Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

Understanding the risk factors of hemagglutinase-associated hypofibrinogenemia can improve the prognosis of patients

We editorialized on this study published by Zou et al . Gastrointestinal bleeding is a common clinical symptom, and hemocoagulase is frequently used to treat hemorrhagic conditions. However, studies have shown that hemocoagulase treatment may induce acquired hypofibrinogenemia, further aggravating the bleeding. Zou et al retrospectively analyzed 109 gastrointestinal bleeding cases to explore the hazards underlying hypofibrinogenemia induced by hemocoagulase, and identified higher total dose of hemocoagulase and female sex, as well as low baseline fibrinogen levels as significant hazards. Consequently, clinicians should be aware of both intrinsic and extrinsic risk factors when using hemocoagulase among this patient population, and remain vigilant for the potential development of hemocoagulase-induced hypofibrinogenemia.

Frailty Predicts Mortality and Procedural Performance in Patients With Non-Variceal Upper Gastrointestinal Bleeding

Introduction

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalization in the United States, with approximately 400 000 admissions annually and a 5%-10% mortality rate. This study aimed to evaluate frailty's impact on NVUGIB outcomes.

Methods

We utilized the 2019 National Readmission Database (NRD) to identify adult patients (≥ 18 years) admitted with a principal diagnosis of NVUGIB using ICD-10-CM codes. NVUGIB hospitalizations were stratified by frailty using the hospital frailty risk score (HFRS) of 5 or more as the cut-off for frailty. Multivariate regression analyses were conducted to analyze the outcomes. STATA 14.2 was used for statistical testing.

Results

Among 218 647 NVUGIB admissions, 99 892 (45.69%) were frail. Frail patients were older, more often female, and had higher comorbidity burdens. They showed significantly greater in-hospital mortality (adjusted odds ratio [aOR] 5.64, 95% CI 4.94-6.44; p < 0.001), acute kidney injury (5.85), respiratory failure (6.93), septic shock (40.94), hemorrhagic shock (2.64), vasopressor use (4.36), mechanical ventilation (6.04), and ICU admission (5.41). Although frail patients had higher odds of esophagogastroduodenoscopy (EGD) with intervention (1.04; p < 0.001), they were less likely to receive EGD within 24 h (0.75; p < 0.001). They also had higher odds of rebleeding (1.18; p < 0.001) and radioembolization (2.69; p < 0.001). Length of stay increased by 2.30 days, total charges rose by $28 518, discharge to rehabilitation was more frequent (3.12; p < 0.01), and 30-day readmission was higher (15.24% vs. 11.43%, HR 1.16; p < 0.001).

Conclusion

Frailty independently predicts worse clinical outcomes and increased resource use in NVUGIB. Recognizing frailty may improve risk stratification and guide more tailored management strategies for this high-risk population.

Posterior Epistaxis Presenting as Upper GI Bleeding in A Healthy 21-Year-Old Patient: A Case Report

A 21-year-old Palestinian woman experienced recurrent hematemesis and melena over 7 months, requiring multiple hospital admissions and blood transfusions. Despite extensive investigations, the bleeding source remained undetermined until a posterior nasal bleed was suspected. Flexible rhinoscopy revealed a dilated sphenopalatine artery, and she was successfully treated with endovascular intervention. It is important for the Gastroenterologists to consider nasal endoscopy for patients with unexplained UGIB.

Environmental and Clinical Factors Concerning Gastrointestinal Bleeding: An Umbrella Review of Meta-Analyses

OBJECTIVES

Gastrointestinal bleeding, an emergency and critical disease, is affected by multiple factors. This study aims to systematically summarize and appraise various factors associated with gastrointestinal bleeding.

DESIGN

Umbrella review.

SETTING AND PARTICIPANTS

Meta-analyses that evaluated environmental and clinical factors concerning gastrointestinal bleeding.

METHODS

We conducted a systematic search to identify eligible meta-analyses. For each included study, the risk estimates, heterogeneity estimates, small-study effects, excess significance tests, and publication biases were recalculated and appraised. Furthermore, we considered the methodologic quality and classified the evidence.

RESULTS

In this study, 51 beneficial and 44 harmful associations were found. This study found that preemptive transjugular intrahepatic portosystemic shunt was the most reliable treatment to reduce gastroesophageal variceal bleeding and mortality risk, followed by antibiotics. For gastroduodenal ulcer bleeding, Yunnan Baiyao and proton pump inhibitors (PPIs) were relatively dependable treatment drugs, and the comparatively reliable prophylactic drugs comprised PPIs and H2-receptor antagonists. Patients with hemodynamic instability and larger ulcers had a higher risk of rebleeding. Both weekend admissions and the combination of selective serotonin reuptake inhibitors and nonsteroidal anti-inflammatory drugs were high-risk factors for upper gastrointestinal bleeding and mortality. We also found that tranexamic acid was a credible drug for overall gastrointestinal bleeding. Meanwhile, aspirin, warfarin, diabetes, and renal failure were all high-risk factors.

CONCLUSIONS AND IMPLICATIONS

Altogether, many factors can substantially influence gastrointestinal bleeding. Therefore, in daily life and clinical practice, we should not only remain cautious in prescribing and taking some drugs but also pay attention to the management of lifestyle and underlying diseases. If necessary, protective drugs should be properly supplemented.

Understanding the role of nutritional status on the outcomes of nonvariceal upper gastrointestinal bleeding: Findings from a retrospective cohort analysis

BACKGROUND & AIMS

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalization worldwide. Malnutrition, on the other hand, varies in prevalence and closely correlates with age and comorbidities. Though malnutrition is linked to poor outcomes generally, its impact on NVUGIB patients remains unexplored.

METHODS

Using the National Readmission Database (NRD) from 2016 to 2020, we employed the International Classification of Diseases, 10th revision, Clinical Modifications (ICD-10-CM) codes to identify adult patients (aged ≥18 years) admitted with a principal diagnosis of NVUGIB. We further stratified NVUGIB hospitalizations based on the presence and severity of malnutrition. Utilizing a multivariate regression model, we assessed the impact of malnutrition on NVUGIB outcomes. STATA 14.2 was utilized for statistical analysis.

