American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding

Efficacy and safety of thalidomide in gastrointestinal angiodysplasias: systematic review and meta-analysis with trial sequential analysis of randomized controlled trials

Background

Gastrointestinal (GI) angiodysplasias is a potential cause of life-threatening bleeding. Thalidomide may have a certain effect on the treatment.

Objectives

We aim to evaluate the efficacy and safety of thalidomide and used trial sequential analysis (TSA) to assess the need for further randomized controlled trials (RCTs).

Design

Meta-analysis of RCTs.

Data sources and methods

We systematically searched Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, WanFang, and China National Knowledge Infrastructure databases for RCTs evaluating thalidomide in GI angiodysplasias without language restrictions. We used a random-effects model to obtain pool data and followed Grading of Recommendations Assessment, Development and Evaluation framework. TSA was employed to control the risk of random errors and to evaluate the validity of our conclusions.

Results

Three RCTs were included involving 279 patients with the proportion of small intestinal angiodysplasias of 87.1%. Thalidomide led to improved mean change of hemoglobin level [mean difference (MD): 3.06, 95% confidence interval: 2.66-3.46] without severe adverse effects occurring. Other secondary endpoints, including effective response rate, cessation of bleeding after treatment, hospitalization rate because of bleeding, change in duration of hospital stays for bleeding, transfused red cell requirements, and overall adverse effects, also showed significantly better outcomes in the thalidomide group compared to the control group. TSA for all outcomes exceeded required information sizes, and cumulative Z curve all traverse trial sequential monitoring boundary.

Conclusion

Almost all of the evidence was of moderate quality, suggesting that thalidomide holds promise for treating GI angiodysplasias, with favorable safety profiles. TSA suggests that conducting large-scale real-world research is recommended over relying solely on RCTs conducted within the same population and trial design.

Trial registration

This meta-analysis protocol was registered on PROSPERO (CRD42023480621).

Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience

A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel-Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn's disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel's diverticulum and Crohn's disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.

Real-time multi-contrast magnetic particle imaging for the detection of gastrointestinal bleeding

Gastrointestinal bleeding, as a potentially life-threatening condition, is typically diagnosed by radiation-based imaging modalities like computed tomography or more invasively catheter-based angiography. Endoscopy enables examination of the upper gastrointestinal tract and the colon but not of the entire small bowel. Magnetic Particle Imaging (MPI) enables non-invasive, volumetric imaging without ionizing radiation. The aim of this study was to evaluate the feasibility of detecting gastrointestinal bleeding by single- and multi-contrast MPI using human-sized organs. A 3D-printed small bowel phantom and porcine small bowel specimens were prepared with a defect within the bowel wall as the source of a bleeding. For multi-contrast MPI, the bowel lumen was filled with an intestinal tracer representing an orally administered tracer. MPI was performed to evaluate the fluid exchange between the vascular compartment of the bowel wall and the lumen while a blood pool tracer was applied. Leakage of the blood pool tracer was observed to the bowel lumen. Multi-contrast MPI enabled co-registration of both tracers at the same location within the bowel lumen indicating gastrointestinal bleeding. Single- and multi-contrast MPI are feasible to visualize gastrointestinal bleeding. Therefore, MPI might emerge as a useful tool for radiation-free detection of bleeding within the entire gastrointestinal tract.

Gastrointestinal bleeding of undetermined origin: What diagnostic strategy to propose?

Gastrointestinal bleeding of undetermined origin (GBUO) is defined as gastrointestinal bleeding without an identified cause or location despite an endoscopic assessment including an esogastroduodenal endoscopy (EOGD) and a total colonoscopy. A distinction is made between exteriorized GBUO and non-exteriorized occult GBUO. The causes in the majority of cases (vascular, inflammatory and tumoral) are located in the small intestine. The diagnostic strategy aiming to locate the origin of the GBUO is a real challenge. Innovation in endoscopic and imaging techniques has enabled minimally invasive exploration of the small intestine. In Europe, there is a strong consensus to recommend a video-capsule endoscopy (VCE) as the first-intention study. If there is reason to suspect intestinal obstruction, VCE is contraindicated and a CT-enteroscopy is then performed as first intention. Enteroscopy is performed as a second-line treatment, either for therapeutic purposes after a positive VCE or CT-enteroclysis, or for diagnostic purposes after a negative VCE. Finally, intraoperative enteroscopy (IOE) coupled with surgical exploration should be reserved either for therapeutic purposes in the event of impossibility or failure of preoperative enteroscopy, or for diagnostic purposes in the event of recurrent GBUO after failure of all other studies and explorations of the small intestine.

Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding (OGIB) has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy. OGIB can present as overt bleeding or occult bleeding, and small bowel lesions are the most common causes. The small bowel can be evaluated using capsule endoscopy, device-assisted enteroscopy, computed tomography enterography, or magnetic resonance enterography. Once the cause of small-bowel bleeding is identified and targeted therapeutic intervention is completed, the patient can be managed with routine visits. However, diagnostic tests may produce negative results, and some patients with small bowel bleeding, regardless of diagnostic findings, may experience rebleeding. Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans. Several studies have identified different factors associated with rebleeding, and a limited number of studies have attempted to create prediction models for recurrence. This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding. These models may aid clinicians in forming tailored patient management and surveillance.

Real-world healthcare costs and resource utilization in patients with von Willebrand disease and angiodysplasia

OBJECTIVE

To describe the economic burden among VWD patients with angiodysplasia compared to VWD patients without angiodysplasia and the general population.

METHODS

This was a retrospective analysis using the Merative MarketScan Commercial and Medicare Databases® (January 2011-September 2020). Selected patients had ≥1 medical claim for VWD or low VWF, ≥1 medical claim for AGD, and ≥3 GI-related bleeding episodes within a year. HCRU and all-cause costs were compared with the VWD (only) and the general cohorts.

