Bleeding as a complication to endoscopic biopsies from the gastric remnant after ulcer surgery

Anticoagulant and Antiplatelet Therapy in Periprocedural Period of Elective Gastrointestinal Endoscopy

Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. Gastrointestinal endoscopy is related to bleeding risk – there is bleeding risk stratification according to endoscopic procedures (high- and low-risk ones). Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. It is recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures and to consider the use of “bridging” therapy with LWMH for patients on Vitamin K antagonists who are at high thrombotic risk. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore, collaboration with a cardiologist is of great importance, at least for some patients.

Safety of Gastrointestinal Endoscopy in Korea: A Nationwide Survey and Population-Based Study

BACKGROUND

Attention should be paid to endoscopy-related complications and safety-related accidents that may occur in the endoscopy unit. This study investigated the current status of complications associated with diagnostic and therapeutic endoscopy in Korea.

METHODS

A questionnaire survey on endoscopy-related complications was conducted in a total of 50 tertiary or general hospitals in Korea. The results were compared to the population-level claims data from the Health Insurance Review & Assessment Service (HIRA), which analyzed endoscopy procedures conducted in 2017 in Korea.

RESULTS

The incidences of bleeding associated with diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and with diagnostic and therapeutic colonoscopy were 0.224% and 3.155% and 0.198% and 0.356%, respectively, in the 2017 HIRA claims data, compared to 0.012% and 1.857%, and 0.024% and 0.717%, in the 50 hospitals surveyed. The incidences of perforation associated with diagnostic and therapeutic EGD and with diagnostic and therapeutic colonoscopy were 0.023% and 0.613%, and 0.007% and 0.013%, respectively, in the 2017 HIRA claims data compared to 0.001% and 0.325%, and 0.017% and 0.206%, in the 50 hospitals surveyed. In the HIRA claims data, the incidence of bleeding/perforation after diagnostic colonoscopy in clinics, community hospitals, general hospitals, and tertiary hospitals was 0.129%/0.000%, 0.088%/0.004%, 0.262%/0.009%, and 0.479%/0.030% respectively, and the corresponding incidence of bleeding/perforation after therapeutic colonoscopy was 0.258%/0.004%, 0.401%/0.007%, 0.408%/0.024%, and 0.731%/0.055%.

CONCLUSION

The incidences of complications associated with diagnostic and therapeutic EGD or colonoscopy tended to increase with the hospital volume in Korea.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0001728.

Gastrointestinal endoscopy in patients on anticoagulant therapy and antiplatelet agents

Periprocedural management of antithrombotics for gastrointestinal endoscopy is a common clinical issue, given the widespread use of these drugs for primary and secondary cardiovascular prevention. For diagnostic procedures, with or without biopsy, no adjustments in antithrombotics are usually needed. For operative procedures, balancing the risk of periprocedural hemorrhage with the continuation of antithrombotics against the chance of recurrent thromboembolic events with their discontinuation may be challenging. Oral anticoagulants need to be temporarily withheld, and consideration must be given to whether a periendoscopic "bridge" therapy, typically a low-molecular-weight heparin, should be used in order to minimize the risk of thromboembolic events. Although some emerging evidence has shown that patients receiving heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to controls, bridging therapy is still recommended for patients on vitamin K antagonists who are at high thrombotic risk. Conversely, bridging therapy is usually not needed for patients taking new oral agents, which are characterized by shorter half-lives, and a rapid offset and onset of action. Management of antiplatelet therapy requires special care in patients on secondary prevention, especially those with coronary stents. This review is intended to summarize the recommendations of updated International Guidelines designed to help the decision-making process in such an intricate field.

Splenosis involving the gastric fundus, a rare cause of massive upper gastrointestinal bleeding: a case report and review of the literature

Splenosis, the autotransplantation of splenic tissue following splenic trauma, is uncommonly clinically significant. Splenosis is typically diagnosed incidentally on imaging or at laparotomy and has been mistakenly attributed to various malignancies and pathological conditions. On the rare occasion when splenosis plays a causative role in a pathological condition, a diagnostic challenge may ensue that can lead to a delay in both diagnosis and treatment. The following case report describes a patient presenting with a massive upper gastrointestinal bleed resulting from arterial enlargement within the gastric fundus secondary to perigastric splenosis. The cause of the bleeding was initially elusive and this case highlights the importance of a thorough clinical history when faced with a diagnostic challenge. Treatment options, including the successful use of transarterial embolization in this case, are also presented.

Ankaferd Blood Stopper for controlling gastrointestinal bleeding due to distinct benign lesions refractory to conventional antihemorrhagic measures

OBJECTIVE

To assess the hemostatic efficacy of the Ankaferd Blood Stopper (ABS, Ankaferd Health Products Ltd, Turkey) hemostatic agent for controlling gastrointestinal bleeding associated with various benign lesions refractory to conventional antihemorrhagic measures.

METHODS

The records of all patients who underwent upper and lower endoscopy procedures at the Turkiye Yuksek Ihtisas Teaching and Research Hospital (Ankara, Turkey) between April 2008 and June 2009 were reviewed. Patients in whom ABS was used as a primary or adjuvant hemostatic agent were included in the study. Rates of bleeding control and postprocedural complications were documented.

RESULTS

Hemostasis with no immediate complications was achieved in all patients within seconds of endoscopic application of ABS.

