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Becq A, Sidhu R, Goltstein LCMJ, Dray X. Recent advances in the treatment of refractory gastrointestinal angiodysplasia. United European Gastroenterol J 2024. [PMID: 39229890 DOI: 10.1002/ueg2.12648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024] Open
Abstract
Gastrointestinal angiodysplasia (GIA) is a common, acquired, vascular abnormality of the digestive tract, and a frequent cause of bleeding. Refractory GIA criteria usually include recurrent bleeding, transfusions and/or repeat endoscopy. Pharmacological and interventional treatments have been the subject of recent high-quality publications. This review provides an overview of the latest updates on non-endoscopic management of refractory GIA. Aortic valve replacement has shown its efficacy in Heyde syndrome and should be considered if indicated. Anti-angiogenic drugs, such as Octreotide and Thalidomide, are efficient treatments of refractory GIA-related bleeding. Somatostatin analogs should, based on efficacy and tolerance profile, be considered first. In the future, a better understanding of the physiopathology of GIA might help develop new-targeted therapies.
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Affiliation(s)
- Aymeric Becq
- Gastroenterology Department, Paris-Est Créteil University, Henri Mondor Hospital, AP HP, Créteil, France
| | - Reena Sidhu
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Academic Unit of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Xavier Dray
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, AP HP, Paris, France
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Goltstein LCMJ, Grooteman KV, Bernts LHP, Scheffer RCH, Laheij RJF, Gilissen LPL, Schrauwen RWM, Talstra NC, Zuur AT, Braat H, Hadithi M, Brouwer JT, Nagengast WB, Oort FA, Tenthof van Noorden J, Kievit W, van Geenen EJM, Drenth JPH. Standard of Care Versus Octreotide in Angiodysplasia-Related Bleeding (the OCEAN Study): A Multicenter Randomized Controlled Trial. Gastroenterology 2024; 166:690-703. [PMID: 38158089 DOI: 10.1053/j.gastro.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/18/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND & AIMS Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting. METHODS The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up. RESULTS We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval [CI], 5.5-16.5) compared with standard of care (21.2; 95% CI, 15.7-26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4-18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3-1.5). CONCLUSIONS Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia. CLINICALTRIALS gov, NCT02384122.
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Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karina V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lucas H P Bernts
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C H Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Nynke C Talstra
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Abraham T Zuur
- Department of Gastroenterology, Tjongerschans, Heerenveen, the Netherlands
| | - Henri Braat
- Department of Gastroenterology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Frank A Oort
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
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Iqbal H, Maharaj D, Chaudhry H, Gulati A, Roytman M. Refractory gastric ulcer bleeding responsive to long-term octreotide. SAGE Open Med Case Rep 2023; 11:2050313X231164856. [PMID: 37051262 PMCID: PMC10084531 DOI: 10.1177/2050313x231164856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/03/2023] [Indexed: 04/14/2023] Open
Abstract
Upper gastrointestinal tract bleeding is a common condition that can cause hemodynamic instability and death if left untreated. Endoscopic hemostasis is often successful; however, some patients may develop refractory bleeding. Pharmacologic management with octreotide is beneficial in patients with variceal bleeding and has been shown in some studies to be effective in refractory bleeding due to angiodysplasia. There is a paucity of literature regarding the usage of long-term octreotide in refractory bleeding secondary to a peptic ulcer. We present a case of a bleeding gastric ulcer that was refractory to endoscopic management but responsive to long-term octreotide therapy.
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Affiliation(s)
- Humzah Iqbal
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
- Humzah Iqbal, Department of Internal Medicine, University of California, San Francisco, 155 N. Fresno St., Fresno, CA 93701, USA.
| | - Dashmeet Maharaj
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Alakh Gulati
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
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Efficacy of pharmacologic treatment for treating gastrointestinal angiodysplasias-related bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2022; 34:1021-1030. [PMID: 35913758 DOI: 10.1097/meg.0000000000002414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION We evaluated the efficacy of pharmacologic treatments for patients with overt or occult bleeding due to gastrointestinal angiodysplasias (GIADs). METHODS A systematic computer-aided literature search across Medline, Cochrane, Scopus and Embase databases was performed. Studies evaluating pharmacologic treatments for patients presenting with GIADs-related overt or occult bleeding were included. Post-treatment rebleeding was the primary outcome. Need for red blood cells (RBC) transfusion, post-treatment hemoglobin levels and adverse events rate comprised secondary outcomes. Results are presented as odds ratio (OR), mean difference (MD) or pooled rates (%) with 95% confidence intervals (95%CI). RESULTS Four types of pharmacologic treatment were identified (25 studies): somatostatin analogs, hormonal therapy, thalidomide and angiogenesis inhibitors. Pharmacologic treatment of any kind led to significantly reduced bleeding episodes [OR (95% CI), 0.08 (0.04-0.18)]. No pharmacologic treatment was superior to others ( P = 0.46). Overall, pooled rebleeding rate post-treatment was 34% (26-43%). Similarly, significantly fewer patients required RBC transfusion during the post-treatment period [0.03 (0.03-0.07)], with no differences among various treatments ( P = 0.83), yielding an overall pooled transfusion rate of 33% (19-46%). Administration of pharmacological treatment led to significant improvement in terms of hemoglobin levels [MD (95% CI), 3.21 g/dL (2.42-3.99)]. The pooled rate of adverse events was 32% (22-42%). CONCLUSION In patients with GIADs administration of any pharmacologic treatment significantly decreases rebleeding episodes and transfusions leading to higher hemoglobin values. One-third of them experience at least one adverse event related to the treatment.