RESULTS

The mean total all-cause costs were $150,101 among patients with VWD and angiodysplasia (n = 34), higher compared to $48,249 among matched VWD patients without angiodysplasia (n = 136) and $31,029 among matched individuals of the general population [n = 136; p-value < 0.0001]. The differences in costs between groups were primarily due to inpatient care. During the 12-month follow-up, VWD patients with symptomatic (n = 35), asymptomatic (n = 81), and suspected (n = 378) angiodysplasia had an average of 4.1, 0.6, and 3.8 gastrointestinal (GI) bleeds, respectively. Desmopressin, VWF concentrates, and aminocaproic acid were the most frequent treatments used. The most frequent procedures to treat GI-related bleeding and underlying lesions were blood transfusion and laser therapy.

CONCLUSIONS

Despite recent therapeutic advances, there is room for considerable reduction of the disease burden in patients with VWD and angiodysplasia.

[Radiologic Diagnosis of Gastrointestinal Bleeding]

Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.

Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study

Background and Aim: Double-balloon enteroscopy (DBE) is a well-established procedure for direct visualisation of the entire small bowel mucosa, and, in contrast with other imaging techniques, allows to perform biopsies and therapeutic interventions. The aim of this study was to evaluate the indications, diagnostic yield, therapeutic yield, and complications of DBE in a cohort of consecutive patients according to patients’ age. Methods: We conducted a retrospective study of consecutive patients who underwent DBE in our endoscopy unit between January 2006 and December 2021. Results: A total of 387 consecutive patients who underwent 460 DBE procedures were included. Mean age of the patients was 63 years. The overall diagnostic yield was 67.6%; vascular lesions were the predominant endoscopic findings (31.5%), followed by polyps or neoplastic masses (17.6%). Older patients (≥65 years) showed statistically higher rates of clinically relevant findings than adult patients (18–65 years) (p = 0.001). Crohn’s disease and polyps or neoplastic masses were more frequent in the younger group (p = 0.009 and p = 0.066, respectively), while vascular lesions and non-specific inflammation were the most common findings in the older group (p < 0.001 and p < 0.001, respectively). The therapeutic intervention rate was 31.7%. Rates of endoscopic treatment were significantly higher in the older group (p < 0.001). Total complications occurred in five procedures (1.1%). Conclusion: In clinical practice, DBE is an efficient diagnostic and therapeutic tool with a high safety profile, particularly in the elderly population.

Three cases of jejunal tumors detected by standard upper gastrointestinal endoscopy: A case series

BACKGROUND

In patients with obscure gastrointestinal bleeding, re-examination with standard upper endoscopes by experienced physicians will identify culprit lesions in a substantial proportion of patients. A common practice is to insert an adult-sized forward-viewing endoscope into the second part of the duodenum. When the endoscope tip enters after the papilla, which is a marker for the descending part of the duodenum, it is difficult to endoscopically judge how far the duodenum has been traversed beyond the second part.

CASE SUMMARY

We experienced three cases of proximal jejunal masses that were diagnosed by standard upper gastrointestinal endoscopy and confirmed with surgery. The patients visited the hospital with a history of melena; during the initial upper gastrointestinal endoscopy and colonoscopy, the bleeding site was not confirmed. Upper gastrointestinal bleeding was suspected; thus, according to guidelines, upper endoscopy was performed again. A hemorrhagic mass was discovered in the small intestine. The lesion of the first patient was thought to be located in the duodenum when considering the general insertion depth of a typical upper gastrointestinal endoscope; however, during surgery, it was confirmed that it was in the jejunum. After the first case, lesions in the second and third patients were detected at the jejunum by inserting the standard upper endoscope as deep as possible.

CONCLUSION

The deep insertion of standard endoscopes is useful for the diagnosis of obscure gastrointestinal bleeding.

Transcatheter arterial embolization for gastrointestinal bleeding: Clinical outcomes and prognostic factors predicting mortality

We evaluated clinical outcome and prognostic factors predicting mortality of transcatheter arterial embolization (TAE) for acute gastrointestinal (GI) bleeding. Fifty-nine patients (42 men, 17 women; mean age 66.1 ± 17.0) who underwent 59 TAE procedures for GI bleeding during 2013-2018 were retrospectively evaluated. Clinical outcomes included technical success, adverse events, and rebleeding and mortality rate within 30 days. The technical success rate was 100%. Angiography showed contrast extravasation in 41 (69.5%) patients and indirect signs of bleeding in 16 (27.1%) patients. Two (3.4%) patients underwent prophylactic embolization. TAE-related adverse events occurred in 7 (11.9%) patients; adverse events were more common for mid GI or lower GI bleeding than for upper GI bleeding (22.6% vs 0%, P = 0.007). Rebleeding within 30 days was observed in 22 (37.3%) patients after TAE. Coagulopathy was a prognostic factor for rebleeding (odds ratio [OR] = 3.53, 95% confidence interval 1.07-11.67, P = .038). Mortality within 30 days occurred in 11 (18.6%) patients. Coagulopathy (OR = 24, 95% confidence interval 2.56-225.32, P = .005) was an independent prognostic factor for mortality within 30 days. TAE is an effective, safe, and potentially lifesaving procedure for GI bleeding. If possible, coagulopathy should be corrected before TAE as it may reduce rebleeding and mortality.

Small intestinal bleeding and stricture caused by Meckel's diverticulum

A 44‐year‐old man presented to our hospital with lower gastrointestinal bleeding. We performed balloon‐assisted enteroscopy, which revealed diverticulum and stricture at the ileum. The patient underwent segmental small bowel resection and diagnosed with Meckel's diverticulum. We should keep in mind the possibility of intestinal stricture due to Meckel's diverticulum.

Obscure Gastrointestinal Bleeding and Capsule Endoscopy: A Win-Win Situation or Not?