RESULTS

Out of the 742,592 adult patients admitted with NVUGIB, 76,603 (10.32 %) had malnutrition, categorized as mild to moderate (3.01 %), severe (4.00 %), and malnutrition of unspecified severity (3.29 %). After adjusting for confounding variables, all-cause in-hospital mortality due to NVUGIB was significantly higher in malnourished patients, corresponding to the severity of malnutrition (adjusted odds ratio [aOR] 1.83 & 3.52 in mild-moderate malnutrition and severe malnutrition respectively; P < 0.01). Similarly, malnutrition was associated with progressively higher odds of acute kidney injury (aOR 1.39 & 1.54 for mild-moderate and severe malnutrition, respectively), septic shock (aOR 2.41 & 5.12), hemorrhagic shock (aOR 1.71 & 2.16), and intensive care unit (ICU) admission (aOR 2.00 & 2.97), all increasing with malnutrition severity (P < 0.01). Procedural analysis showed lower odds of diagnostic EGD (aOR 0.95 & 0.92), EGD within 24 h (aOR 0.75 & 0.67), and overall EGD (aOR 0.80 & 0.66) in malnourished patients, but higher odds of rebleeding requiring repeat EGD (aOR 1.12 & 1.19) and radioembolization (aOR 2.04 & 2.75), both rising with malnutrition severity (P < 0.01). Finally, resource utilization estimated by total hospitalization charges, length of stay, discharge to rehabilitation facilities (aOR 1.99 & 2.66), and 30-day readmission rates (aOR 1.29 & 1.38) were also significantly higher among patients with malnutrition (P < 0.01).

CONCLUSION

Malnutrition exacerbates the outcomes of NVUGIB including higher in-hospital mortality rates, morbidity and resource utilization. Early identification and targeted management of malnutrition in NVUGIB patients are crucial to reducing adverse outcomes and optimizing healthcare resources.

The role of shock indexes and RDW/albumin ratio in upper gastrointestinal bleeding : Predicting adverse outcomes

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) is a common condition in emergency departments (ED). The aim of this study is to evaluate the effectiveness of the red blood cell distribution width (RDW) to albumin ratio and three types of shock index (SI) as predictors of adverse outcomes in patients with UGIB in the ED.

METHODS

The study was designed as a retrospective, single-center study, and patients were screened using electronic medical records. Glasgow Blatchford, RDW/albumin ratio, SI, modified SI (MSI), and age SI were calculated, and adverse outcomes were defined as ICU admission, red blood cell transfusion, in-hospital mortality, and 30-day mortality. The effectiveness of these parameters in predicting adverse outcomes in UGIB patients admitted to the ED was evaluated.

RESULTS

The study enrolled 174 patients, of whom 17.2% required admission to the ICU, 33.9% received red blood cell transfusions, and 10.3% died within 30 days. Patients with adverse outcomes had significantly higher SI, MSI, age SI, and RDW/albumin ratio values. All four indices were statistically significant predictors of adverse outcomes (area under the curve [AUC] SI: 0.676; AUC MSI: 0.706; AUC age SI: 0.778; AUC RDW/albumin: 0.787). Age SI showed significantly higher prognostic performance in predicting adverse outcomes than SI and MSI.

CONCLUSION

The present study suggests that SI, MSI, age SI, and RDW/albumin ratio may be useful in predicting adverse outcomes in patients with UGIB. The RDW/albumin ratio was effective in predicting mortality, while age SI showed a higher predictive ability for adverse outcomes compared to SI and MSI.

Management of gastrointestinal bleed in the intensive care setting, an updated literature review

Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.

Predictors of Short and Long-term Rebleeding in Patients With Overt Gastrointestinal Bleeding: A Prospective Study

BACKGROUND

We aimed to identify predictors of rebleeding in patients with overt gastrointestinal bleeding (GIB) and to develop a rebleeding index.

METHODS

This was a prospective study of patients admitted with GIB from 2013 to 2023 at a tertiary care center. Rebleeding was defined as the recurrence of visible bleeding after initial stabilization, endoscopic evaluation, and/or hemostatic therapy, accompanied by a change in vital signs or a hemoglobin (Hgb) decrease of ≥2 g/dL. Independent predictors were determined after adjusting for confounders.

RESULTS

Seven hundred ninety-seven patients with GIB were recruited between 2013 and 2023 and were followed up until death or January 2023. In-hospital, 1-month, 1-year, and end of follow-up rebleeding rates were: 5.3%, 8.9%, 16.2%, and 21.8%, respectively. Sources of rebleeding were different from the original sources in 36% of patients. Predictors of 1-month rebleeding included need for ≥3 packed red blood cell (PRBC) units (HR=1.86; p=0.041), endoscopic stigmata of recent hemorrhage (SRH) (HR=1.99; p=0.007), and Hgb level (HR=0.82; p=0.018; lower Hgb predicts higher rebleeding risk). A rebleeding index based on SRH, Hgb level, and ≥3 PRBC units showed modest performance (AUC=0.68), with higher scores indicating increased rebleeding risk. At the end of follow-up, SRH remained a predictor (HR=1.61; p=0.003), whereas antiplatelets on admission or discharge appeared protective against rebleeding (HR=0.66; p=0.021; HR=0.63; p=0.026).

CONCLUSION

Predictors of rebleeding after GIB were SRH, PRBC transfusion, and lowest Hgb. The novel index based on these predictors performed favorably compared with the GBS, Rockall systems for UGUB and ABC scores. These data will help guide management and risk stratification of patients with GIB.

Prognosis of major bleeding based on residual variables and machine learning for critical patients with upper gastrointestinal bleeding: A multicenter study

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a significant cause of morbidity and mortality worldwide. This study investigates the use of residual variables and machine learning (ML) models for predicting major bleeding in patients with severe UGIB after their first intensive care unit (ICU) admission.

METHODS

The Medical Information Mart for Intensive Care IV and eICU databases were used. Conventional ML and long short-term memory models were constructed using pre-ICU and ICU admission day data to predict the recurrence of major gastrointestinal bleeding. In the models, residual data were utilized by subtracting the normal range from the test result. The models included eight algorithms. Shapley additive explanations and saliency maps were used for feature interpretability.

RESULTS

Twenty-five ML models were developed using data from 2604 patients. The light gradient-boosting machine algorithm model using pre-ICU admission residual data outperformed other models that used test results directly, with an AUC of 0.96. The key factors included aspartate aminotransferase, blood urea nitrogen, albumin, length of ICU admission, and respiratory rate.

