasCorrer grandes distancias • Sondas de Gastrostomia u otrosSondas de Gastrostomia u otros dispositivosdispositivos
- 13. CAUSAS VASCULARESCAUSAS VASCULARES • Angiodisplasias y ectasias vascularesAngiodisplasias y ectasias vasculares • Gastropatia hipertensiva portalGastropatia hipertensiva portal • HemangiomasHemangiomas • Sindrome del nevo azulSindrome del nevo azul • Estomago en sandiaEstomago en sandia TRASTORNOS INFLAMATORIOSTRASTORNOS INFLAMATORIOS • Ulcera pepticaUlcera peptica • Hernia hiatal (erosiones de Cameron)Hernia hiatal (erosiones de Cameron) • Enfermedad intestinal inflamatoriaEnfermedad intestinal inflamatoria • Esprue CeliacoEsprue Celiaco • Enfermedad de WhippleEnfermedad de Whipple • Gastroenteritis eosinofilicaGastroenteritis eosinofilica • Diverticulo de MeckelDiverticulo de Meckel • Ulcera cecalUlcera cecal
- 14. INVESTIGACION CLINICAINVESTIGACION CLINICA Historia clinicaHistoria clinica • Anemia cronicaAnemia cronica • PicaPica • Perdida de peso, AnorexiaPerdida de peso, Anorexia • Sintomas dispepticosSintomas dispepticos Examen fisicoExamen fisico • Signos de Anemia cronicaSignos de Anemia cronica • PapiledemaPapiledema • CoiloniquiaCoiloniquia • Glositis y queilosisGlositis y queilosis • LinfadenopatiaLinfadenopatia • HepatoesplenomegaliaHepatoesplenomegalia
- 15. INVESTIGACION CLINICAINVESTIGACION CLINICA PRUEBAS DE LABORATORIOPRUEBAS DE LABORATORIO • Test para identificar la deficiencia de FeTest para identificar la deficiencia de Fe Frotis de sangre perifericaFrotis de sangre periferica Hb y HtoHb y Hto Concentraciones sericas de Fe y TransferrinaConcentraciones sericas de Fe y Transferrina • Test para identificar la sangre fecalTest para identificar la sangre fecal Preparados con Guayaco (Tarjetas Hemoccult)Preparados con Guayaco (Tarjetas Hemoccult) Perdida de sangre fecal debe ser mayor a 10Perdida de sangre fecal debe ser mayor a 10 ml/dia para que el test sea positivoml/dia para que el test sea positivo ThevenonThevenon • Endoscopia y RadiografiaEndoscopia y Radiografia
- 16. TABLE 7-40A. TESTS FOR FECAL OCCULT BLOOD Test Reaction Advantages Disadvantages Guaiac - based testing Hydrogen peroxide (catalyst) Inexpensive Low sensitivity Phenol (guaiac) Coloress ® Quinone (blue) Simple Low positive predictive value Peroxidase activity HemoQuant® Step 1 Step 2 Stool heated ® in reducing acid to remove heme iron Purification by extraction to yield free prophyrin solution Quantitative Detects upper gastrointestinal bleeding Does not outperform guaiac testing in screening trials Immunochemical testing HemeSelect® Direct reaction of antibody with hemoglobin Highly sensitive for blood 16 - 24 h Incubation period Detects only intact hemoglobin Not tested in screening trials
- 19. FUNDAMENTO DEL TEST DE GUAYACO BASADO EN LA ACCION PEROXIDASA
- 21. FALSOS POSITIVOS EN EL TEST DE GUAYACO FALSOS NEGATIVOSFALSOS NEGATIVOS • Agentes reductores: Vitamina CAgentes reductores: Vitamina C FALSOS POSITIVOS:FALSOS POSITIVOS: • Alimentos con alta actividad deAlimentos con alta actividad de peroxidasa (Carnes rojas)peroxidasa (Carnes rojas)
- 22. COLONOSCOPIACOLONOSCOPIA Endoscopia altaEndoscopia alta CapsulaCapsula endoscopicaendoscopica Suplemento oral de FeSuplemento oral de Fe No se requiereNo se requiere valoracionvaloracion diagnosticadiagnostica posteriorposterior EnteroscopiaEnteroscopia AngiografiaAngiografia TAC abdominalTAC abdominal Enteroscopia transoperatoriaEnteroscopia transoperatoria Considerar malabsorcionConsiderar malabsorcion
Notas del editor