Obscure gastrointestinal bleeding (OGIB) refers to bleeding of uncertain origin that persists or recurs after negative workup using any of the radiologic evaluation modalities. It can be divided into two types based on whether clinically evident bleeding is present, namely, obscure overt and obscure occult bleeding. As the visualization of the bowel mucosa is challenging, capsule endoscopy (CE) is the ideal go-to procedure as the process is wireless, ingestible, small, disposable, and, most importantly, non-invasive. This review article has compiled various studies to shed light on the guidelines for using CE, its structure and procedure, patient preferences, diagnostic yield, cost-effectiveness, and the future. The goal of this review is to show the influence of CE on OGIB on the aspects mentioned earlier.

A rare case of small bowel arteriovenous malformation presenting as obscure gastrointestinal bleeding

Lower gastrointestinal (GI) bleeding (LGIB) is a common surgical condition, which is frequently encountered in the emergency department. The most common origin of LGIB is from the colo-rectal region. However, in majority of cases where no apparent bleeding source is identified, small bowel is the area of concern. Here, we report an uncommon cause of small bowel bleeding that manifested as LGIB. A 63-year-old woman presented to emergency department with 2-day history of dark red rectal bleeding. The upper and lower GI endoscopy did not reveal any source of bleeding. Due to the ongoing blood loss, the hemoglobin level dropped significantly, necessitating blood transfusion. Subsequently, an emergency computed tomography mesenteric angiogram was performed, which showed extravasation of contrast into the distal ileum. She underwent a laparotomy where an arteriovenous malformation of the ileum was noticed. A limited ileal resection was performed, followed by primary anastomosis. She recovered well post-operatively with no further bleeding.

Colonic angiodysplasia: a culprit of obscure gastrointestinal bleeding in a patient with Heyde syndrome

A 77-year-old woman presented with obscure gastrointestinal bleeding requiring multiple hospitalisations and blood transfusions. The patient underwent repeated investigations over four hospital admissions across a span of two months. These included upper and lower gastrointestinal endoscopy, video capsule endoscopy as well as CT enterography, without definitive localisation or treatment of the source of bleeding. Finally, a technetium-99m-labelled red blood cell scan demonstrated a ‘blush’ at the proximal transverse colon on delayed imaging. Targeted colonoscopic evaluation showed a subcentimetre angiodysplastic lesion in the corresponding spot at the proximal transverse colon with slow persistent oozing. Endoscopic clips were applied with successful haemostasis. The patient recovered well without further symptom recurrence 5 months postdischarge. We review the literature on colonic angiodysplasias and discuss the diagnostic challenges in obscure gastrointestinal bleeding.

Video Capsule Endoscopy Optimal Timing in Overt Obscure Gastrointestinal Bleeding

Video capsule endoscopy (VCE) has become the noninvasive diagnostic standard in the investigation of overt obscure gastrointestinal bleeding (OGIB), with a high positive and negative predictive value. However, the diagnostic yield of the VCE is thought to depend on when it was performed. We evaluate the optimal timing performing VCE relative to overt OGIB to improve the diagnostic yield. A total 271 patients had admitted and underwent VCE for overt OGIB between 2007 and 2016 in Samsung Medical Center, Seoul, Korea. To evaluate the diagnostic yield of VCE for overt OGIB with respect to timing of the intervention, diagnostic yield was analyzed according to the times after latest bleeding. The finding of VCE was classified into P0 or P1 (no potential for bleeding or uncertain hemorrhagic potential) and P2 (high potential for bleeding, such as active bleeding, typical angiodysplasia, large ulcerations or tumors). The P2 lesion was found in 106 patients and diagnostic yield of was 39.1% for overt OGIB. Diagnostic yield of VCE to detect P2 lesion was higher when it is performed closer to the time of latest bleeding (timing of VCE between the VCE and latest bleeding: <24 h, 43/63 (68.3%); 1 days, 16/43 (34.9%); 2 days, 18/52 (34.6%); 3 days, 13/43 (30.2%); 4 days, 7/28 (25.0%); 5–7 days, 6/24 (25.0%), and ≥8 days, 4/18 (22.2%); ptrend < 0.001). The interval between the VCE and latest bleeding were categorized into <24 h (n = 63), 1–2 days (n = 95), 3–7 days (n = 95) and ≥8 days (n = 18). Multivariable analyses showed the odds ratio for P2 lesion detection was 4.99 (95% confidence interval, 1.47–16.89) in <24 h group, compared with ≥8 days group (p < 0.010). The overall re-bleeding rate for those with P2 lesion was higher than for those with P0 or P1 lesion at the end of mean follow up of 2.5 years. The proportion of patients who underwent therapeutic intervention including surgery, endoscopic intervention and embolization was higher when VCE is performed closer to the time of latest bleeding (p = 0.010). Early deployment of VCE within 24 h of the latest GI bleeding results in a higher diagnostic yield for patients with overt OGIB and consequently resulted in a higher therapeutic intervention rate

Anemia as a Problem: GEH Approach

BACKGROUND

Anemia is present in almost 5% of adults worldwide and accompanies clinical findings in many diseases. Diseases of the gastrointestinal (GI) tract and liver are a common cause of anemia, so patients with anemia are often referred to a gastroenterologist.

SUMMARY

Anemia could be caused by various factors such as chronic bleeding, malabsorption, or chronic inflammation. In clinical practice, iron deficiency anemia and the combined forms of anemia due to different pathophysiological mechanisms are most common. Esophagogastroduodenoscopy, colonoscopy, and the small intestine examinations in specific situations play a crucial role in diagnosing anemia. In anemic, GI asymptomatic patients, there are recommendations for bidirectional endoscopy. Although GI malignancies are the most common cause of chronic bleeding, all conditions leading to blood loss, malabsorption, and chronic inflammation should be considered. From a gastroenterologist's perspective, the clinical spectrum of anemia is vast because many different digestive tract diseases lead to bleeding. Key Messages: The gastroenterological approach in solving anemia's problem requires an optimal strategy, consideration of the accompanying clinical signs, and the fastest possible diagnosis. Although patients with symptoms of anemia are often referred to gastroenterologists, the diagnostic approach requires further improvement in everyday clinical practice.