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Paulin MV, Cosford K, Sato‐Takada K, Koo ST, Carr A. Successful medical management of an acute life‐threatening haemorrhagic crisis related to acquired colonic vascular ectasia in a dog. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Mathieu Victor Paulin
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine University of Saskatchewan Saskatoon Saskatchewan Canada
| | - Kevin Cosford
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine University of Saskatchewan Saskatoon Saskatchewan Canada
| | | | - Siu To Koo
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine University of Saskatchewan Saskatoon Saskatchewan Canada
| | - Anthony Carr
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine University of Saskatchewan Saskatoon Saskatchewan Canada
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Khedr A, Mahmoud EE, Attallah N, Mir M, Boike S, Rauf I, Jama AB, Mushtaq H, Surani S, Khan SA. Role of octreotide in small bowel bleeding. World J Clin Cases 2022; 10:9192-9206. [PMID: 36159407 PMCID: PMC9477697 DOI: 10.12998/wjcc.v10.i26.9192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | | | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George School of Medicine, Grenada, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Del Cueto-Aguilera Á, García-Compeán D, Jiménez-Rodríguez A, Borjas-Almaguer O, Wah-Suárez M, González-González J, Maldonado-Garza H. Efficacy of octreotide in bleeding recurrence from small bowel angioectasia: A comparative study. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:411-419. [DOI: 10.1016/j.rgmxen.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
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Cheema HI, Roark R, Hassan S, Chakrala K, Tharian B, Anastasiou J. Comparison Between Intravenous and Intramuscular Octreotide in the Management of Heyde’s Syndrome. Cureus 2022; 14:e25461. [PMID: 35783893 PMCID: PMC9239735 DOI: 10.7759/cureus.25461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 11/17/2022] Open
Abstract
Heyde’s syndrome is defined as a triad of aortic stenosis, anemia due to angiodysplasia-related bleeding, and von Willebrand syndrome type 2A. It is a rare disease and a diagnostic challenge. Treatment modalities include symptomatic management, blood transfusions, aortic valve replacement, and medications such as octreotide. Here, we report the case of a patient who was resistant to symptomatic management, aortic valve replacement, as well as intravenous octreotide.
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Del Cueto-Aguilera Á, García-Compeán D, Jiménez-Rodríguez A, Borjas-Almaguer O, Wah-Suárez M, González-González J, Maldonado-Garza H. Eficacia del octreótido sobre la recurrencia hemorrágica de las angiectasias del intestino delgado. Estudio comparativo. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022. [DOI: 10.1016/j.rgmx.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Goltstein LCMJ, Grooteman KV, Rocco A, Holleran G, Frago S, Salgueiro PS, Aparicio T, Scaglione G, Chetcuti Zammit S, Prados-Manzano R, Benamouzig R, Nardone G, McNamara D, Benallaoua M, Michopoulos S, Sidhu R, Kievit W, Drenth JPH, van Geenen EJM. Effectiveness and predictors of response to somatostatin analogues in patients with gastrointestinal angiodysplasias: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:922-932. [PMID: 34508668 DOI: 10.1016/s2468-1253(21)00262-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are vascular malformations that often cause red blood cell transfusion-dependent anaemia. Several studies suggest that somatostatin analogues might decrease rebleeding rates, but the true effect size is unknown. We therefore aimed to investigate the efficacy of somatostatin analogues on red blood cell transfusion requirements of patients with gastrointestinal angiodysplasias and to identify subgroups that might benefit the most from somatostatin analogue therapy. METHODS We did a systematic review and individual patient data meta-analysis. We searched MEDLINE, Embase, and Cochrane on Jan 15, 2016, with an updated search on April 25, 2021. All published randomised controlled trials and cohort studies that reported on somatostatin analogue therapy in patients with gastrointestinal angiodysplasias were eligible for screening. We excluded studies without original patient data, single case reports, small case series (ie, <10 participants), studies in which patients had a specific aetiology of gastrointestinal angiodysplasias, and studies in which somatostatin analogue therapy was initiated simultaneously with other treatment modalities. Authors of eligible studies were invited to share individual patient data. Aggregated data was used if individual patient data were not provided. The primary outcome was the mean reduction in the number of red blood cell transfusions during somatostatin analogue therapy, compared with baseline, expressed as the incidence rate ratio (IRR) and absolute mean decrease. We defined patients as either good responders (≥50% reduction in the number of red blood cell transfusions) or poor responders (<50% reduction). A mixed-effects negative binomial regression was used to account for clustering of patients and skewness in data. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42020213985. FINDINGS We identified 11 eligible studies (one randomised controlled trial and ten cohort studies) of moderate-to-high quality and obtained individual patient data from the authors of nine (82%) studies. The remaining two (18%) studies provided sufficient information in the published manuscript to extract individual patient data. In total, we analysed data from 212 patients. Somatostatin analogues reduced the number of red blood cell transfusions with an IRR of 0·18 (95% CI 0·14-0·24; p<0·0001) during a median treatment duration of 12 months (IQR 6·0-12·0) and follow-up period of 12 months (12·0-12·0), correlating with a mean absolute decrease in the number of red blood cell transfusions from 12·8 (95% CI 10·4-15·8) during baseline to 2·3 (1·9-2·9) during follow-up-ie, a reduction of 10·5 red blood cell transfusions (p<0·0001). 177 (83%) of 212 patients had a good response to somatostatin analogue therapy (defined as at least a 50% reduction in the number of red blood cell transfusions). Heterogeneity across studies was moderate (I2=53%; p=0·02). Location of gastrointestinal angiodysplasias in the stomach compared with angiodysplasias in the small bowel and colon (IRR interaction 1·92 [95% CI 1·13-3·26]; p=0·02) was associated with worse treatment response. Octreotide was associated with a better treatment response than lanreotide therapy (IRR interaction 2·13 [95% CI 1·12-4·04]; p=0·02). The certainty of evidence was high for the randomised controlled trial and low for the ten cohort studies. Adverse events occurred in 38 (18%) of 212 patients receiving somatostatin analogue therapy, with ten (5%) discontinuing this therapy because of adverse events. The most common adverse events were loose stools (seven [3%] of 212), cholelithiasis (five [2%]), flatulence (four [2%]), and administration site reactions (erythema, five [2%]). INTERPRETATION Somatostatin analogue therapy is safe and effective in most patients with red blood cell transfusion-dependent bleeding due to gastrointestinal angiodysplasias. Somatostatin analogue therapy is more effective in patients with angiodysplasias located in the small bowel and colon, and octreotide therapy seems to be more effective than lanreotide therapy. FUNDING The Netherlands Organisation for Health Research and Development and the Radboud University Medical Center.
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Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Karina V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Santiago Frago
- Department of Digestive Diseases, Miguel Servet University Hospital, Zaragoza, Spain
| | - Paulo S Salgueiro
- Gastroenterology Department, Centro Hospitalar Universitário do Porto-Hospital de Santo António, Porto, Portugal
| | - Thomas Aparicio
- Department of Gastroenterology, Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | | | | | - Raul Prados-Manzano
- Department of Gastroenterology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Robert Benamouzig
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Mourad Benallaoua
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | | | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Wietske Kievit
- Radboud Institute for Health Science, Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
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11
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Lara LF, Silva R, Thakkar S, Stanich PP, Mai D, Samarasena JB. Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter. VideoGIE 2020; 5:162-167. [PMID: 32258850 PMCID: PMC7125393 DOI: 10.1016/j.vgie.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background and Aims GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. Methods Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. Results Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization. Conclusions In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rogelio Silva
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Mai
- University of California, Irvine, California USA
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12
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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds. Dig Dis Sci 2019; 64:2923-2932. [PMID: 31190204 PMCID: PMC6744377 DOI: 10.1007/s10620-019-05683-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease. AIMS To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias. METHODS We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size. RESULTS Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3). CONCLUSIONS This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.