- Table 7-40A and Figure 7-40B. Fecal occult blood testing has only one purpose in clinical practice, ie, the detection of colorectal neoplasia. In clinical practice, fecal occult blood testing is sometimes used in evaluation of patients with upper gastrointestinal tract symptoms such as dyspepsia or to monitor patients ingesting nonsteroidal anti-inflammatory drugs. However, no study has defined the sensitivity, specificity, or clinical implications of fecal occult blood testing in these patients. In fact, fecal occult blood tests performed in these patients are actually still screening tests for colorectal cancer. Any positive fecal occult blood test should lead a patient to colonic imaging for colorectal cancer. Clinical testing for occult blood can be performed using guaiac-based tests, quantitative tests for porphyrin derivatives such as HemoQuant (University of Minnesota) or immunochemical tests (Table 7-40A). Only guaiac-based tests are used widely. Several tests employ guaiac-impregnated filter paper on a card. Of these, the best studied is the Hemoccult II Card (SmithKline Diagnostics, San Jose, CA). Hemoccult SENSA (SmithKline Diagnostics) is a newer guaiac-based test which is more sensitive and readable [69] than Hemoccult II (Figure 7-40B). Some guaiac-based tests have been developed that employ guaiac-impregnated paper that is dropped into the toilet bowel. These tests offer the theoretical advantage of improved patient compliance. However, improved compliance has not been proven in large clinical trials. Furthermore, the sensitivity and specificity of such tests has not been thoroughly studied, and it cannot be recommended for clinical practice. Guaiac is a natural occurring phenolic compound. In the presence of an oxidizing agent, guaiac is converted to a quinone, which is a blue color. The product should be unequivocally blue in order to be considered positive. In the guaiac reaction, hemoglobin supplies pseudoperoxidase activity, which permits oxidation. Addition of a developing solution containing hydrogen peroxide is usually necessary. Hydrogen peroxide serves as a catalyst for the oxidative reaction.The HemoQuant test provides a quantitative measure of stool occult blood. The test measures not only intact heme but also biochemical breakdown derivatives of heme. Therefore, this test is more likely to detect occult bleeding from the upper gastrointestinal tract than other testing methods. In clinical practice, HemoQuant does not perform better than guaiac-based testing as a screening measure for colorectal cancer [70]. Unfortunately, there is a substantial overlap between the amount of bleeding that occurs in normal individuals and the amount that occurs in patients with colorectal cancer. This overlap is an insurmountable obstacle to the effectiveness of occult blood testing for colorectal cancer. Immunochemical testing, which detects only intact hemoglobin, is probably the most sensitive and specific fecal occult blood test for colorectal cancer [69]. However, it is more expensive than guaiac testing, and major advantages in effectiveness and cost-effectiveness over guaiac testing have not been proven in clinical screening trials. (Figure 7-40B, Courtesy of SmithKline Diagnostics, San Jose, CA) References: [69]. St. John, Young GP, Alexeyeff MA, et al. Evaluation of new occult blood tests for detection of colorectal neoplasia. Gastroenterology 1993 104 1661-1668 [70]. Ahlquist DA, Wieand HS, Moertel CH, et al. Accuracy of fecal occult blood screening for colorectal neoplasia. JAMA 1993 269 1262-1267
- Figure 3-49. Depiction of the principle behind the peroxidase-guaiac-based tests for fecal occult blood such as Hemoccult (SmithKline Diagnostics, San Jose, CA). The colorless guaiac indicator, which is impregnated in the card, turns blue when oxidized in the presence of hydrogen peroxide and the peroxidase activity of hemoglobin. This type of test is the basis for all major screening trials of fecal occult blood testing for colorectal cancer.