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia

Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.

Obscure Gastrointestinal Bleeding Due to Non-steroidal Anti-inflammatory Drug-Induced Colopathy

Obscure gastrointestinal (GI) bleeding poses a diagnostic challenge and is associated with high mortality. We report a case of life-threatening obscure GI bleeding precipitated by the ingestion of a non-steroidal anti-inflammatory drug (NSAID). The source of bleeding could not be identified preoperatively, and hence exploratory laparotomy was performed. An ileocaecal resection was undertaken based on the findings of the intraoperative enteroscopy. However, the bleeding recurred and repeated endoscopy examination identified the source to be multiple NSAID-induced ulcers that were scattered in the colo-rectum. The bleeding stopped spontaneously after a period of intensive supportive therapy and sulphasalazine enemas. This case highlights the diagnostic challenge of obscure GI bleeding. It also highlights the potentially life-threatening danger of GI bleeding secondary to NSAID-induced colopathy, even after a short course of treatment.

Image-Enhanced Capsule Endoscopy Improves the Identification of Small Intestinal Lesions

Image-enhanced endoscopy is useful for diagnosing and identifying lesions in the gastrointestinal tract. Recently, image-enhanced endoscopy has become a breakthrough technology that has attracted significant attention. This image enhancing technology is available for capsule endoscopy, which is an effective tool for small intestinal lesions and has been applied in flexible spectral color enhancement technology and in contrast capsule like narrow-band imaging. In this field, most researchers focus on improving the visibility and detection of small intestinal lesions. This review summarizes previous studies on image-enhanced capsule endoscopy and aims to evaluate the efficacy of this technology.

A novel gene associated with small bowel bleeding in patients taking low-dose aspirin

OBJECTIVE

We have previously revealed the clinical factors and genetic polymorphisms associated with gastrointestinal mucosal injury and bleeding, induced by low-dose aspirin (LDA). After performing genome-wide analysis of single nucleotide polymorphisms (SNPs) using the Drug Metabolizing Enzymes and Transporters (DMET) system among drug metabolism and transporter genes, certain SNPs were found to increase the risk for LDA-induced small bowel bleeding. The aim of this study was to identify the SNPs involved in LDA-induced small bowel bleeding.

SUBJECTS AND METHODS

Subjects were patients taking LDA, with small bowel bleeding diagnosed using capsule endoscopy. We investigated the clinical characteristics and the previously identified SNPs, that were examined by the DNA direct sequence method.

RESULTS

56 patients with bleeding and 410 controls taking LDA were enrolled. The risk factors associated with small bowel bleeding included smoking, cerebrovascular diseases, chronic renal failure, non-steroidal anti-inflammatory drug (NSAID) or anticoagulants combination, and two SNPs (CYP4F11 20043G>A (D446N) rs1060463, GSTP1 313A>G rs1695). After propensity score matching, GSTP1 rs1695 was significantly associated with small bowel bleeding.

CONCLUSION

The GSTP1 SNP may be a predictive marker for small bowel bleeding among patients taking LDA.

Development and Verification of a Deep Learning Algorithm to Evaluate Small-Bowel Preparation Quality

Capsule endoscopy (CE) quality control requires an objective scoring system to evaluate the preparation of the small bowel (SB). We propose a deep learning algorithm to calculate SB cleansing scores and verify the algorithm’s performance. A 5-point scoring system based on clarity of mucosal visualization was used to develop the deep learning algorithm (400,000 frames; 280,000 for training and 120,000 for testing). External validation was performed using additional CE cases (n = 50), and average cleansing scores (1.0 to 5.0) calculated using the algorithm were compared to clinical grades (A to C) assigned by clinicians. Test results obtained using 120,000 frames exhibited 93% accuracy. The separate CE case exhibited substantial agreement between the deep learning algorithm scores and clinicians’ assessments (Cohen’s kappa: 0.672). In the external validation, the cleansing score decreased with worsening clinical grade (scores of 3.9, 3.2, and 2.5 for grades A, B, and C, respectively, p < 0.001). Receiver operating characteristic curve analysis revealed that a cleansing score cut-off of 2.95 indicated clinically adequate preparation. This algorithm provides an objective and automated cleansing score for evaluating SB preparation for CE. The results of this study will serve as clinical evidence supporting the practical use of deep learning algorithms for evaluating SB preparation quality.

Leptin and Obesity: Role and Clinical Implication

The peptide hormone leptin regulates food intake, body mass, and reproductive function and plays a role in fetal growth, proinflammatory immune responses, angiogenesis and lipolysis. Leptin is a product of the obese (ob) gene and, following synthesis and secretion from fat cells in white adipose tissue, binds to and activates its cognate receptor, the leptin receptor (LEP-R). LEP-R distribution facilitates leptin's pleiotropic effects, playing a crucial role in regulating body mass via a negative feedback mechanism between adipose tissue and the hypothalamus. Leptin resistance is characterized by reduced satiety, over-consumption of nutrients, and increased total body mass. Often this leads to obesity, which reduces the effectiveness of using exogenous leptin as a therapeutic agent. Thus, combining leptin therapies with leptin sensitizers may help overcome such resistance and, consequently, obesity. This review examines recent data obtained from human and animal studies related to leptin, its role in obesity, and its usefulness in obesity treatment.

The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding

The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.

Gastrointestinal bleeding from angiodysplasia in von Willebrand disease: Improved diagnosis and outcome prediction using videocapsule on top of conventional endoscopy

BACKGROUND

Despite a high prevalence of angiodysplasia, no specific guidelines are available for the modalities of endoscopic exploration of gastrointestinal (GI) bleeding in von Willebrand disease (VWD). Whether VWD patients could benefit from video capsule endoscopy (VCE) looking for angiodysplasia eligible to endoscopic treatment or at high risk of bleeding is unknown.