CONCLUSIONS

ABS may have a role as a primary treatment or as an adjuvant to conventional modalities used to control gastrointestinal bleeding. Prospective controlled studies are needed to help establish its efficacy and, perhaps, offer a comparison with conventional hemostatic interventions.

Complications of endoscopy

This article focuses on potential complications of standard upper and lower endoscopic procedures. Adverse events associated with endoscopic retrograde cholangiopancreatography, EUS, and certain advanced therapeutic techniques such as mucosal resection are not covered. Rather, the article focuses on the recognition of preprocedure risk factors for various complications and the diagnosis and management for procedure-related adverse events.

Complications of endoscopy

BACKGROUND

Although most gastrointestinal endoscopic procedures are performed by gastroenterologists, surgeons often assist in the management of patients with complications. This review provides an introduction to the incidence, prevention, and treatment of complications that may occur after upper endoscopy, colonoscopy, percutaneous endoscopic gastrostomy, and endoscopic retrograde cholangiopancreatography.

METHODS

Systematic review of the literature.

RESULTS

Preprocedural complications include medication effects and adverse effects of bowel preparation. Major procedural complications consist primarily of perforation and hemorrhage. Percutaneous endoscopic gastrostomy tube placement may be complicated by fistula and obstruction. There is also a risk of infectious disease transmission, both to and from the patient.

CONCLUSIONS

Endoscopy, like all invasive procedures, carries significant potential risks for the patient. In practiced hands, and with awareness of the problems that may arise, many complications may be avoided and others successfully managed.

Gastrointestinal bleeding after cold biopsy

Cold biopsy of the gastric mucosa is useful in many gastroduodenal disorders. Antral biopsies are done with increasing frequency to confirm Helicobacter pylori infection and to determine the type and content of gastritis. Gastrointestinal bleeding after gastric cold biopsy is rare. We report two patients who developed melena after cold biopsy of the gastric antrum. Repeat gastroscopies excluded lesions other than the biopsied sites as the source of bleeding. Colonoscopies in both cases did not reveal any evidence of lower GI bleed. Relevant medications include amlodipine, in case 1, and brufen, which was used in case 2 but discontinued before biopsy. Literature review has shown the rarity of clinically significant hemorrhage resulting from gastric cold biopsy. Nevertheless, all patients undergoing gastroscopy should be informed of this potential complication.

Clinical significance of dysplasia in gastric remnant biopsy specimens

BACKGROUND

Dysplasia often is found in biopsy specimens from the gastric stump some 20 years after ulcer surgery. A high frequency of patients with severe dysplasia in the nonoperated stomach develop carcinoma but the clinical significance of dysplasia in the gastric stump is still confounding.

METHODS

In the current study, two groups of patients were evaluated. One group of 22 patients, found at the first investigation in an endoscopic screening study with moderate dysplasia in the gastric stump, were regularly followed up to 18 years with endoscopy and biopsies. In the second part of the investigation, the authors evaluated 17 patients from the same endoscopic screening study, who at any instance during the 18 years were found to have severe dysplasia in biopsy specimens from the gastric remnant.

RESULTS

In three of the 22 patients with moderate dysplasia, stump carcinoma was diagnosed 2, 2, and 6 years, respectively, after the first endoscopic examination. Severe dysplasia was found in two other patients at one occasion but later investigations only revealed moderate dysplasia. The remainder of the patients in this group had either persisting moderate dysplasia or mild dysplasia at follow-up. Seven (41%) of the 17 patients with severe dysplasia had stump carcinoma within a median time of 2 years (range, 1-11). Two other patients had surgery based on suspicion of carcinoma, but had only severe dysplasia in the surgical specimen. Finally, three men died (after 1, 2, and 17 years, respectively) of unrelated disease without suspicion of stump carcinoma and five patients were followed between 6 and 18 years without signs of malignant development.

CONCLUSIONS

Patients with moderate and, especially, severe dysplasia in the gastric remnant are at high risk for gastric carcinoma. Severe dysplasia calls for endoscopic surveillance at short intervals. For patients with moderate dysplasia a close surveillance for 2 years followed by biannual evaluation appears sufficient.

Endoscopic screening during 17 years for gastric stump carcinoma. A prospective clinical trial

In an attempt to reduce mortality in gastric stump carcinoma a defined cohort of operated peptic ulcer patients was followed up with an endoscopic screening programme. From 1930 and through 1960, 1575 patients were operated on for peptic ulcer disease at the Dept. of Surgery in Lund, Sweden. Of 838 still alive in January 1973, 682 were selected for geographical reasons and were offered endoscopic screening with biopsy at regular intervals. Three hundred and fifty-four patients came to the first examination. The follow-up programme was individualized thereafter with screening at 1- to 3-year intervals, depending on endoscopic and histologic findings. The remaining patients have, since then, constituted a control group, followed up only through death certificates and the Swedish Cancer Registry. By December 1989, 202 patients in the screening group had died and 320 in the control group. During the 17 years of follow-up 12 patients in the screening group died of gastric cancer, compared with 14 in the control group, even though 17 cases of early gastric cancer were diagnosed and operated on in the first group, compared with only 2 in the latter. We conclude that regular endoscopic screening does not reduce gastric cancer mortality and can thus not be recommended in asymptomatic patients previously subjected to partial gastric resection due to peptic ulcer disease.

Cytological brush entrapment: a hazard in the stomach postoperatively

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