- Table 7-40A and Figure 7-40B. Fecal occult blood testing has only one purpose in clinical practice, ie, the detection of colorectal neoplasia. In clinical practice, fecal occult blood testing is sometimes used in evaluation of patients with upper gastrointestinal tract symptoms such as dyspepsia or to monitor patients ingesting nonsteroidal anti-inflammatory drugs. However, no study has defined the sensitivity, specificity, or clinical implications of fecal occult blood testing in these patients. In fact, fecal occult blood tests performed in these patients are actually still screening tests for colorectal cancer. Any positive fecal occult blood test should lead a patient to colonic imaging for colorectal cancer. Clinical testing for occult blood can be performed using guaiac-based tests, quantitative tests for porphyrin derivatives such as HemoQuant (University of Minnesota) or immunochemical tests (Table 7-40A). Only guaiac-based tests are used widely. Several tests employ guaiac-impregnated filter paper on a card. Of these, the best studied is the Hemoccult II Card (SmithKline Diagnostics, San Jose, CA). Hemoccult SENSA (SmithKline Diagnostics) is a newer guaiac-based test which is more sensitive and readable [69] than Hemoccult II (Figure 7-40B). Some guaiac-based tests have been developed that employ guaiac-impregnated paper that is dropped into the toilet bowel. These tests offer the theoretical advantage of improved patient compliance. However, improved compliance has not been proven in large clinical trials. Furthermore, the sensitivity and specificity of such tests has not been thoroughly studied, and it cannot be recommended for clinical practice. Guaiac is a natural occurring phenolic compound. In the presence of an oxidizing agent, guaiac is converted to a quinone, which is a blue color. The product should be unequivocally blue in order to be considered positive. In the guaiac reaction, hemoglobin supplies pseudoperoxidase activity, which permits oxidation. Addition of a developing solution containing hydrogen peroxide is usually necessary. Hydrogen peroxide serves as a catalyst for the oxidative reaction.The HemoQuant test provides a quantitative measure of stool occult blood. The test measures not only intact heme but also biochemical breakdown derivatives of heme. Therefore, this test is more likely to detect occult bleeding from the upper gastrointestinal tract than other testing methods. In clinical practice, HemoQuant does not perform better than guaiac-based testing as a screening measure for colorectal cancer [70]. Unfortunately, there is a substantial overlap between the amount of bleeding that occurs in normal individuals and the amount that occurs in patients with colorectal cancer. This overlap is an insurmountable obstacle to the effectiveness of occult blood testing for colorectal cancer. Immunochemical testing, which detects only intact hemoglobin, is probably the most sensitive and specific fecal occult blood test for colorectal cancer [69]. However, it is more expensive than guaiac testing, and major advantages in effectiveness and cost-effectiveness over guaiac testing have not been proven in clinical screening trials. (Figure 7-40B, Courtesy of SmithKline Diagnostics, San Jose, CA) References: [69]. St. John, Young GP, Alexeyeff MA, et al. Evaluation of new occult blood tests for detection of colorectal neoplasia. Gastroenterology 1993 104 1661-1668 [70]. Ahlquist DA, Wieand HS, Moertel CH, et al. Accuracy of fecal occult blood screening for colorectal neoplasia. JAMA 1993 269 1262-1267
- Table 7-41. False-negative guaiac reactions may occur in the presence of reducing agents, most notably vitamin C. Foods high in peroxidase activity may cause false-positive reactions [71]. This reaction is particularly important for red meat, which should be avoided if rehydration is used. Iron supplements, contrary to widely held beliefs, do not cause false-positive guaiac reactions. However, the dark color of feces in patients on iron supplements may confuse the card reader. Ingestion of aspirin or nonsteroidal anti-inflammatory drugs are very likely to cause a positive reaction that is not the result of colonic neoplasia and should be avoided if possible. References: [71]. Simon JB, Occult blood screening for colorectal carcinoma: A critical review. Gastroenterology 1985 88 820-837