OBJECTIVES

To assess the diagnostic efficacy for angiodysplasia and the prognostic value of VCE on top of conventional endoscopy in VWD patients with GI bleeding.

PATIENTS/METHODS

A survey was sent to the 30 centers of the French-network on inherited bleeding disorders to identify VWD patients referred for endoscopic exploration of GI bleeding from January 2015 to December 2017. Data obtained included patient characteristics, VWD phenotype/genotype, GI bleeding pattern, results of endoscopic investigations, and medical management applied including endoscopic therapy. We assessed by Kaplan-Meier analysis the recurrence-free survival after the first GI bleeding event according to endoscopic categorization and, in patients with angiodysplasia, to the presence of small-bowel localizations on VCE exploration.

RESULTS

GI bleeding source localization was significantly improved when including VCE exploration (P < .01), even in patients without history of angiodysplasia (P < .05). Patients with angiodysplasia had more GI bleeding recurrences (P < .01). A lower recurrence-free survival was observed in patients with angiodysplasia (log-rank test, P = .02), and especially when lesions were located in the small bowel (log-rank test, P < .01), even after endoscopic treatment with argon plasma coagulation (log-rank test, P < .01).

CONCLUSION

VCE should be more systematically used in VWD patients with unexplained or recurrent GI bleeding looking for angiodysplasia eligible to endoscopic treatment or at high risk of relapse.

P2Y12 Inhibitors Exacerbate Low-dose Aspirin-induced Small Bowel Injury in Dual Antiplatelet Therapy

Objective Antithrombotic drugs are being used increasingly frequently to prevent cardiovascular diseases. Few studies have evaluated small bowel mucosal injury induced by dual antiplatelet therapy (DAPT). The aim of the present study was to evaluate small bowel mucosal injury induced by DAPT compared with other antithrombotics using video capsule endoscopy (VCE). Methods The study included chronic users of antithrombotics who underwent VCE for obscure gastrointestinal bleeding between January 2007 and July 2018. We evaluated the instances of small bowel injury classified into erosions and ulcers. Results Overall, 183 patients (114 men and 69 women; mean age, 73.6 years old) were enrolled, and the study groups comprised 49 patients taking low-dose aspirin (LDA) only, 50 taking anticoagulants only, 37 being treated with DAPT, 33 on combined LDA and anticoagulants, and 14 taking P2Y12 inhibitors. Small bowel erosions and ulcers were most frequently observed in the DAPT group, with frequencies of 78.4% and 37.8%, respectively. Exacerbating factors of small bowel ulcers were DAPT [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.2-7.7] and age over 80 years old (OR 2.4, 95% CI 1.1-5.4). Conclusion P2Y12 inhibitors seem to exacerbate LDA-induced small bowel injury. Preventive strategies for small bowel injury induced by LDA, especially DAPT, are urgently required.

Inspecting the total gastrointestinal tract by consecutive bidirectional double-balloon enteroscopy in patients with suspected small bowel bleeding

BACKGROUND/AIMS

This study aimed to investigate the feasibility, efficiency, and clinical significance of examining the total gastrointestinal (GI) tract by consecutive bidirectional double-balloon enteroscopy (DBE) within 1 day in patients with suspected small-bowel bleeding.

MATERIALS AND METHODS

From January 2016 to January 2018, the clinical and endoscopic data of 41 patients with suspected small-bowel bleeding undergoing DBE aimed at inspecting the total GI tract within 1 day.

RESULTS

A success rate of 87.8% (36/41) for examining the total GI tract with no adverse event was achieved by consecutive bidirectional DBE performed within 1 day. The total examination time was 140.61±36.41 (range, 82-270) minutes. Positive or negative findings of bleeding were detected in 51.2% (21/41) and 48.8% (20/41) patients, respectively. Single bleeding etiology with non-small-bowel lesions (NSBLs) or small-bowel lesions (SBLs) was detected in 12.2% (5/41) and 26.8% (11/41) of patients, respectively. Dual bleeding etiologies, including NSBLs and SBLs, were detected in 12.2% (5/41) of patients. A re-bleeding rate of positive or negative findings was different (4.8% vs. 40.0%; p<0.05).

CONCLUSION

Consecutive bidirectional DBE within 1 day can achieve complete vision of the total GI tract with a considerable success rate and high safety. This strategy may provide an option for detecting bleeding etiology throughout the GI tract. A negative finding with this method cannot absolutely exclude missed bleeding etiology and re-bleeding.

Surgical management of hiatal hernia vs medical therapy to treat bleeding Cameron lesions: a systematic review and meta-analysis

INTRODUCTION

Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL).

METHODS AND PROCEDURES

A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy.

RESULTS

Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I² = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management.

CONCLUSIONS

This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Positive Fecal Occult Blood Test is a Predictive Factor for Gastrointestinal Bleeding after Capsule Endoscopy in Patients with Unexplained Iron Deficiency Anemia: A Korean Multicenter CAPENTRY Study

BACKGROUND/AIMS

Capsule endoscopy (CE) is recommended as the primary method for the evaluation of unexplained anemia. This study aimed to assess the diagnostic yield of CE in patients with unexplained iron deficiency anemia (IDA) without overt bleeding, and to evaluate their long-term outcomes and related clinical factors.

METHODS

Data of patients who underwent CE for the evaluation of IDA were reviewed from a CE registry in Korea. Additional clinical data were collected by the involved investigators of each hospital through a review of medical records.

RESULTS

Among a total of 144 patients, the diagnostic yield of CE was 34%. Gastrointestinal (GI) bleeding was found in 6.3% (n=9) of the patients (occult bleeding in four patients and overt bleeding in five patients) during a mean follow-up of 17.8 months. Patients with a positive fecal occult blood test (FOBT) result at the initial diagnosis had a higher rate of GI bleeding after CE (p=0.004). In addition, a positive FOBT result was the only independent predictive factor for GI bleeding (hazard ratio, 5.30; 95% confidence interval, 1.41-19.85; p=0.013).