CONCLUSIONS

ML models using residuals improved the accuracy and interpretability in predicting major bleeding during ICU admission in patients with UGIB. These interpretable features may facilitate the early identification and management of high-risk patients, thereby improving hemodynamic stability and outcomes.

Polypharmacy and Drug-Drug Interactions in Elderly Patients With Gastrointestinal Bleeding: A Single-Center Retrospective Study

INTRODUCTION

Gastrointestinal (GI) bleeding is a significant clinical presentation in elderly patients, where comorbidities, polypharmacy, and drug-drug interactions markedly increase the risk of bleeding. The aim of this study was to evaluate the types of medications prescribed during the six months prior to the patients' admission and the potential risks associated with drug interactions in patients aged 65 and older diagnosed with GI bleeding.

METHODS

This retrospective study included 49 patients aged 65 and older who were admitted to the emergency department of Kırklareli Training and Research Hospital with a diagnosis of GI bleeding between January 1 and December 31, 2022. Patient demographics, type of GI bleeding (upper or lower), duration of hospital stay, clinical outcomes, and medications prescribed during the six months prior to hospitalization were recorded. Statistical analyses were performed using GraphPad Prism 8.0. Continuous variables were reported as mean±standard deviation and categorical variables were analyzed using Fisher's exact test and Chi-square test, with a significance level of p<0.05.

RESULTS

The study included 49 patients, comprising 25 (51.02%) males and 24 (49.98%) females, with a mean age of 78.4±7.6 years. Female patients had a significantly higher mean age than males (p=0.045). Upper GI bleeding (81.6%) was more prevalent than lower GI bleeding (18.4%), with no statistically significant gender difference (p=0.7252). The mortality rate was 10.2%, with all deceased patients being female and diagnosed with upper GI bleeding (p=0.0226). A total of 110 medications were prescribed during the six months prior to hospitalization. Drug interactions were identified in 28 patients, with 67.9% classified as moderate and 28.6% as major. NSAIDs, anticoagulants, and antidepressants were the most frequently involved drug groups, significantly heightening the risk of GI bleeding.

CONCLUSION

Polypharmacy and drug-drug interactions are critical factors that contribute to the increased risk of GI bleeding in elderly patients. Comprehensive evaluation of medication regimens and strategies to mitigate polypharmacy are essential for improving patient safety and outcomes in this population.

Clinical Epidemiology, Etiology, and Outcomes of Upper Gastrointestinal Bleeding at a Tertiary Center in Bahrain: A Retrospective Study

Background Upper gastrointestinal bleeding (UGIB) is one of the most common major medical emergencies. This study sought to determine the epidemiology, clinical characteristics, and outcomes of UGIB in the largest major tertiary care center in Bahrain, compared to regional and international cohorts. Methods We conducted a retrospective cohort study of all patients diagnosed with UGIB between April 2021 and April 2022 in Salmaniya Medical Complex, Bahrain's largest tertiary-level public hospital. The primary outcomes measured included 30-day mortality rates and one-year readmission rates. Other variables collected included demographic factors, baseline characteristics, comorbidities, symptomatology, endoscopic findings, and etiologies of the bleeding. Results A total of 212 patients with UGIB were included. The mean age of the patients was 56.7 ± 19.1 years. More than 50% of patients with UGIB presented with melena and symptoms of anemia. The most common cause of UGIB in Bahrain was duodenal ulcers, which were found in 75 patients (37.7%). One in two patients with UGIB required packed red blood cells, while fresh-frozen plasma and platelet transfusions were reserved for severe cases. The readmission rate within one year of discharge (14.2%) was associated with smoking, cardiac history, melena, gastric malignancy, and rescope during admission. The 30-day mortality (15.6%) was associated with comorbidities of chronic kidney disease, cerebrovascular disease, and hematochezia on presentation. Conclusion Overall, the mortality rate of UGIB in Bahrain is higher than in countries in the region, the UK, and the US, signaling potential gaps in management and a reflection of a more complex patient population.

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

Hemangioendothelioma as a rare cause of lower gastrointestinal bleeding - a case report

INTRODUCTION AND IMPORTANCE

Gastrointestinal bleeding is a serious health threat, especially when it originates from the small intestine, often termed small bowel bleeding (SBB). Hemangioendothelioma, a rare vascular tumor, can be a significant yet uncommon cause of gastrointestinal bleeding. This case report highlights hemangioendothelioma's diagnostic challenges and clinical significance in SBB.

CASE PRESENTATION

A 16-year-old female experienced six months of intermittent massive rectorrhagia and melena, along with nausea, vomiting, loss of appetite, and abdominal pain. Initial endoscopic investigations, including colonoscopy and enteroscopy, did not identify the bleeding source. Imaging studies, including a CT scan and Meckel's scintigraphy, were also inconclusive. Persistent bleeding and a significant drop in hemoglobin levels led to exploratory laparotomy with intraoperative enteroscopy, which revealed a nodular lesion in the small intestine. Histopathological examination confirmed the lesion as hemangioendothelioma. Surgical resection of the lesion stopped the bleeding, and the patient recovered without complications, remaining asymptomatic during follow-ups at one and six months post-surgery.

CLINICAL DISCUSSION

Hemangioendothelioma is a rare, locally aggressive vascular tumor that can present with abdominal pain, bowel obstruction, anemia, and gastrointestinal bleeding. Due to its rarity and location, it often goes undetected in conventional endoscopy. The definitive diagnosis is made through histopathological examination, which shows characteristic endothelial cells and vascular structures. Surgical excision is the primary treatment, although there is a risk of recurrence and metastasis.

CONCLUSION

This case underscores hemangioendothelioma's diagnostic challenges and clinical relevance in obscure gastrointestinal bleeding. Intraoperative enteroscopy plays a crucial role in the diagnosis and management. Clinicians should consider hemangioendothelioma in similar cases to ensure appropriate treatment and management.

Risk factors for hemocoagulase-associated hypofibrinogenemia in patients with gastrointestinal bleeding

BACKGROUND

With the widespread use of hemocoagulase in patients with gastrointestinal bleeding, clinicians have become increasingly concerned about coagulation disorders associated with this medication. Risk factors for hypofibrinogenemia associated with hemocoagulase are poorly understood.

AIM

To determine risk factors for hemocoagulase-associated hypofibrinogenemia in patients with gastrointestinal bleeding.

