Appendiceal bleeding: A case report

lNTRODUCTlON

The common causes of lower gastrointestinal bleeding are mostly known to be diseases of the colon,rectum, and terminal ileum[1]. However, appendiceal bleeding as the origin is extremely rare.Diverticulum, angiodysplasia, inflammation, and neoplasm are the usual etiologies for appendiceal bleeding[2,3]. Vascular diseases, such as angiodysplasia and Dieulafoy’s lesion, are one of the most common causes of massive bleeding and sometimes can be life-threatening[1,4]. We report herein a case of lower gastrointestinal bleeding due to appendiceal Dieulafoy’s lesion, with a literature review.

CASE PRESENTATlON

Chief complaints

The patient had been previously diagnosed with hemorrhoids and hypertension, but was taking no medications.

History of present illness

The patient reported having experienced approximately 600-800 mL bloody stools before presentation to the hospital. The patient also reported having experienced loss of consciousness for a few seconds.No other gastrointestinal symptoms, such as nausea, vomiting, or abdominal pain, were experienced during the process. The patient denied past history of hematochezia.

History of past illness

A 32-year-old male presented to the emergency department of our hospital with hematochezia that had lasted for 6 h.

Personal and family history

The authors declare that they have no conflict of interest.

Physical examination

The patient’s temperature was 36.5 °C, heart rate was 95 beats per minute, respiratory rate was 20 breaths per minute, blood pressure (measured with electronic cuff) was 147/105 mmHg, and oxygen saturation in room air was 99%. The physical examination showed an anemic appearance, without any other pathological signs.

Laboratory examinations

The laboratory tests showed that hemoglobin was 102 g/L (normal range: 130-175 g/L), revealing a mild anemia. Other routine relevant examinations, such as platelet counts and for markers of coagulation function, and liver and renal function, yielded normal findings. Unfortunately, the patient passed bloody stools again 1 d after conservative treatment in our department, with his hemoglobin level dropping to 86 g/L.

Imaging examinations

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

根据以上数据验证，丁辛醇装置汽提废水水质较好，符合循环水水质要求。在实际运行中丁辛醇装置汽提废水回用于循环冷却水的难度主要在于：在刚开工不稳定阶段，COD波动较大，不利于微生物的控制。对此我们应在刚开工不稳定阶段将丁辛醇汽提废水切出系统，并不断监测丁辛醇汽提废水水质，待水质各项指标稳定后方可切入循环水系统[3]。

FlNAL DlAGNOSlS

从理论计算和实验研究结果看，超高速动能武器对地打击效应与已有常规钻地弹差异很大，集中体现在侵彻深度趋近极限、成坑效应和地冲击效应显著等方面。目前对超高速动能武器的防护尚缺乏成熟的设计规范，文献[20]提出了一种“硬-软-硬分层配置”的遮弹防护结构方案，通过数值模拟计算，验证了方案的可行性。本文在该遮弹防护结构方案的基础上，提出了4种靶体分层设计优化方案，称为“软硬结合、分层配置”。

TREATMENT

We suspected that the source of bleeding was the appendix, which prompted an emergency laparoscopic appendectomy. During that surgery, no signs of acute appendicitis or diverticulitis were observed; however, a large amount of blood clots was observed through the longitudinal incision of the appendix. A vessel stump was also found on the mucosa of the appendix (Figure 1C). Pathologically, a caliber-persistent artery was detected near the vessel stump of the mucosa surface, corresponding to Dieulafoy’s lesion within the appendix (Figure 1D).

OUTCOME AND FOLLOW-UP

The patient had no recurrent hematochezia or melena, and was discharged from the hospital 6 d after the surgery. Follow-up 2 wk later showed no evidence of rebleeding.

PCR反应体系采用康为公司提供的Mix 50 μL。扩增程序参考汪琛颖等[8]的方法。扩增产物经含EB核酸染料的2%琼脂糖凝胶电泳(电压为80 V)检测后，应用全自动数码凝胶成像分析系统(Tanon 2500)进行观察、拍照。

DlSCUSSlON

Several modalities, such as colonoscopy, contrast-enhanced abdominal CT, and angiography, can be applied in diagnosing appendiceal bleeding[2,3,9]. In our case, colonoscopy directly revealed the active bleeding from the appendiceal orifice. For such cases, emergency colonoscopy for acute lower gastrointestinal bleeding should be utilized, at least to the terminal ileum. In addition, the orifice of the appendix should be carefully observed. Contrast-enhanced abdominal CT is useful in evaluating diverticulum, neoplasm, or acute inflammation. Although mesenteric artery angiography requires bleeding of more than 0.5 mL/min, vessel embolization is feasible in controlling acute bleeding[9].