CONCLUSION

Positive FOBT is a predictive factor for GI bleeding during follow-up after CE in patients with unexplained IDA without overt bleeding. Thus, patients with positive FOBT need to be more closely followed up.

Timing of Transfusion, not Hemoglobin Variability, is Associated with 3-Month Outcomes in Acute Ischemic Stroke

Objectives: This study aimed to investigate whether transfusions and hemoglobin variability affects the outcome of stroke after an acute ischemic stroke (AIS).

METHODS

We studied consecutive patients with AIS admitted in three tertiary hospitals who received red blood cell (RBC) transfusion (RBCT) during admission. Hemoglobin variability was assessed by minimum, maximum, range, median absolute deviation, and mean absolute change in hemoglobin level. Timing of RBCT was grouped into two categories: admission to 48 h (early) or more than 48 h (late) after hospitalization. Late RBCT was entered into multivariable logistic regression model. Poor outcome at three months was defined as a modified Rankin Scale score ≥3.

RESULTS

Of 2698 patients, 132 patients (4.9%) received a median of 400 mL (interquartile range: 400-840 mL) of packed RBCs. One-hundred-and-two patients (77.3%) had poor outcomes. The most common cause of RBCT was gastrointestinal bleeding (27.3%). The type of anemia was not associated with the timing of RBCT. Late RBCT was associated with poor outcome (odd ratio (OR), 3.55; 95% confidence interval (CI), 1.43-8.79; p-value = 0.006) in the univariable model. After adjusting for age, sex, Charlson comorbidity index, and stroke severity, late RBCT was a significant predictor (OR, 3.37; 95% CI, 1.14-9.99; p-value = 0.028) of poor outcome at three months. In the area under the receiver operating characteristics curve comparison, addition of hemoglobin variability indices did not improve the performance of the multivariable logistic model.

CONCLUSION

Late RBCT, rather than hemoglobin variability indices, is a predictor for poor outcome in patients with AIS.

Dieulafoy lesion: two pediatric case reports

Background

Massive gastrointestinal bleeding in children is uncommon. Dieulafoy lesion is an uncommon disease which may lead to massive and repeated upper gastrointestinal hemorrhage. We report two cases of gastric Dieulafoy lesion successfully treated with either band ligation or endoscopic hemoclipping.

Case presentation

First case report: A previously healthy 18-month-old female infant with E. coli sepsis, pneumonia and respiratory failure with bilateral pneumothorax requiring chest drainage. Over a few days, the patient presented hematemesis and melena with progressively worsening anemia. The esophagogastroduodenoscopy revealed an arterial vessel with eroded apex located between the body and the fundus of the stomach. Two elastic bands were applied which resulted in resolution of hematemesis and melena and improvement of the anemia.

Second case report: A 8-year-old male was admitted to our department with sudden massive hematemesis and melena. Clinical examination revealed anemia (hemoglobin, 6.8 g/dl). Esophagogastroduodenoscopy revealed a mucosal erosion with visible vessel located along the small curvature, close to the antrum. Three hemostatic clips were placed on the Dieulafoy lesion and hemostasis was obtained.

Conclusions

we showed that, similar to gastric DL in adult patients,, gastric DL in pediatric patients can be successfully treated with endoscopic therapy, and both hemoclipping and band ligation are suitable techniques.

Endoscopic Algorithm for Management of Gastrointestinal Bleeding in Patients With Continuous Flow LVADs: A Prospective Validation Study

BACKGROUND

Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization.

METHODS

We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis.

RESULTS

We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%).

CONCLUSIONS

Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

The Predicament of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device: Pathophysiology, Evaluation, and Management

Heart failure affects over 5 million Americans, with numbers expected to rise. While heart transplantation is the most effective long-term strategy for end-stage heart failure, there is a limited cardiac donor pool, and these organs are often unavailable at the time of need. Left ventricular assist devices, therefore, continue to be used to bridge this gap. Originally implanted as a bridge to transplant, these devices are now additionally utilized as destination therapy for patients ineligible for transplant. With the widespread applicability of these devices for not just temporary measures, but also for prolonged use, the short- and long-term impact on other organ systems has become more evident. For example, gastrointestinal (GI) bleeding, with an incidence approaching 30%, is one such complication post-continuous-flow left ventricular assist device implantation. This high incidence of GI bleeding is thought to stem from a combination of factors, including the need for concomitant anticoagulant and antiplatelet therapy, and intrinsic device-related properties resulting in acquired Von Willebrand disease and arteriovenous malformations. Due to the significant morbidity associated with these GI bleeding events, a standardized protocol optimizing medical and endoscopic management, alongside close coordination between the gastroenterology and cardiology services, should be advocated for and ultimately employed.

Utility of fecal immunochemical test vs guaiac fecal occult blood test for assessment of gastrointestinal bleed in hospitalized patients

BACKGROUND

Guaiac fecal occult blood testing (gFOBT) is often used "off-label" for gastrointestinal (GI) bleeding. Fecal Immunochemical Test (FIT) is increasingly replacing gFOBT in colorectal cancer screening and may play a role in assessment for significant bowel disease. We examined the concordance of FIT with gFOBT (Hemoccult Sensa II) among inpatients and between day 1 and day 3 gFOBT results.

METHODS

FIT was performed alongside gFOBT on all inpatient stool sent for occult blood to the Winnipeg Health Sciences Centre laboratory over 1 y. gFOBT was performed on days 1 and 3 post stool collection, while FIT was performed on day 1 only.

RESULTS

Positivity rates were highest for Day 1 gFOBT (27.7%), and lowest for FIT (18.3%). Concordance between FIT and Days 1 and 3 gFOBT for negative test results (96.4% and 94.1%) was significantly higher than that expected by chance alone (58.7% and 61.3%, P < .001). Similarly, concordance for positive test results (55.8% and 55.6%) was significantly higher as well as for days 1 and 3 gFOBT results.