METHODS

We performed a retrospective analysis of the medical documentation of hospitalized patients treated with hemocoagulase for gastrointestinal bleeding. Hypofibrinogenemia was defined as a decrease in plasma fibrinogen concentration to less than 2.0 g/L. The included patients were divided into two groups: acquired hypofibrinogenemia group and non-hypofibrinogenemia group. We used logistic regression analysis to identify potential risk factors and established risk assessment criteria by employing a receiver operating characteristic curve.

RESULTS

There were 36 patients in the acquired hypofibrinogenemia group and 73 patients in the non-hypofibrinogenemia group. The hypofibrinogenemia group showed higher rates of intensive care unit admissions (P = 0.021), more female patients (P = 0.005), higher in-hospital mortality (P = 0.027), larger hemocoagulase doses (P = 0.026), more Packed Red Cells transfusions (P = 0.024), and lower baseline fibrinogen levels (P < 0.000). Binary logistic regression was employed to examine the risk factors associated with acquired hypofibrinogenemia. The analysis revealed that baseline fibrinogen [odds ratio (OR) 0.252, 95%CI: 0.137-0.464, P < 0.000], total hemocoagulase doses (OR 1.074, 95%CI: 1.015-1.137, P = 0.014), and female gender (OR 2.856, 95%CI: 1.015-8.037, P = 0.047) were statistically significant risk factors.

CONCLUSION

Higher doses of total hemocoagulase, female gender, and a lower baseline fibrinogen level were risk factors for hemocoagulase-associated hypofibrinogenemia in patients with gastrointestinal bleeding.

Ionically assembled hemostatic powders with rapid self-gelation, strong acid resistance, and on-demand removability for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is bleeding in the upper part of the gastrointestinal tract with an acidic and dynamic environment that limits the application of conventional hemostatic materials. This study focuses on the development of N-[(2-hydroxy-3-trimethylammonium) propyl] chitosan chloride/phytic acid (HTCC/PA, HP) powders with fast hemostatic capability and strong acid resistance, for potential applications in managing UGIB. Upon contact with liquids within 5 seconds, HP powders rapidly transform into hydrogels, forming ionic networks through electrostatic interactions. The ionic crosslinking process facilitates the HP powders with high blood absorption (3.4 times of self-weight), sufficient tissue adhesion (5.2 and 6.1 kPa on porcine skin and stomach, respectively), and hemostasis (within 15 seconds for in vitro clotting). Interestingly, the PA imparts the HP powders with strong acid resistance (69.8% mass remaining after 10 days of incubation at pH 1) and on-demand removable sealing while HTCC contributes to fast hemostasis and good wet adhesion. Moreover, the HP powders show good biocompatibility and promote wound healing. Therefore, these characteristics highlight the promising clinical potential of HP powders for effectively managing UGIB.

Hemobilia: A Narrative Review of Current Diagnostic Techniques and Emerging Management Strategies

Hemobilia is a relatively uncommon but important cause of gastrointestinal bleeding. It occurs due to abnormal communications between the biliary system and surrounding vasculature, often caused by surgical interventions, trauma, infections, or malignancies. The rise of advanced hepato-pancreato-biliary techniques, including radiofrequency ablation and transjugular intrahepatic portosystemic shunt (TIPS) placement, necessitates careful evaluation for the potential presence of hemobilia during the post-procedural period of these patients. Hemobilia can be difficult to diagnose, as common symptoms like jaundice, abdominal pain, and gastrointestinal bleeding are not always present together. Imaging techniques such as Doppler ultrasound, contrast-enhanced computed tomography (CT), and angiography are critical for identifying the source of bleeding. Treatment typically focuses on achieving hemostasis and ensuring proper bile flow, with options including endoscopic techniques, angiography with transcatheter arterial embolization, and, in severe cases, surgical intervention. This review highlights recent advances in diagnostic and therapeutic approaches, emphasizing the need for early recognition and tailored interventions to improve patient outcomes.

MLFA-UNet: A multi-level feature assembly UNet for medical image segmentation

Medical image segmentation is crucial for accurate diagnosis and treatment in medical image analysis. Among the various methods employed, fully convolutional networks (FCNs) have emerged as a prominent approach for segmenting medical images. Notably, the U-Net architecture and its variants have gained widespread adoption in this domain. This paper introduces MLFA-UNet, an innovative architectural framework aimed at advancing medical image segmentation. MLFA-UNet adopts a U-shaped architecture and integrates two pivotal modules: multi-level feature assembly (MLFA) and multi-scale information attention (MSIA), complemented by a pixel-vanishing (PV) attention mechanism. These modules synergistically contribute to the segmentation process enhancement, fostering both robustness and segmentation precision. MLFA operates within both the network encoder and decoder, facilitating the extraction of local information crucial for accurately segmenting lesions. Furthermore, the bottleneck MSIA module serves to replace stacking modules, thereby expanding the receptive field and augmenting feature diversity, fortified by the PV attention mechanism. These integrated mechanisms work together to boost segmentation performance by effectively capturing both detailed local features and a broader range of contextual information, enhancing both accuracy and resilience in identifying lesions. To assess the versatility of the network, we conducted evaluations of MFLA-UNet across a range of medical image segmentation datasets, encompassing diverse imaging modalities such as wireless capsule endoscopy (WCE), colonoscopy, and dermoscopic images. Our results consistently demonstrate that MFLA-UNet outperforms state-of-the-art algorithms, achieving dice coefficients of 91.42%, 82.43%, 90.8%, and 88.68% for the MICCAI 2017 (Red Lesion), ISIC 2017, PH2, and CVC-ClinicalDB datasets, respectively.

Heyde Syndrome Unveiled: A Case Report with Current Literature Review and Molecular Insights

Heyde syndrome, marked by aortic stenosis, gastrointestinal bleeding from angiodysplasia, and acquired von Willebrand syndrome, is often underreported. Shear stress from a narrowed aortic valve degrades von Willebrand factor multimers, leading to angiodysplasia formation and von Willebrand factor deficiency. This case report aims to raise clinician awareness of Heyde syndrome, its complexity, and the need for a multidisciplinary approach. We present a 75-year-old man with aortic stenosis, gastrointestinal bleeding from angiodysplasia, and acquired von Willebrand syndrome type 2A. The patient was successfully treated with argon plasma coagulation and blood transfusions. He declined further treatment for aortic stenosis but was in good overall health with improved laboratory results during follow-up. Additionally, we provide a comprehensive review of the molecular mechanisms involved in the development of this syndrome, discuss current diagnostic and treatment approaches, and offer future perspectives for further research on this topic.