The average age of the included cases was 50.3 years (range: 21-76 years). In terms of sex, 5 males and 2 females are reported on herein. Similar to previous reports, the most likely cause of hospitalization was massive hematochezia, rather than melena[3]. Pathological analyses showed the main vascular factors of appendiceal bleeding to be angiodysplasia and Dieulafoy’s lesion. Dieulafoy’s lesion is caused by an abnormal artery that fails to diminish to the minute size of the mucosal capillary microvasculature[11]. The most common location of Dieulafoy’s lesion is the stomach. Others have reported Dieulafoy’s lesion in the esophagus, duodenum, small intestine, colon, and rectum[12-15]; however, an appendiceal Dieulafoy’s lesion is extremely rare. Among the included publications, there were only 2 cases of appendiceal bleeding due to Dieulafoy’s lesion published in English language[5,7], with ours being the third case.

Acute lower gastrointestinal bleeding is commonly encountered in clinical practice, with colon being responsible for the majority of cases[1]. Appendiceal bleeding, on the other hand, is an extremely rare cause, and as such may be missed or misdiagnosed.Although lower gastrointestinal bleeding is generally less severe than upper gastrointestinal bleeding - with spontaneous cessation of the bleeding occurring in most cases, appendiceal bleeding attributed to vascular diseases, such as angiodysplasia and Dieulafoy’s lesion, may result in massive lower gastrointestinal bleeding and sometimes can be lifethreatening[1,4]. As a clinician, having an awareness of appendiceal bleeding is significant. A literature search of relevant articles on the PubMed/MEDLINE database, from January 1977 to November 2021,was conducted, using the key words of “appendix bleeding” or “appendix hemorrhage”. Six articles regarding appendiceal bleeding due to vascular diseases were identified (Table 1)[5-10].

A reliable and effective choice of treatment for appendiceal bleeding is appendectomy[2]. Other attempts, including vessel embolization and endoscopic therapy (therapeutic barium enema and endoclips), have been reported as successful for controlling bleeding[9,16,17]; however, the risk of acute appendicitis and rebleeding after vessel embolization and endoscopic therapy are unmanageable, and the patient may still require an appendectomy[9,17]. Studies for the feasibility of vessel embolization and endoscopic therapy continue to be warranted.

CONCLUSlON

We present a treatment experience of appendiceal bleeding caused by Dieulafoy’s lesion. Although appendiceal bleeding is a rare cause of acute lower gastrointestinal bleeding, clinicians should consider it during differential diagnosis.

469 Risk factors of intravesical recurrence after upper-tract urothelial carcinoma surgery

FOOTNOTES

Zhou SY designed and drafted the manuscript; Guo MD performed the colonoscopy; Ye XH revised the manuscript for important intellectual content; and all authors approved the final version of the manuscript.

Bleeding of the appendix.

the Natural Science Foundation of Zhejiang Province, No. LQ19H030003; and Key Project of Jinhua Science and Technology Bureau, No. 2018A32022.

Consent was obtained from the patient for publication of this report and any accompanying images.

The personal and family history-taking revealed no information relevant to the current case.

An emergency colonoscopy was performed, and extended up to the terminal ileum. During the procedure, blood clots in the cecum were first washed out and we were then able to observe a large quantity of fresh blood oozing out of the appendiceal orifice (Figure 1A). In addition, contrast-enhanced abdominal computed tomography (CT) scan showed a high-density area in the appendix without any signs of acute appendicitis, tumor, or diverticulum (Figure 1B).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

针对实验设计方案中所采用的单点并联接地设计方案，与单点串联联接地方案对比，对于输入信号噪声的抑制对比结果如图8、图9所示。

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当然，产假制度也有其消极影响。一方面，对于企业来说，员工休产假会打乱企业平常的节奏，企业还要承担部分因员工产假而导致的工作调动、缴纳社保、工资等费用。另一方面，对于女职工自身而言，她们会因为休产假而长期脱离工作岗位，可能存在着影响个人晋升与职业长期发展的担忧。公司和员工在产假这个问题上进行博弈，由于雇主拥有权力和信息方面的绝对优势，可以通过释放一些模棱两可的信息和隐晦的威胁，从而对员工产生压力并且在实际操作中变相降低她们的收入等。

Sheng-Yue Zhou 0000-0001-5808-2545; Mao-Dong Guo 0000-0003-4016-0773; Xiao-Hua Ye 0000-0002-8358-4093.

Wang JJ

从初中数学教材的角度出发来看，学生首先学习的函数图像是一次函数图像，老师在实际教学中往往根据一个具体函数表达式，首先通过一些计算，然后完成列表、描点、连线这三部曲，就此得到一次函数的图像，再往后就是学习反比例函数图像以及二次函数图像，其教学历程“自然”的让人找不出任何瑕疵，很少有人会在这块内容的教学上提出异议.就这样，函数图像在不经意之间来到了我们身边，我们对此习以为常.

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