CONCLUSIONS

We found no benefit in delayed testing for 3 days post collection. FIT provides equivalent results to gFOBT in hospitalized patients.

Updates on management of nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Upper gastrointestinal bleeding (UGIB) is a common and life-threatening condition in the United States and worldwide.

RECENT FINDINGS

There have been several exciting recent advances in the endoscopic management of UGIB. One such advance is the recent approval of Hemospray by US Food and Drug Administration in May 2018. Another one is the emerging role of video capsule endoscopy as a triage and localization tool for UGIB patients. Finally, the development of new reversal agents for antithrombotic medications is an important advance in the management of life-threatening upper gastrointestinal bleed.

SUMMARY

In this article, we will broadly review the management of nonvariceal UGIB, focusing primarily on the data addressing these new advances.

Capsule endoscopy for small-intestinal disorders: Current status

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam^® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCE as pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

History of malignancy and relevant symptoms may predict a positive computed tomography enterography in obscure gastrointestinal bleeds

BACKGROUND AND AIM

This study aimed to assess the clinical utility of computed tomography enterography (CTE) and identify factors associated with a diagnostic CTE for patients with obscure gastrointestinal bleeding (OGIB).

METHODS

A retrospective observational study was performed at a Canadian tertiary care center from 2005 to 2015. A total of 138 patients underwent a CTE for OGIB. Univariate and multivariate logistic regressions were performed to determine factors associated with a diagnostic CTE. A highly sensitive clinical rule was then developed to help identify OGIB patients for whom a CTE may be beneficial in their clinical work-up.

RESULTS

A possible bleeding source was identified in 30 (22%) cases. The presence of abdominal or constitutional symptoms as well as history of colorectal cancer was significantly associated with a positive CTE in univariate and multivariate analyses (P < 0.05). A positive CTE could be predicted based on the presence of abdominal or constitutional symptoms and history of colorectal cancer with 90% sensitivity (95% CI 74-98%) in our population.

CONCLUSION

CTE identified a possible source of OGIB in one in five cases. In patients with the presence of abdominal or constitutional symptoms and a personal history of colorectal cancer, CTE may contribute to their diagnostic work-up.

Use of video capsule endoscopy to identify gastrointestinal lesions in dogs with microcytosis or gastrointestinal hemorrhage

Background

Video capsule endoscopy (VCE) is a noninvasive imaging modality that can identify mucosal lesions not detected with traditional endoscopy or abdominal sonography. In people, VCE is used in diagnostic and management protocols of various gastrointestinal (GI) disorders, particularly in GI bleeding of obscure origin or unexplained iron deficiency anemia (IDA).

Objective

To evaluate the utility of VCE in the identification of mucosal lesions in dogs with evidence of GI hemorrhage.

Animals

Sixteen client‐owned dogs that underwent VCE.

Methods

Retrospective case‐control study. Medical records were reviewed to include dogs with microcytosis, low normal mean corpuscular volume, or clinical GI bleeding that received VCE.

Results

Median age of dogs was 8.7 years (range, 8 months to 15 years) with a median weight of 21.7 kg (range, 6.9‐62.5 kg). Abdominal ultrasound (16), abdominal radiography (4), and abdominal CT (1) did not identify a cause for GI blood loss. Gastric mucosal lesions were identified by VCE in 15 of 16 dogs and small intestinal lesions in 12 of 14 dogs, with 2 capsules remaining in the stomach. Endoscopy was performed in 2 dogs before VCE; 1 dog had additional small intestinal lesions identified through the use of VCE.

Conclusions and Clinical Importance

Video capsule endoscopy is a minimally invasive diagnostic tool that can identify GI lesions in dogs presenting with microcytosis with or without GI hemorrhage when ultrasonography is inconclusive; however, the majority of lesions identified would have been apparent with conventional endoscopy.

[Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types]

Background/Aims

The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB.

Methods

This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed.

Results

The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p<0.001). TAE sites were upper GIB in 67, mid GIB in 74, and lower GIB in 22. The technical success rate was 99.3% (133/134), and the clinical success rate was 63.0% (104/163). The prophylactic embolization group showed lower clinical success rate than the targeted embolization group (44.8% vs. 67.9%, p=0.06). The TAE-related complication rate was 12.9% (21/163). Ischemia and/or infarction was more common after TAE for mid and lower GIB than for upper GIB (15.6% vs. 3.0%, p=0.007).

Conclusions

Angiography with or without TAE was an effective method for acute GIB. Targeted embolization should be performed if possible given that it has a higher clinical success rate.

Long-term results with lanreotide in patients with recurrent gastrointestinal angiodysplasias bleeding or obscure gastrointestinal bleeding. Benefits in efficacy and procedures consumption

BACKGROUND

Gastrointestinal angiodysplasias (GIAD) bleeding and obscure gastrointestinal bleeding (OGIB) are increasing health problems. Somatostatin analogues have been proposed as rescue therapy, but data for lanreotide are scarce.

OBJECTIVE

To determine the efficacy, safety and resource saving of long-acting lanreotide for GIAD and OGIB.

METHODS

Retrospective study including adults with GIAD bleeding or OGIB and lanreotide treatment for at least 6 consecutive months. Demographics, comorbidities and treatments were collected. Anaemia and health resource consumption were analysed and compared between the year before and three years after starting lanreotide. Complete response was defined as a lack of new blood transfusion or endovenous iron dose need.

RESULTS

Twenty-seven patients (mean age 76.8 years) were included, 63% taking anticoagulants/antiplatelets. The bleeding was attributable to angiodysplasia in 85.2%, of whom half had multi-site lesions. Lanreotide was administered for a median of 27.1 months. During follow-up of up to 3 years (mean 32.5 months), 18.5% of patients achieved complete response and around 60% a 50% reduction of health resource consumption. Haemoglobin values improved (p = .007), while admission time, blood/iron infusions, and the number of endoscopies decreased significantly (p<.05) at least up to the second year. There were no relevant side effects during the follow-up period.