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Muftah M, Mulki R, Dhere T, Keilin S, Chawla S. Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Ann Gastroenterol 2018; 32:113-123. [PMID: 30837783 PMCID: PMC6394262 DOI: 10.20524/aog.2018.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.
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Affiliation(s)
- Mayssan Muftah
- Department of Medicine (Mayssan Muftah), Atlanta, United States
| | - Ramzi Mulki
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Tanvi Dhere
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Steven Keilin
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Saurabh Chawla
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States.,Grady Memorial Hospital (Saurabh Chawla), Atlanta, United States
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15
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Frago S, Alcedo J, Martín Pena-Galo E, Lázaro M, Ollero L, de la Llama N. Long-term results with lanreotide in patients with recurrent gastrointestinal angiodysplasias bleeding or obscure gastrointestinal bleeding. Benefits in efficacy and procedures consumption. Scand J Gastroenterol 2018; 53:1496-1502. [PMID: 30621520 DOI: 10.1080/00365521.2018.1547921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Santiago Frago
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Javier Alcedo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragon)
| | - Edgar Martín Pena-Galo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - María Lázaro
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Leticia Ollero
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Natalia de la Llama
- c Department of Pharmacy , Miguel Servet University Hospital , Zaragoza , Spain
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16
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Abstract
Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.
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Affiliation(s)
- Grainne Holleran
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
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17
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Nardone G, Compare D, Martino A, Rocco A. Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis 2018; 50:542-548. [PMID: 29610020 DOI: 10.1016/j.dld.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
Angioectasias (AD) belong to benign vascular malformations of the gastrointestinal tract and are responsible for about 4-7% of upper non variceal bleeding, 30-40% of small bowel occult bleeding and 3-40% of colonic bleeding episodes. Gastrointestinal haemorrhage secondary to AD represents an important diagnostic and therapeutic problem that negatively impacts on the quality of life of patients and heath care costs. Endoscopic interventions are the mainstay in both diagnosis and treatment of vascular malformations. However, in a substantial percentage of the cases, age of the patients, comorbidities, clinical severity of anaemia and blood loss as well as size, site and number of lesions prevent this therapeutic approach. Hormonal therapy, thalidomide and somatostatin analogues have been investigated for their potential role as rescue therapies in controlling AD bleeding although, thus far, no recommendations have been provided on their use in this clinical setting. In order to implement appropriate prescription of pharmacological agents to manage gastrointestinal bleeding due to ADs, the Italian Society of Gastroenterology (SIGE) nominated a panel of experts who reviewed the available clinical literature and produced practical clinical recommendations.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alberto Martino
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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18
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Benamouzig R, Benallaoua M, Saurin JC, Boubaya M, Cellier C, Laugier R, Vincent M, Boustière C, Gincul R, Samaha E, Grandval P, Aparicio T, Airinei G, Bejou B, Bon C, Raynaud JJ, Levy V, Sautereau D. Efficacy and safety of pasireotide-LAR for the treatment of refractory bleeding due to gastrointestinal angiodysplasias: results of the ANGIOPAS multicenter phase II noncomparative prospective double-blinded randomized study. Therap Adv Gastroenterol 2018; 11:1756283X18756260. [PMID: 29479375 PMCID: PMC5818089 DOI: 10.1177/1756283x18756260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/31/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding. METHODS A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg (n = 10) or placebo (n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment. RESULTS The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0-26) and 11.5 pRBC units in the placebo group (range 0-23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes. CONCLUSION This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.
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Affiliation(s)
| | | | | | | | | | - René Laugier
- Gastroenterology Unit, Timone Hospital, Marseille, France
| | | | | | - Rodica Gincul
- Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Elia Samaha
- Gastroenterology Unit, Georges-Pompidou Hospital, Paris, France
| | | | | | | | - Bakhtiar Bejou
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | - Cyriaque Bon
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | | | - Vincent Levy
- Clinical Research Unit, Avicenne Hospital, Bobigny, France
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19
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Chetcuti Zammit S, Koulaouzidis A, Sanders DS, McAlindon ME, Rondonotti E, Yung DE, Sidhu R. Overview of small bowel angioectasias: clinical presentation and treatment options. Expert Rev Gastroenterol Hepatol 2018; 12:125-139. [PMID: 28994309 DOI: 10.1080/17474124.2018.1390429] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.
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Affiliation(s)
| | | | - David S Sanders
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | - Mark E McAlindon
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | | | - Diana E Yung
- b Endoscopy Unit , the Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Reena Sidhu
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
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20
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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21
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Cúrdia-Gonçalves T, Rosa B, Cotter J. New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:648-656. [PMID: 26940680 DOI: 10.17235/reed.2016.4240/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and is the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation, but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and post-procedure care. The aim of this paper is to review the extended approach to the patient with non-portal hypertension related UGIB.
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Affiliation(s)
| | - Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Portugal
| | - José Cotter
- Gastroenterology, Hospital da Senhora da Oliveira, Portugal
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22
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Vuddanda V, Jazayeri MA, Turagam MK, Lavu M, Parikh V, Atkins D, Bommana S, Yeruva MR, Di Biase L, Cheng J, Swarup V, Gopinathannair R, Olyaee M, Ivaturi V, Natale A, Lakkireddy D. Systemic Octreotide Therapy in Prevention of Gastrointestinal Bleeds Related to Arteriovenous Malformations and Obscure Etiology in Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:1390-1399. [PMID: 29759670 DOI: 10.1016/j.jacep.2017.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 04/05/2017] [Accepted: 04/11/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding. BACKGROUND AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs. METHODS In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6 months' follow-up. RESULTS After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA2DS2-VASc score 3 ± 1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36 (78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and 1 required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p < 0.001). CONCLUSIONS Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief from bleeding.
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Affiliation(s)
- Venkat Vuddanda
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Mohammad-Ali Jazayeri
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Mohit K Turagam
- Division of Cardiology, University of Missouri, Columbia, Missouri
| | - Madhav Lavu
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Valay Parikh
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Donita Atkins
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Sudharani Bommana
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Madhu Reddy Yeruva
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Jie Cheng
- Texas Heart Institute, St. Luke's Hospital, Houston, Texas
| | | | | | - Mojtaba Olyaee
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas
| | - Vijay Ivaturi
- Department of Pharmacy Practice and Science University of Maryland, Baltimore
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Cardiovascular Research Institute, University of Kansas Hospital, Kansas City, Kansas.