UI-EWD hemostatic powder in the management of refractory lower gastrointestinal bleeding: a multicenter study

INTRODUCTION

Lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. A novel adhesive endoscopic hemostatic powder (UI-EWD/NexpowderTM, Nextbiomedical, Incheon, South Korea) has been developed and recently utilized for LGIB hemostasis. The aim of the current study was to assess the efficacy and safety of UI-EWD as a rescue therapy for the treatment of refractory LGIB.

METHODS

In this study, a total of 59 consecutive patients with LGIB who experienced initial hemostasis failure with conventional endoscopic therapy were enrolled into this multicenter single-arm study. These patients subsequently underwent UI-EWD application for the refractory LGIB hemostasis. We evaluated the success rate of hemostasis, re-bleeding rate within 30 d, and adverse events related to UI-EWD.

RESULTS

UI-EWD was successfully administered to the bleeding sites in all enrolled refractory bleeding patients. Hemostasis was achieved in the entirety of the 59 patients (100%). The cumulative re-bleeding rate within 30 d was 8.5% (5/59). There were no UI-EWD-related adverse events, such as perforation nor embolism.

CONCLUSION

Based on our results, the utilization of UI-EWD demonstrated a remarkable success rate in achieving hemostasis for refractory LGIB, while also exhibiting promising outcomes in reducing the re-bleeding rate within a 30-day period. Particularly, UI-EWD exhibits a favorable safety profile across all segments of the colon in cases of refractory LGIB.

The Value of Colonoscopy in Assessing Rectal Bleeding in Patients Referred From Outpatient Care Units in Erbil, Iraq

BACKGROUND AND OBJECTIVES

Rectal bleeding denotes bleeding from the lower colon or rectum, specifically from a location distal to the ligament of Treitz. Lower gastrointestinal bleeding (LGIB) is very common in adults of all ages. This study aimed to review the diagnostic findings of colonoscopy in outpatients who had nonurgent rectal bleeding and identify common pathologies causing rectal bleeding in patients at Erbil and Rizgary Teaching Hospitals in Iraq.

METHODS

We selected 400 male and female patients from outpatient departments with evidence of rectal bleeding, referring them to the gastroenterology units of Erbil and Rizgary Hospitals in Erbil, Iraq. Patients with upper gastrointestinal bleeding (UGIB) sources and other symptoms were excluded from the study. We prepared the bowel, subjected all patients to a colonoscopy, and recorded the findings. Where necessary, biopsies were also taken. A diagnosis was made based on the colonoscopic findings.

RESULTS

The total number of patients was 400. Their mean age + SD was 44.9 + 15.9 years, ranging from 18 to 83 years, and the highest proportion of the diagnoses was hemorrhoids, either alone (n = 140, 35%) or in combination with other diseases. The results indicated that 48 (40%) males aged < 45 years had hemorrhoids, compared with 33 (33.7%) males aged ≥ 45 years; for females, 29 (30.9%) in those aged < 45, compared to 30 (34.1%) in those aged ≥ 45. The next two prevalent diagnoses in the total sample were inflammatory bowel disease (n = 31, 7.8%) and colorectal tumor (n = 37, 9.3%). It was observed that around one-fifth (n = 79, 19.8%) of the sample was normal.

CONCLUSION

This study highlights the leading causes of LGIB as diagnosed through colonoscopy. The main causes and patterns of LGIB across gender and age groups in Erbil were generally similar to other settings but with some differences. Hemorrhoids caused the most rectal bleeding, followed by tumors and then inflammatory bowel disease. The older group had more cases of diverticulosis than the younger group. Although most findings were benign, colonoscopy should be strongly considered for outpatients (young and old) with nonurgent rectal bleeding.

Transcatheter arterial embolization for small-bowel bleeding: technical and clinical outcomes and risk factors for early recurrent bleeding

Background

This study evaluated the technical and clinical outcomes of transcatheter arterial embolization (TAE) in patients with acute small-bowel bleeding (SBB) and aimed to identify potential risk factors for early recurrent bleeding after TAE.

Methods

Thirty-one patients with SBB managed with TAE between January 2006 and December 2021 were included. Technical and clinical success was defined as angiographic occlusion of the bleeding artery and disappearance of clinical or laboratory signs of persistent bleeding without major complications. Complications were classified according to the Society of Interventional Radiology's guidelines. Kaplan-Meier estimates assessed overall survival, and logistic regression models determined risk factors for clinical success and early rebleeding.

Results

Technical and clinical success were achieved in 30/31 (97%) and 19 (61%), respectively. Early recurrent bleeding was present in 9 (29%) patients, and was treated by repeat embolization in 4 patients, conversion to surgery in 4, and comfort therapy in 1 patient. TAE-related small bowel ischemia requiring surgery was found in 2 (6.5%) patients. Thirty-day and in-hospital mortality were 19% (6/31) and 23% (7/31), respectively; overall 5-year estimated survival was 60%. Thrombocytopenia and elevated prothrombin time (PT)/activated partial thromboplastin time (aPTT) levels prior to TAE were identified as risk factors for clinical failure (P=0.0026 and P=0.027, respectively), and for residual or early recurrent bleeding (P<0.001 and P=0.01, respectively).

Conclusions

TAE is safe and effective for managing severe SBB; however, early recurrent bleeding was found in nearly one third of patients. Thrombocytopenia and elevated PT/aPTT levels were risk factors for early recurrent bleeding.

Impact of connective tissue diseases on inpatient outcomes in gastrointestinal bleeding: insights from a national database analysis

Background

Connective tissue diseases (CTDs) are characterized by immune system dysregulation, which can profoundly impact the gastrointestinal (GI) system. While GI bleeding is a well-recognized cause of mortality and morbidity in the USA, its occurrence in patients with CTD remains documented but underexplored in terms of inpatient outcomes. GI bleeding in CTD is attributed to factors such as vasculopathy and drug-related risks, notably steroids and non-steroidal anti-inflammatory drugs (NSAIDs). This research seeks to conduct a comprehensive national-level analysis, utilizing the National Inpatient Sample (NIS), to compare GI bleeding outcomes between patients with CTD and those without this condition.