CONCLUSION

Long-term treatment with lanreotide significantly improves anaemia and decreases health resource consumption in patients with recurrent GIAD bleeding or OGIB.

Yield of capsule endoscopy in obscure gastrointestinal bleeding: A comparative study between premenopausal and menopausal women

AIM

To evaluate differences in capsule endoscopy (CE) performed in the setting of obscure gastrointestinal bleeding (OGIB) among premenopausal women (PMW) and menopausal women (MW).

METHODS

Retrospective, single-center study, including female patients submitted to CE in the setting of OGIB between May 2011 and December 2016. Patients were divided into 2 groups according to age, considering fertile age as ≤ 55 years and postmenopausal age as > 55 years. The diagnostic yield (DY), the rebleeding rate and the time to rebleed were evaluated and compared between groups. Rebleeding was defined as a drop of Hb > 2 g/dL or need for transfusional support or presence of melena/hematochezia.

RESULTS

A hundred and eighty three female patients underwent CE for OGIB, of whom 30.6% (n = 56) were PMW and 69.4% (n = 127) were MW. The DY was 30.4% in PMW and 63.8% in MW. The most common findings were angiodysplasias in both groups (PMW: 21.4%, MW: 44.9%) (P = 0.003). In PMW, only 1.8% required therapeutic endoscopy. In 17.3% of MW, CE findings led to additional endoscopic treatment. Rebleeding at 1, 3 and 5 years in PMW was 3.6%, 10.2%, 10.2% and 22.0%, 32.3% and 34.2% in MW. Postmenopausal status was significantly associated with higher DY (P < 0.001), TY (P = 0.003), rebleeding (P = 0.031) and lower time to rebleed (P = 0.001).

CONCLUSION

PMW with suspected OGIB are less likely to have significant findings in CE. In MW DY, need for endoscopic treatment and rebleeding were significantly higher while time to rebleed was lower.

The etiology of potential small-bowel bleeding depending on patient's age and gender

Background

Whether the etiology of potential small-bowel bleeding depends on the age and gender of the patient is not yet fully understood.

Methods

A total of 1953 patients who underwent video capsule endoscopy (VCE) to evaluate potential small-bowel bleeding and were registered in the Capsule Endoscopy Nationwide Database Registry from 2003 to 2014 were eligible for this study. VCE findings and the etiology of small-bowel bleeding were analyzed by age and gender.

Results

The diagnostic yield of VCE was 48.4% (95% CI: 46.2%-50.6%) and the diagnosis rate of etiology of potential small-bowel bleeding was 61.4% (95% CI: 59.2%-63.6%). The etiology of potential small-bowel bleeding depends on the age and gender of the patient. Crohn's disease and small-bowel diverticular diseases were more prevalent etiology of potential small-bowel bleeding in the young adults group (< 40 years) whereas angiodysplasia was revealed to be a most common etiology in elderly group (≥ 60 years), reaching statistical significance (p<0.00152) by Bonferroni correction.

Conclusions

The etiology of potential small-bowel bleeding depends on the age of the patient. Thus, an individualized lesion-specific diagnostic approach based on age might be needed for patients with potential small-bowel bleeding.

Radiologic Assessment of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding represents a broad differential of disease throughout the GI tract. The proper diagnostic evaluation of patients presenting with symptoms of GI bleeding depends on the overall clinical acuity and suspected source locations. The radiologic assessment of these patients is centered around computed tomography (CT) angiography, CT enterography, conventional angiography, and nuclear scintigraphy.

Nonisolated Small Bowel Gastrointestinal Angiodysplasias are Associated With Higher Rebleeding Rates When Compared With Isolated Small Bowel Gastrointestinal Angiodysplasia on Video Capsule Endoscopy

BACKGROUND

Gastrointestinal angiodysplasias (GIAD) are commonly diagnosed in the small bowel but can be located in other areas of the gastrointestinal tract. About half of patients diagnosed with GIAD have more than 1 lesion and 20% of patients have GIAD in both the small bowel and a source outside of the small bowel (nonisolated to small bowel GIAD or NISGIAD). The remaining patients with GIAD have lesions isolated to the small bowel (ISGIAD). Complications including rebleeding, hospitalization and mortality rates have not been previously analyzed between these 2 groups.

AIM

To compare rebleeding, hospitalization and mortality rates between ISGIAD and NISGIAD. The secondary goals were to evaluate comorbidities that may be associated with ISGIAD and/or NISGIAD, and to determine if any of these comorbidities are associated with a higher risk of rebleeding from GIAD.

MATERIALS AND METHODS

This was a retrospective study that included 425 patients who underwent video capsule endoscopy between 2006 and 2013. Patients underwent esophagogastroduodenoscopy and colonoscopy before video capsule endoscopy. The primary indications for workup included obscure gastrointestinal bleeding. After exclusion criteria, 87 patients diagnosed with GIAD remained, 57 patients with ISGIAD and 30 with NISGIAD. Categorical variables were compared by the Fisher exact test or χ test and continuous data were compared using the Student T test.

RESULTS

Risk factors associated with rebleeding rates included coronary artery disease, chronic kidney disease, and congestive heart failure on multivariate analysis. Odds ratios for rebleeding was found in patients with NISGIAD (odds ratio, 4.222; P=0.036). There was no difference in hospitalization rates between patients with ISGIAD and NISGIAD. There was no statistically significant difference in mortality from any cause at 30, 60, and 90 days in patients with ISGIAD and NISGIAD.

CONCLUSIONS

In this retrospective analysis of GIAD at a single institution, patients with NISGIAD compared with ISGIAD had a 4 times odds of rebleeding within 1 year after capsule endoscopy. This is a novel study, as the distribution of GIAD has not been previously described as being a risk factor for rebleeding.