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Chetcuti Zammit S, Sanders DS, Sidhu R. Lanreotide in the management of small bowel angioectasias: seven-year data from a tertiary centre. Scand J Gastroenterol 2017; 52:962-968. [PMID: 28506132 DOI: 10.1080/00365521.2017.1325929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Haemorrhage from small bowel angioectasias (SBAs) can be debilitating to patients who are very often elderly and have multiple comorbidities. Our aim was to assess the use of lanreotide in addition to endotherapy in patients with SBAs. METHOD Patients with SBAs on capsule endoscopy (CE) who received lanreotide injections from January 2010 to till the present day at the Royal Hallamshire Hospital in Sheffield were included. Baseline demographics were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes. RESULTS Twelve patients (67% males, mean age 74 SD ± 15.5 years) were included. All patients had multiple comorbidities. Lanreotide was given at a dosage of 60 mg (42%), 90 mg (33%) or 120 mg (25%). It was given at a four-week interval in 75% of patients and at a six-week interval in 17% of patients. One patient (8%) received a single dose. The mean duration of treatment was 19 months SD ± 14.5. Only 17% of patients had their lanreotide stopped due to cholelithiasis. There was a significant improvement in mean haemoglobin: 86.8 versus 98.0 (131-166 g/L, p = .012). The mean number of bleeding episodes (4.18 versus 1.09, p = .010) and packed red cells (323 versus 152, p = .006) received improved. Patients required less DBEs ± APCs after starting lanreotide (19 versus 11 p = .048). CONCLUSION Lanreotide is a useful adjuvant treatment to therapeutic enteroscopy in patients with refractory obscure gastrointestinal bleeding due to SBAs. It improves haemoglobin levels, reduces transfusion requirements, bleeding episodes and number of DBEs. Overall, it has a good safety profile.
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Affiliation(s)
- S Chetcuti Zammit
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - D S Sanders
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - R Sidhu
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
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24
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Martins NB, Chaput KJ, Stawicki SP, Modi R. Octreotide as an adjunct in the management of arterial gastrointestinal bleeding: Should it be considered in refractory cases of obscure origin? Int J Crit Illn Inj Sci 2017; 7:8-11. [PMID: 28382252 PMCID: PMC5364774 DOI: 10.4103/ijciis.ijciis_14_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Noel B Martins
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Kimberly J Chaput
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ronak Modi
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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25
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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26
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Abstract
BACKGROUND Small bowel angiodysplasias (SBA) account for 50% of obscure gastrointestinal bleeding. Lesions bleed recurrently and current treatments are relatively ineffective at reducing re-bleeding. Little is known about the natural history of SBA which is needed to guide treatment decisions and counsel patients on prognosis. AIM The aim of this study is to describe the natural history of a cohort of patients with SBA. METHODS Patients with SBA were identified retrospectively and clinical and outcome information were collected. Logistic regression analysis was performed to identify factors associated with re-bleeding. RESULTS SBAs were found in 86 patients of which 54% (n = 47) were female, and the average age was 71.6 years. The majority (69%) had multiple lesions, mean of 2.76/patient, and 65% were located in the jejunum. Follow-up was available in 65% (n = 56). There was a significant increase in haemoglobin level from 10.05g/dL to 11.94g/dL, p < 0.001 after mean follow up of 31.9 (6-62) months. Re-bleeding events occurred in 80% (n = 45), with an average of 2.91/person. The mean interval between diagnosis and the first re-bleeding event was 10.7 months. Of the group overall, 70% (n = 40) required transfusions during follow up, and 67% required hospitalisation due to re-bleeding. About 50% received a directed treatment, including argon plasma coagulation, somatostatin analogues, or surgical resection. A total of 3.5% (n = 2) died as a direct consequence of bleeding from SBAs. Multiple lesions (p = 0.048) and valvular heart disease (p = 0.034) were predictive of re-bleeding. CONCLUSION Our results show the significant impact of SBA on patients' morbidity, with high rates of re-bleeding, persistent anaemia and a mortality rate of 3.5%, despite the use of currently available medical and endoscopic therapies.
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Affiliation(s)
- Grainne Holleran
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Barry Hall
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Lina Zgaga
- b Department of Public Health and Primary Care , Trinity College Dublin , Ireland
| | - Niall Breslin
- c Department of Gastroenterology , Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
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Grooteman KV, van Geenen EJM, Drenth JPH. Multicentre, open-label, randomised, parallel-group, superiority study to compare the efficacy of octreotide therapy 40 mg monthly versus standard of care in patients with refractory anaemia due to gastrointestinal bleeding from small bowel angiodysplasias: a protocol of the OCEAN trial. BMJ Open 2016; 6:e011442. [PMID: 27619827 PMCID: PMC5030574 DOI: 10.1136/bmjopen-2016-011442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Gastrointestinal angiodysplasias are an important cause of difficult-to-manage bleeding, especially in older patients. Endoscopic coagulation of angiodysplasias is the mainstay of treatment, but may be difficult for small bowel angiodysplasias because of the inability to reach them for endoscopic intervention. Some patients are red blood cell (RBC) transfusion dependent due to frequent rebleeding despite endoscopic treatment. In small cohort studies, octreotide appears to decrease the number of bleeding episodes in patients with RBC transfusion dependency due to gastrointestinal angiodysplasias. This trial will assess the efficacy of octreotide in decreasing the need for RBC transfusions and parenteral iron in patients with anaemia due to gastrointestinal bleeding of small bowel angiodysplasias despite endoscopic intervention. STUDY DESIGN Randomised controlled, superiority, open-label multicentre trial. PARTICIPANTS 62 patients will be included with refractory anaemia due to small bowel angiodysplasias, who are RBC transfusion or iron infusion dependent despite endoscopic intervention and oral iron supplementation. INTERVENTION Patients will be randomly assigned (1:1) to standard care or 40 mg long-acting octreotide once every 4 weeks for 52 weeks, in addition to standard care. The follow-up period is 8 weeks. MAIN OUTCOME MEASURES The primary outcome is the difference in the number of blood and iron infusions between the year prior to inclusion and the treatment period of 1 year. Important secondary outcomes are the per cent change in the number of rebleeds from baseline to end point, adverse events and quality of life. ETHICS AND DISSEMINATION The trial received ethical approval from the Central Committee on Research Involving Human Subjects and from the local accredited Medical Research Ethics Committee of the region Arnhem-Nijmegen, the Netherlands (reference number: 2014-1433). Results will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER NCT02384122; Pre-results.