Methods

Utilizing the extensive NIS database covering 2020, we conducted a retrospective analysis of GI bleeding patients with CTD, identified through the International Classification of Diseases, 10th Revision (ICD-10). The primary outcome was in-hospital mortality. The secondary outcomes included rate of urgent esophagogastroduodenoscopy (EGD) and colonoscopy-endoscopy in 1 day or less, total rate of EGD and colonoscopy, rate of EGD and Colonoscopy with intervention, rate of complications including acute kidney injury (AKI), blood transfusion, sepsis, pneumonia, pulmonary embolism (PE) and healthcare utilization. Employing Stata software, we utilized multivariate logistic and linear regression analyses to adjust for confounders.

Results

There were 455,494 hospitalizations for GI bleeding and 19,874 involved patients with CTDs. The in-hospital mortality rate was significantly lower for CTD patients at 2.1%, compared to 2.4% for non-CTD patients [adjusted odds ratio (aOR): 0.79, 95% confidence interval (CI): 0.63-0.99, P=0.04]. CTD patients showed increased odds of total EGD, urgent colonoscopy, and total colonoscopy; however, these changes were not statistically significant. CTD patients had higher odds of complications, including PE (6.87% vs. 4.12%, P=0.009). However, there were no significant differences in mean length of hospital stay and total hospital charges (THCs) compared to non-CTD patients.

Conclusions

Patients with CTD exhibited a lower in-hospital mortality rate compared to those without CTD. The elevated risk of PE underscores the importance of implementing prophylactic measures for these patients.

Artificial Intelligence for Identification of Images with Active Bleeding in Mesenteric and Celiac Arteries Angiography

PURPOSE

The purpose of this study is to evaluate the efficacy of an artificial intelligence (AI) model designed to identify active bleeding in digital subtraction angiography images for upper gastrointestinal bleeding.

METHODS

Angiographic images were retrospectively collected from mesenteric and celiac artery embolization procedures performed between 2018 and 2022. This dataset included images showing both active bleeding and non-bleeding phases from the same patients. The images were labeled as normal versus images that contain active bleeding. A convolutional neural network was trained and validated to automatically classify the images. Algorithm performance was tested in terms of area under the curve, accuracy, sensitivity, specificity, F1 score, positive and negative predictive value.

RESULTS

The dataset included 587 pre-labeled images from 142 patients. Of these, 302 were labeled as normal angiogram and 285 as containing active bleeding. The model's performance on the validation cohort was area under the curve 85.0 ± 10.9% (standard deviation) and average classification accuracy 77.43 ± 4.9%. For Youden's index cutoff, sensitivity and specificity were 85.4 ± 9.4% and 81.2 ± 8.6%, respectively.

CONCLUSION

In this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of this study show the potential of an AI-based algorithm to accurately classify images with active bleeding. Further studies using a larger dataset are needed to improve accuracy and allow segmentation of the bleeding.

Duodenal Varices Presenting as Lower Gastrointestinal Bleeding

Duodenal varices pose a significant clinical challenge due to their association with severe gastrointestinal bleeding. This condition requires attention because of its acute severity, high morbidity, and mortality rates. The presented case underscores the importance of advancing both knowledge and treatment approaches for duodenal varices. This pursuit is aimed not only at improving immediate clinical outcomes but also at deepening our understanding of complications related to portal hypertension.

Bacterial vampirism mediated through taxis to serum

Bacteria of the family Enterobacteriaceae are associated with gastrointestinal (GI) bleeding and bacteremia and are a leading cause of death, from sepsis, for individuals with inflammatory bowel diseases. The bacterial behaviors and mechanisms underlying why these bacteria are prone to bloodstream entry remain poorly understood. Herein, we report that clinical isolates of non-typhoidal Salmonella enterica serovars, Escherichia coli, and Citrobacter koseri are rapidly attracted toward sources of human serum. To simulate GI bleeding, we utilized an injection-based microfluidics device and found that femtoliter volumes of human serum are sufficient to induce bacterial attraction to the serum source. This response is orchestrated through chemotaxis and the chemoattractant L-serine, an amino acid abundant in serum that is recognized through direct binding by the chemoreceptor Tsr. We report the first crystal structures of Salmonella Typhimurium Tsr in complex with L-serine and identify a conserved amino acid recognition motif for L-serine shared among Tsr orthologues. We find Tsr to be widely conserved among Enterobacteriaceae and numerous World Health Organization priority pathogens associated with bloodstream infections. Lastly, we find that Enterobacteriaceae use human serum as a source of nutrients for growth and that chemotaxis and the chemoreceptor Tsr provide a competitive advantage for migration into enterohemorrhagic lesions. We define this bacterial behavior of taxis toward serum, colonization of hemorrhagic lesions, and the consumption of serum nutrients as 'bacterial vampirism', which may relate to the proclivity of Enterobacteriaceae for bloodstream infections.

Variceal hemorrhage in a patient with cirrhosis and congenital hemophilia A: A therapeutic challenge

We describe the case of a 61-year-old male patient with a history of hemophilia A and previous hepatitis C virus infection with sustained virological response and no previous documentation of cirrhosis, who was admitted for variceal bleeding. He was taken for endoscopic evaluation with evidence of active variceal hemorrhage requiring rubber band ligation. Patients with congenital coagulation disorders, such as hemophilia A, are excluded from international guidelines for gastrointestinal bleeding, making their management and counseling challenging. In this article, we describe the specific interventions to be performed in patients with hemophilia A and upper gastrointestinal tract bleeding, specifically variceal bleeding, focusing on pre-endoscopic and endoscopic management.

Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review

Acute upper and lower gastrointestinal (GI) bleeding may be a potentially life-threatening event that requires prompt recognition and an early effective management, being responsible for a considerable number of hospital admissions. Methods. We perform a clinical review to summarize the recent international guidelines, helping the physician in clinical practice. Older people are a vulnerable subgroup of patients more prone to developing GI bleeding because of several comorbidities and polypharmacy, especially related to an increased use of antiplatelet and anticoagulant drugs. In addition, older patients may have higher peri-procedural risk that should be evaluated. The recent introduction of reversal strategies may help the management of GI bleeding in this subgroup of patients. In this review, we aimed to (1) summarize the epidemiology and risk factors for upper and lower GI bleeding, (2) describe treatment options with a focus on pharmacodynamics and pharmacokinetics of different proton pump inhibitors, and (3) provide an overview of the clinical management with flowcharts for risk stratification and treatment. In conclusion, GI is common in older patients and an early effective management may be helpful in the reduction of several complications.