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Affiliation(s)
- K V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Iannone A, Principi M, Barone M, Losurdo G, Ierardi E, Di Leo A. Gastrointestinal bleeding from vascular malformations: Is octreotide effective to rescue difficult-to-treat patients? Clin Res Hepatol Gastroenterol 2016; 40:373-7. [PMID: 27595456 DOI: 10.1016/j.clinre.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/15/2016] [Accepted: 02/09/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal vascular malformations are responsible for 2-8% of all cases of bleeding and 30-40% of all obscure hemorrhages, being the most frequent cause of occult bleeding in older people. The aim of this review was to provide an up-to-date report about the use of octreotide in bleeding from both hereditary and acquired vascular malformations of the gastrointestinal tract. A systematic literature search was performed, using the keywords "gastrointestinal vascular malformation", "octreotide", "angiodysplasia", "portal hypertensive gastropathy", "gastric antral vascular ectasia", and "hereditary vascular malformations". The first line therapy of acute/chronic bleeding from digestive vascular malformations is endoscopy, followed by angiographic embolization and surgical resection when this is unsuccessful. In the setting of difficult-to-treat patients, octreotide has been proposed as an alternative therapeutic strategy. Studies reported in the literature show a high efficacy and safety of octreotide, but described only a small number of enrolled patients, heterogeneous therapeutic schedules and short-term follow-up, with the exception of acute bleeding from esophageal varices. As a consequence, the use of octreotide is not approved in this setting and it is currently still prescribed as an off-label drug. Studies in larger populations are needed to confirm the promising results observed in the small case series reports, so as to provide physicians with a treatment option for patients without available alternatives. Octreotide could also determine a strong decrease in the management costs of these clinical conditions, and especially, could dramatically reduce hospital admission costs.
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Affiliation(s)
- Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Small Intestinal Angioectasias Are Not Randomly Distributed in the Small Bowel and Most May Be Reached by Push Enteroscopy. J Clin Gastroenterol 2016; 50:561-5. [PMID: 26485105 DOI: 10.1097/mcg.0000000000000425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
GOALS The goal was to describe the location of angioectasias within small bowel on capsule endoscopy and the utility of push enteroscopy versus deep enteroscopy in treatment of overt bleeding from these. BACKGROUND Overt bleeding from small bowel angioectasias is a clinical challenge. Thalidomide and octreotide can be difficult to prescribe and may not be effective. Endoscopy remains a mainstay of treatment for overt bleeding from angioectasias but data regarding the long-term efficacy of endoscopic therapy are limited. We sought to define the location of small bowel angioectasias using capsule endoscopy and review our outcomes for push and double-balloon enteroscopy. METHODS We retrospectively reviewed all 428 capsule endoscopy studies from the Veterans Administration Hospital in West Haven, CT from 2005 to 2012. Location of angioectasias was evaluated using lead mapping and small bowel transit time. RESULTS We identified 69 patients with small bowel angioectasia. At least 66.8% of lesions were in duodenum or ligament of Treitz, with 78.3% within the first 25% of small bowel transit. Twenty-four patients underwent endoscopic treatment of overt bleeding from small bowel angioectasias. Thirty-three percent rebled requiring multiple procedures. Eight patients had 10 anterograde double-balloon examinations. Only 2 patients had both cessation of bleeding with double balloon and lesions outside the reach of push enteroscopy. CONCLUSIONS Push enteroscopy for bleeding angioectasias is effective in many patients. Deep enteroscopy may not benefit most patients as most angioectasias are proximal. Patients with deeper lesions tended to have multiple lesions and rebleeding despite deep enteroscopy.
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Velasco N, Imtiaz T, Shah AA, Koulaouzidis A. Successful treatment of refractory midgut bleeding with ocreotide and corticosteroids in a dialysis patient with suspected sarcoidosis. BMJ Case Rep 2016; 2016:bcr-2016-215513. [PMID: 27417989 DOI: 10.1136/bcr-2016-215513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We present a case of severe and recurrent small-bowel bleeding, due to multiple intestinal angiodysplasias, in a female patient with chronic renal failure due to suspected sarcoidosis. Over the years, she required numerous admissions and >200 units of blood for symptomatic anaemia. However, following a small-bowel capsule endoscopy that revealed several small-bowel angiectasis, she was treated successfully with octreotide and corticosteroids. Her transfusion requirements and hospital admissions were reduced drastically. Moreover, hypercalcaemia and liver function tests also normalised after treatment and double-balloon enteroscopy confirmed the complete resolution of these angiodysplasias. This case presentation confirms the usefulness of octreotide in the management of small-bowel angiodysplasias in dialysis patients and highlights the additional benefit of corticosteroids in portal hypertension due to suspected sarcoidosis.
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Harris AN, Armentano RA, Torres AR, Gallagher AE. Use of endoscopic-assisted argon plasma coagulation for the treatment of colonic vascular ectasia (angiodysplasia) in an adult dog. J Am Vet Med Assoc 2016; 248:526-31. [PMID: 26885595 DOI: 10.2460/javma.248.5.526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CASE DESCRIPTION A 10-year-old neutered male mixed-breed dog was evaluated for a 5-year history of intermittent hematochezia and chronic anemia that were unresponsive to medical treatment. CLINICAL FINDINGS Colonoscopy revealed multifocal areas of coalescing tortuous mucosal blood vessels throughout the colon and rectum. Colonic vascular ectasia (angiodysplasia) was diagnosed on the basis of the endoscopic appearance of the lesions. TREATMENT AND OUTCOME The dog failed to respond to traditional medical treatments for colonic vascular ectasia and required multiple plasma and blood transfusions. The dog received 4 endoscopic-assisted argon plasma coagulation treatments, which resulted in long-term resolution of gastrointestinal hemorrhage. Colonic perforation occurred during the third argon plasma coagulation treatment. The perforation was surgically repaired. The dog remained free from clinical signs of colonic vascular ectasia for > 1 year after the third argon plasma coagulation treatment and was euthanized because of clinical deterioration associated with progressive heart disease. CLINICAL RELEVANCE Endoscopic-assisted argon plasma coagulation treatment is a novel treatment for dogs with colonic vascular ectasia and provided long-term resolution of clinical signs for the dog of this report. In human patients, complications associated with endoscopic-assisted argon plasma coagulation treatment include colonic perforation, which also occurred in the dog of this report.
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Compagna R, Serra R, Sivero L, Quarto G, Vigliotti G, Bianco T, Rocca A, Amato M, Danzi M, Furino E, Milone M, Amato B. Tailored treatment of intestinal angiodysplasia in elderly. Open Med (Wars) 2015; 10:538-542. [PMID: 28352751 PMCID: PMC5368880 DOI: 10.1515/med-2015-0091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 11/04/2015] [Indexed: 01/10/2023] Open
Abstract
Background Angiodysplasia of the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and severe anemia in elderly. Different treatments exist for this kind of pathology. Methods The aim of this work was to study 40 patients treated for intestinal angiodysplasia with two different kind of endoscopic treatments: argon plasma coagulation (APC) and bipolar electrocoagulation (BEC). Results Age of patients was similar in both groups (76,2 ± 10.8 years vs 74,8 ± 8,7 years, P = 0,005). Angiodysplasia treated were located in small bowel, right colon, left colon, transverse colon and cecum. We analysed number of treatment, recurrence, hospital discharge, needs of blood transfusions before and after endoscopic treatment. Number of treatment was the same in both groups (1,2 ± 0,2 vs 1,1 ± 0,1, P < 0,001). We had more recurrence in patients treated with BEC (4/20 vs 2/20, P < 0,001). Hospital discharge was comparable in both groups (5,3 ± 3,1 days vs 5,4 ± 2,8 years, P < 0.001) Conclusions Treatment of angiodysplasia in elderly is not easy. Different kinds of treatment could be adopted. APC and BEC are both safe and effective. The choice of a treatment should consider several factors: age, comorbidity, source of bleeding. In conclusion we think that treatment of bleeding for angiodysplasia in elder population should be a tailored treatment.
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Affiliation(s)
- Rita Compagna
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy ; Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy .; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy ; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Luigi Sivero
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Gennaro Quarto
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Gabriele Vigliotti
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Tommaso Bianco
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Aldo Rocca
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Michele Danzi
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Ermenegildo Furino
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy . Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy ; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
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Holleran G, Hall B, Breslin N, McNamara D. Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial. United European Gastroenterol J 2015; 4:70-6. [PMID: 26966525 DOI: 10.1177/2050640614559121] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/12/2014] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Small bowel angiodysplasias account for over 50% of causes of small bowel bleeding and carry a worse prognosis than lesions located elsewhere in the gastrointestinal tract. Re-bleeding rates are high even after first-line endoscopic therapy and are associated with high levels of morbidity for affected patients. Small trials of long-acting somatostatin analogues have shown promising results but have not yet been assessed in patients with refractory small bowel disease. AIM The purpose of this study was to assess the effect of long-acting somatostatin analogues in reducing re-bleeding rates and transfusion requirements, and improving haemoglobin levels in patients with refractory small bowel angiodysplasia. METHODS Patients with refractory small bowel angiodysplasia were treated with 20 mg of long-acting octreotide for a minimum of three months. Response was assessed according to: rates of re-bleeding, haemoglobin levels, transfusion requirements, and side effects. RESULTS A total of 24 patients were initially treated and 20 received at least three doses. Rates of complete, partial and non-response were 70%, 20% and 10% respectively. Average haemoglobin rates increased from 9.19 g/dl to 11.35 g/dl (p = 0.0027, 95% confidence interval (CI) -3.5 to -1.1) in the group overall and 70% remained transfusion-free after a mean treatment duration of 8.8 months. The rate of adverse events was higher than previously reported at 30%. CONCLUSION Long-acting somatostatin analogues offer a therapeutic advantage in a significant proportion of patients with small bowel angiodysplasia. With careful patient selection and close observation, a long-acting somatostatin analogue should be considered in all patients with persistent anaemia attributable to refractory disease in conjunction with other standard treatments.
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Affiliation(s)
- Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Barry Hall
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Niall Breslin
- Department of Gastroenterology, Tallaght Hospital, Dublin, Ireland
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
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Somatostatin analogs in the medical management of occult bleeding of the lower digestive tract. Gastroenterol Res Pract 2015; 2015:702921. [PMID: 25838821 PMCID: PMC4369896 DOI: 10.1155/2015/702921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 03/03/2015] [Indexed: 12/14/2022] Open
Abstract
The management of occult bleeding from the lower digestive tract can be very challenging. In cases of identified angiodysplasia, the first line management options can be limited by a number of clinical or anatomical factors and an alternative approach might be required, including the use of medications. Somatostatin analogs have been considered as an effective and well-tolerated alternative management option in a number of cases where the endoscopic therapeutic approach is not practical or is unsuccessful, in patients with coagulopathies or who need concomitant anticoagulation or antiplatelet treatment. Despite the lack of double-blinded randomized placebo-control trials and despite the limitations of the available evidence in the literature, including small sample size, variable dosing, and administration routes, there is a consistent agreement in the literature that somatostatin analogs are a safe, well-tolerated, and effective therapeutic option for managing refractory or occult bleeding from the lower digestive tract, with particular reference to patients with angiodysplasia, where endoscopic or surgical management is either not feasible or unsuccessful and other pharmacological options are not preferred.
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[Usefulness of octreotride in preventing non-variceal gastroinetestinal bleeding in liver cirrhosis: A report of two cases]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:386-7. [PMID: 25728741 DOI: 10.1016/j.gastrohep.2014.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 06/18/2014] [Accepted: 06/19/2014] [Indexed: 11/22/2022]
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Successful use of long-acting octreotide for intractable chronic gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 2015; 60:48-53. [PMID: 25162361 DOI: 10.1097/mpg.0000000000000540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Octreotide reduces splanchnic blood flow and is effective in controlling gastrointestinal bleeding (GIB) caused by portal hypertension. Monthly long-acting octreotide (OCT-LAR) with an efficacy and safety profile similar to subcutaneous daily administration presents an attractive option for long-term therapy. We report our experience with OCT-LAR for severe/recurrent GIB in children with portal hypertension secondary to chronic liver disease or portal vein thrombosis who were unresponsive to standard interventions. METHODS A total of 9 patients, 7 boys, who received OCT-LAR between 2000 and 2009 were studied retrospectively (median age at first bleeding 21 months, range 1 month-14.5 years). The dose (2.5-20 mg intramuscularly monthly) was extrapolated from that used in adult acromegaly and neuroendocrine tumours (10-60 mg/mo). Response to treatment was assessed by comparing the number of bleeding events, hospital admissions for acute bleeding, and number of blood units required during the year before and year after starting OCT-LAR. RESULTS OCT-LAR led to a reduction in the number of bleeding episodes in all of the children and to cessation of bleeding in 7. Two children listed for transplantation because of severe GIB were removed from the list. No serious adverse effects immediately attributable to OCT-LAR were observed. One child developed growth hormone deficiency and hypothyroidism during a prolonged period of treatment with subcutaneous octreotide before commencing OCT-LAR. CONCLUSIONS OCT-LAR can control severe intractable recurrent GIB in children with portal hypertension. Prospective randomised controlled trials and pharmacokinetic studies are indicated to establish the optimum dose and length of treatment of OCT-LAR and confirm its efficacy and long-term safety in children.