Efficacy of ferric carboxymaltose on haemoglobin response among older patients with gastrointestinal bleeding: a randomised clinical trial

BACKGROUND

Acute gastrointestinal bleeding (AGIB) is common in older patients but the use of iron in this context remains understudied.

AIMS

This study aimed to evaluate prospectively the efficacy of ferric carboxymaltose to treat anaemia in older patients after AGIB.

METHODS

This randomised double-blinded placebo-controlled clinical trial was conducted in 10 French centres. Eligible patients were 65 years or more, had controlled upper or lower gastrointestinal bleeding and a haemoglobin level of 9-11 g/dl. Patients were randomly assigned, in a 1:1 ratio, to receive either one intravenous iron injection of ferric carboxymaltose or one injection of saline solution. The primary endpoint was the difference in haemoglobin level between day 0 and day 42. Secondary endpoints were treatment-emergent adverse events, serious adverse events, rehospitalisation and improvement of quality of life (QOL) at day 180.

RESULTS

From January 2013 to January 2017, 59 patients were included. The median age of patients was 81.9 [75.8, 87.3] years. At day 42, a significant difference in haemoglobin level increase was observed (2.49 g/dl in the ferric carboxymaltose group vs. 1.56 g/dl in the placebo group, P = 0.02). At day 180, QOL, measured on European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, improved by 10.5 points in the ferric carboxymaltose group and by 8.2 points in the placebo group (P = 0.56). Rates of adverse events and rehospitalisation were similar in the two groups.

CONCLUSIONS

Intravenous iron seems safe and effective to treat anaemia in older patients after AGIB and should be considered as a standard-of-care treatment. ClinicalTrials.gov (NCT01690585).

Unveiling the Unlikely: Extraskeletal Ewing Sarcoma Masquerading as Gastrointestinal Bleeding

While Ewing sarcoma is traditionally a malignant tumor of bone, it may uncommonly present extra-skeletally, leading to an array of puzzling presentations depending on the tissue involved. Here, we describe the case of a 66-year-old man who presented to the primary care office for evaluation of intermittent melena. He ultimately underwent capsule endoscopy and developed a secondary small bowel obstruction, unveiling his neoplasm. The tumor was then resected and managed with surveillance only, and the patient remains without evidence of disease after four years of follow-up.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

A low-cost miniature immunosensor for haemoglobin as a device for the future detection of gastrointestinal bleeding

Gastrointestinal bleeding (GIB) is a serious medical condition, which requires immediate attention to establish the cause of the bleeding. Here, we present the development of a miniaturised electrochemical impedance spectroscopy (EIS) device for the detection of GIB. The device performs EIS measurements up to 100 kHz. Following the development of an immunosensor for haemoglobin (Hb) on screen printed electrodes, the EIS device was used for detecting Hb as an early indication of bleeding. The sensor was able to detect Hb in a redox solution in a linear range between 5 μg mL-1 and 60 μg mL-1, with a limit of detection of 13.3 μg mL-1. It was also possible to detect Hb in simulated intestinal fluid, without the need for a redox solution, within a range of 10 μg mL-1 to 10 mg mL-1 with a limit of detection of 2.31 mg mL-1. The miniature EIS device developed in this work is inexpensive, with an estimated cost per unit of £30, and has shown a comparable performance to existing commercial tools, demonstrating its potential to be used in the future as an ingestible sensor to detect GIB. All these measurements were carried out in a purpose built flow cell with supporting hardware electronics outside the cell. Integration of the hardware and the sensing electrodes was demonstrated in pill form. This pill after integration sampling fluidics has potential to be used in detecting gastrointestinal bleeding.

Bacterial vampirism mediated through taxis to serum

Bacteria of the family Enterobacteriaceae are associated with gastrointestinal (GI) bleeding and bacteremia and are a leading cause of death, from sepsis, for individuals with inflammatory bowel diseases. The bacterial behaviors and mechanisms underlying why these bacteria are prone to bloodstream entry remains poorly understood. Herein, we report that clinical isolates of non-typhoidal Salmonella enterica serovars, Escherichia coli, and Citrobacter koseri are rapidly attracted toward sources of human serum. To simulate GI bleeding, we utilized a custom injection-based microfluidics device and found that femtoliter volumes of human serum are sufficient to induce the bacterial population to swim toward and aggregate at the serum source. This response is orchestrated through chemotaxis, and a major chemical cue driving chemoattraction is L-serine, an amino acid abundant in serum that is recognized through direct binding by the chemoreceptor Tsr. We report the first crystal structures of Salmonella Typhimurium Tsr in complex with L-serine and identify a conserved amino acid recognition motif for L-serine shared among Tsr orthologues. By mapping the phylogenetic distribution of this chemoreceptor we found Tsr to be widely conserved among Enterobacteriaceae and numerous World Health Organization priority pathogens associated with bloodstream infections. Lastly, we find that Enterobacteriaceae use human serum as a source of nutrients for growth and that chemotaxis and the chemoreceptor Tsr provides a competitive advantage for migration into enterohaemorrhagic lesions. We term this bacterial behavior of taxis toward serum, colonization of hemorrhagic lesions, and the consumption of serum nutrients, as 'bacterial vampirism' which may relate to the proclivity of Enterobacteriaceae for bloodstream infections.

Randomised controlled trial of early magnetically controlled capsule endoscopy for the prevention of gastrointestinal bleeding in patients at high bleeding risk scheduled for percutaneous coronary intervention: MACE-GPS study protocol

INTRODUCTION

Limited data are available regarding the decision-making process for preventing gastrointestinal bleeding in patients at high risk of bleeding scheduled for percutaneous coronary intervention (HBPCI), especially due to the lack of a simple, accurate and sensitive methods for gastrointestinal injury detection. This randomised trial aims to assess the effects of early magnetically controlled capsule endoscopy (MCE) in patients with HBPCI for the prevention of gastrointestinal bleeding compared with conventional management.

METHODS AND ANALYSIS

The Magnetic-Assisted Capsule Endoscopy Gastrointestinal bleeding Protection Strategy (MACE-GPS) is a multicentre, open-label, randomised controlled trial. Patients admitted for HBPCI will be randomised and placed into two study groups. In the early MCE group, 1228 patients will undergo MCE following admission to the hospital. If necessary, these patients may further undergo a multidisciplinary approach to determine treatment based on the MCE findings. A total of 1228 patients in the control group will undergo conventional treatment based on the attending cardiologist's interpretation of their clinical presentations. The primary end point is the incidence of gastrointestinal bleeding within 12 months of enrolment.