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Salgueiro P, Marcos-Pinto R, Liberal R, Lago P, Magalhães R, Magalhães M, Ferreira J, Pedroto I. Octreotide Long-Acting Release is effective in preventing gastrointestinal bleeding due to angiodysplasias. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2014. [DOI: 10.1016/j.jpg.2014.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nardone G, Compare D, Scarpignato C, Rocco A. Long acting release-octreotide as "rescue" therapy to control angiodysplasia bleeding: A retrospective study of 98 cases. Dig Liver Dis 2014; 46:688-94. [PMID: 24893688 DOI: 10.1016/j.dld.2014.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/25/2014] [Accepted: 04/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients. AIM To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding. METHODS 98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1mg tid for 28 days and, then from day 14, long acting release-octreotide 20mg monthly, for 6 months. RESULTS The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy. CONCLUSION Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology, Division of Gastroenterology, Department of Clinical Sciences, University of Parma, Parma, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
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Abstract
The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.
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Affiliation(s)
- Deepak Gunjan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak K Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Swanson E, Mahgoub A, MacDonald R, Shaukat A. Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review. Clin Gastroenterol Hepatol 2014; 12:571-82. [PMID: 24013107 DOI: 10.1016/j.cgh.2013.08.038] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 07/24/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies. METHODS We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality. RESULTS We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01). CONCLUSIONS In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.
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Affiliation(s)
- Eric Swanson
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Amar Mahgoub
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Roderick MacDonald
- Minnesota Evidence based Practice Center, Center for Chronic Disease and Outcome Research, Minneapolis, Minnesota
| | - Aasma Shaukat
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota.
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Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:474-83; quiz 484. [PMID: 24642577 DOI: 10.1038/ajg.2014.19] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 01/03/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs. METHODS We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery. RESULTS Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively. CONCLUSIONS Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs.
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Ballew CC, Surratt JF, Collins TL, Shah N. Gastrointestinal bleeding in patients with ventricular assist devices: what every cardiac nurse should know. Prog Transplant 2013; 23:229-34. [PMID: 23996942 DOI: 10.7182/pit2013954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients with end-stage heart failure are increasingly being treated with implantation of a long-term ventricular assist device. As the use of these devices has grown, health care providers have been faced with managing clinically significant gastrointestinal bleeding in this population. Gastrointestinal bleeding is not uncommon and is reported to occur in 13% to 44% of patients treated with ventricular assist devices. Interestingly, because patients with ventricular assist devices are housed on units accustomed to managing the device, cardiac nurses are often asked about the management of gastrointestinal bleeding. This article describes the possible causes of, the array of diagnostic procedures for, and treatments for this complication. It is critical to develop an understanding of this topic so cardiac nurses can partner with other subspecialty groups to manage this population.
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Affiliation(s)
- Carole C Ballew
- University of Virginia Health System, Charlottesville, VA, USA.
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Fabbiocchi F, Pirondini M, Trabattoni D, Ferrari C, Bartorelli AL, De Franchis R, Kaplan AV, Jayne JE. How should I treat a patient with life-threatening gastrointestinal bleeding early after coronary drug-eluting stent implantation? EUROINTERVENTION 2013; 9:880-4. [PMID: 23838321 DOI: 10.4244/eijv9i7a143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND A 68-year-old man was referred for stable angina pectoris and a large apical perfusion defect on stress myocardial scintigraphy. Medical history included chronic oral anticoagulation with warfarin due to longstanding atrial fibrillation, type 2 diabetes mellitus, hypertension, and dyslipidaemia. INVESTIGATION Coronary angiography. DIAGNOSIS Severe stenosis of the mid left anterior descending coronary artery. TREATMENT Percutaneous coronary intervention with implantation of drug-eluting stent.
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Affiliation(s)
- Franco Fabbiocchi
- Department of Clinical Sciences and Community Health, Cardiovascular Section, Centro Cardiologico Monzino, IRCCS University of Milan, Milan, Italy
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Bon C, Aparicio T, Vincent M, Mavros M, Bejou B, Raynaud JJ, Zampeli E, Airinei G, Sautereau D, Benamouzig R, Michopoulos S. Long-acting somatostatin analogues decrease blood transfusion requirements in patients with refractory gastrointestinal bleeding associated with angiodysplasia. Aliment Pharmacol Ther 2012; 36:587-93. [PMID: 22831465 DOI: 10.1111/apt.12000] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 04/27/2012] [Accepted: 07/10/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) may be the cause of recurrent bleeding, despite endoscopic treatment. AIM To evaluate the effect of long-acting somatostatin analogues on blood transfusion requirements, in patients with refractory bleeding due to GIADs. METHODS Consecutive patients with recurrent bleeding from GIADs were enrolled. They received somatostatin analogue treatment for at least 6 months. The efficacy was evaluated in terms of blood transfusions, frequency of bleeding episodes and haemoglobin level during 6 months of treatment (Period During) compared to a 6-months' period before treatment (Period Before). RESULTS Fifteen patients were enrolled from 2007 to 2010. The median duration of somatostatin analogue treatment was 12 months (range: 6-36). The number of transfusions significantly decreased in Period During compared with Period Before [median number: 2 (0-14) vs. 10 (6-24); P < 0.001]. The percentage of patients who experienced a bleeding event was lower during somatostatin analogues treatment (20% vs. 73%; P = 0.01). The mean haemoglobin level was significantly higher when somatostatin analogues were offered [median: 10 g/dL (9-13) vs. 7 (5-8.5); P < 0.001]. None of the patients discontinued treatment due to side effects. CONCLUSIONS Long-acting somatostatin analogues treatment decreased transfusion needs in patients with refractory bleeding from gastrointestinal angiodysplasias. Bleeding episodes were limited and haemoglobin improved during treatment. Long-acting somatostatin analogues may represent an option for the management of patients with chronic bleeding due to gastrointestinal angiodysplasias.
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Affiliation(s)
- C Bon
- Department of Gastroenterology, Avicenne Hospital, APHP, Bobigny, France
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Lee BL, Turner J, Hurley J, Green J, Hawkes N, Alcolado R. Two for the price of one: a dual treatment benefit of long-acting octreotide in occult bleeding and diuretic intractable ascites. Frontline Gastroenterol 2011; 2:226-229. [PMID: 28839614 PMCID: PMC5517236 DOI: 10.1136/fg.2010.003459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2011] [Indexed: 02/04/2023] Open
Abstract
Transfusion-dependent anaemia and portal hypertension are recognised complications of hereditary haemorrhagic telangiectasia (HHT). The anaemia is a result of chronic bleeding from gastrointestinal telangiectasias, which are usually multiple and located throughout the gastrointestinal tract. As a result, treatment with argon plasma coagulation via gastroscopy and or colonoscopy is often insufficient to prevent ongoing blood loss. Portal hypertension in HHT occurs as a result of blood shunting between the hepatic artery and the portal vein within the liver. The somatostatin analogue octreotide has been used as a treatment for bleeding angiodysplasia; however, its possible role as a treatment for diuretic intractable ascites secondary to portal hypertension has not been previously established. The authors report a case that apparently illustrates a dual benefit of long-acting octreotide in the management of both occult bleeding and refractory ascites in a patient with HHT.
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Affiliation(s)
- Bee Leng Lee
- Department of Gastroenterology, Llandough Hospital, UK,Department of Gastroenterology, Royal Glamorgan Hospital, UK
| | - Jeff Turner
- Department of Gastroenterology, Llandough Hospital, UK
| | - Joanna Hurley
- Department of Gastroenterology, Llandough Hospital, UK
| | - John Green
- Department of Gastroenterology, Llandough Hospital, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, UK
| | - Ruth Alcolado
- Department of Gastroenterology, Royal Glamorgan Hospital, UK
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Classen CF, Haffner D, Hauenstein C, Wolf R, Kyank U. Long-time octreotide in an adolescent with severe haemorrhagic gastrointestinal vascular malformation. BMJ Case Rep 2011; 2011:bcr.05.2011.4291. [PMID: 22688939 DOI: 10.1136/bcr.05.2011.4291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Gastrointestinal vascular malformations are a rare cause of acute or chronic blood loss. Usually they are treated by endoscopic obliteration or surgical resection. When such a therapy is inapplicable, pharmacotherapy may be required. At the age of 15 years, our female patient suffered from transfusion dependent recurrent gastrointestinal haemorrhage due to multiple gastrointestinal vascular malformations. Gastroscopy, coloscopy and capsule endoscopy revealed numerous foci making both endoscopic obliteration and complete surgical resection impossible. Neither regular transfusions nor substitution with coagulation factors were helpful. However, subcutaneous octreotide resulted in immediate stop of bleeding. Initial treatment by daily subcutaneous injections was followed by monthly depot application. Over 3 years only 2 transfusions had to be given. The patient required thyroxin substitution, otherwise, no side effects occurred and the girl had a good quality of life. The authors conclude that octreotide is safe and effective in gastrointestinal angiodysplasias inaccessible to endoscopy or surgery.
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Treatment of gastrointestinal angiodysplasia and unmet needs. Dig Liver Dis 2011; 43:515-22. [PMID: 21239239 DOI: 10.1016/j.dld.2010.12.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 11/23/2010] [Accepted: 12/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasia (GIAD) may either be asymptomatic or induce overt or obscure bleeding with a high risk of recurrence. Numerous therapeutic options are available but evidence bases are lacking. AIM We conducted a comprehensive review of pharmacological and endoscopic treatments for previous or active bleeding GIAD and established the unmet needs of the clinicians. METHODS Clinical trials, series, and reports, having been selected through PubMed inquiry, manual searching, and reference list reviewing, were classified by levels of evidence. RESULTS Controlled studies focusing on GIAD treatment, excluding other GI vascular malformations, are rare. Endoscopic destruction, preferably using non-contact endoscopic techniques, is most often proposed as a first-line treatment for GIAD (expert level). In addition, APC is preferred over Nd:Yag laser due to the lower risk of perforation (expert level). Pharmacological treatments for GIAD are considered either when endoscopy fails to access the AD or in order to prevent rebleeding for "chronic bleeding patients." Octreotide and oestroprogestative treatments are the best evaluated drugs; however, no appropriate comparison on cost-effectiveness and tolerance has been performed. CONCLUSIONS The most effective therapeutic strategy for bleeding GIAD is currently inconclusive, and new trials should be performed to address unmet needs.
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Fisher L, Lee Krinsky M, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Cash BD, Decker GA, Fanelli RD, Friis C, Fukami N, Harrison ME, Ikenberry SO, Jain R, Jue T, Khan K, Maple JT, Strohmeyer L, Sharaf R, Dominitz JA. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010; 72:471-9. [PMID: 20801285 DOI: 10.1016/j.gie.2010.04.032] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 04/19/2010] [Indexed: 02/06/2023]
Abstract
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.
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Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010; 55:2129-34. [PMID: 20393879 DOI: 10.1007/s10620-010-1193-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 03/07/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Vascular malformation of the gastrointestinal tract is an uncommon cause for gastrointestinal bleeding. Traditionally, gastroenterologists prefer to use endoscopic modalities like argon plasma coagulation and electrocoagulation to treat accessible lesions. The role of somatostatin analogues (octreotide) in preventing recurrent bleeding in these patients is unclear. The use of pharmacological treatments would be useful especially in refractory bleeding, inaccessible lesions and in patients who are at high risk for invasive interventions. AIMS To systematically review pooled clinical response rates from prospective studies using somatostatin analogues for prevention of recurrent bleeding from gastrointestinal angiodysplasia and quantify the effects that therapy has on the use of blood transfusions. METHODS We searched several electronic databases including Pubmed for full journal articles published after 1966 reporting on the use of somatostatin analogues in the treatment of gastrointestinal angiodyplasia. We hand searched the reference lists of all retrieved articles. Prospective studies involving ten or more patients were included in the analysis. We calculated the pooled proportion of patients who had a clinical response to therapy in the selected studies and the weighted mean difference in transfusion requirements before and after therapy. Heterogeneity between the studies was assessed using the I2 statistic. RESULTS A total of three studies involving 62 patients met the inclusion criteria. The proportional meta-analysis showed a clinical response to treatment of 0.76 (95% CI 0.64-0.85). The weighted mean difference in transfusion requirements before starting therapy (control group) and after treatment initiation (treatment group) was -2.2 (95% CI -3.9 to -0.5). No significant heterogeneity was seen between the studies. CONCLUSIONS A significant number of patients with bleeding gastrointestinal angiodysplasia respond to treatment with octreotide by reducing the need for blood products. As all the included studies had small sample sizes, multicenter randomized trials are needed to confirm these findings. However, it seems reasonable to administer octreotide especially in patients with refractory bleeding, inaccessible lesions and in patients at high risk for other interventions.
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Affiliation(s)
- Colin Brown
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
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