ETHICS AND DISSEMINATION

The MACE-GPS trial has been approved by the ethics committees of all participating sites. Participant recruitment began in April 2023 and will be completed in April 2025, and the 1-year follow-up will be completed in April 2026. The study results will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300070025.

Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model.

METHODS

A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated.

RESULTS

All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract.

CONCLUSION

This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.

Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review

Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.

Diagnostic accuracy of RBC scintigraphy and CTA for detection of patients with suspected lower gastrointestinal bleeding: a systematic review and meta-analysis

OBJECTIVE

Detection of lower gastrointestinal bleeding (LGIB) through noninvasive modalities is very important in the successful management of LGIB. RBC scintigraphy and CT have a role in the detection of LGIB and guiding the management of patient by localization of the bleeding site. However, only a small number of studies have evaluated the role of RBC scintigraphy and CT in the diagnosis of LGIB. This systematic review was conducted to evaluate the diagnostic performance of RBC scintigraphy and CT in the detection of LGIB in patients with clinical or biochemical findings suspicious of LGIB.

METHODS

This systematic review followed PRISMA guidelines. Searches in PubMed, Scopus, and Embase were conducted using relevant keywords, and articles published through 30 April 2022, were included. Using endoscopy or surgical outcomes as the reference standard, the numbers of true and false positives and true and false negatives were extracted. Pooled estimates of diagnostic test accuracy - including sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and summary ROC (SROC) curve - were generated using bivariate random-effects meta-analysis.

RESULTS

Three studies comprising 171 patients were included in the systematic review and meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using RBC scintigraphy were 0.787 (95% CI, 0.643-0.893), 0.289 (95% CI, 0.164-0.443), 1.214 (95% CI, 0.923-1.597) and 0.576 (95% CI, 0.296-1.121) respectively. The area under the SROC curve was 0.73. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using CT were 0.931 (95% CI, 0.772-0.992), 0.870 (95% CI, 0.737-0.951), 6.085 (95% CI, 0.840-44.097), 0.126 (95% CI, 0.006-2.509) respectively. The area under the SROC curve was 0.095.

CONCLUSION

RBC scintigraphy has overall good sensitivity and CTA has excellent sensitivity specificity, positive and negative likelihood ratio in the detection of LGIB in patients with clinical or biochemical findings suspicious for LGIB.CTA along with RBC scintigraphy can be used algorithmically to rule out patients who do not have a localization for the site of LGIB thereby helping these patients to avoid invasive procedures like endoscopy or surgical explorations.

Treating Deep Venous Thrombosis in a Background of Crohn's Disease: A Clinical Conundrum

Deep venous thrombosis (DVT) commonly affects the lower extremities, often as a result of prolonged immobilization. However, upper limb DVT is an atypical presentation, typically associated with risk factors such as the use of a peripherally inserted central catheter (PICC) line. This case report describes an uncommon case of DVT management in a patient with Crohn's disease, a condition more frequently characterized by painful lower gastrointestinal symptoms and chronic diarrhea. A 22-year-old male with a history of Crohn's disease developed swelling and purplish discoloration at the brachial site of a PICC line site. Laboratory results indicated anemia with a hemoglobin level of 9.9 g/dL and a hematocrit of 31.9%. Doppler ultrasound confirmed the DVT in the left long axillary, left subclavian, and left long basilic veins. Given the patient's concurrent lower gastrointestinal bleeding, a cautious approach was required to balance the risks and benefits of anticoagulation. Upon recommendation by Hematology, a prophylactic dose of enoxaparin was initiated and subsequently escalated to a therapeutic dose as tolerated. The patient's condition was closely monitored, and he successfully reached the full therapeutic regimen without complications. This case underscores the importance of individualized DVT treatment strategies in the context of concurrent Crohn's disease, offering insights into managing anticoagulation in the presence of bleeding risks.

Enteroscopy versus Video Capsule Endoscopy for Automatic Diagnosis of Small Bowel Disorders-A Comparative Analysis of Artificial Intelligence Applications

BACKGROUND

Small bowel disorders present a diagnostic challenge due to the limited accessibility of the small intestine. Accurate diagnosis is made with the aid of specific procedures, like capsule endoscopy or double-ballon enteroscopy, but they are not usually solicited and not widely accessible. This study aims to assess and compare the diagnostic effectiveness of enteroscopy and video capsule endoscopy (VCE) when combined with artificial intelligence (AI) algorithms for the automatic detection of small bowel diseases.

MATERIALS AND METHODS

We performed an extensive literature search for relevant studies about AI applications capable of identifying small bowel disorders using enteroscopy and VCE, published between 2012 and 2023, employing PubMed, Cochrane Library, Google Scholar, Embase, Scopus, and ClinicalTrials.gov databases.

RESULTS

Our investigation discovered a total of 27 publications, out of which 21 studies assessed the application of VCE, while the remaining 6 articles analyzed the enteroscopy procedure. The included studies portrayed that both investigations, enhanced by AI, exhibited a high level of diagnostic accuracy. Enteroscopy demonstrated superior diagnostic capability, providing precise identification of small bowel pathologies with the added advantage of enabling immediate therapeutic intervention. The choice between these modalities should be guided by clinical context, patient preference, and resource availability. Studies with larger sample sizes and prospective designs are warranted to validate these results and optimize the integration of AI in small bowel diagnostics.

CONCLUSIONS

The current analysis demonstrates that both enteroscopy and VCE with AI augmentation exhibit comparable diagnostic performance for the automatic detection of small bowel disorders.

Cecal Dieulafoy lesion is a rare cause of lower gastrointestinal bleeding: A case report

Dieulafoy lesions are a rare but life-threatening cause of gastrointestinal bleeding. Colonic Dieulafoy lesions are exceptionally rare, comprising only 2% of these lesions. We present a case of cecal Dieulafoy lesion as an unusual cause of lower gastrointestinal bleeding-along with hemoptysis. An 81-year-old male with pulmonary hypertension presented with a one-day history of hematochezia. He subsequently developed new small-volume hemoptysis/hematemesis with increasing oxygen requirements. Bronchoscopy revealed old blood in the left lower lobe, with no active bleeding. The hemoptysis was attributed to severe pulmonary hypertension. Colonoscopy revealed a 2-mm cecal Dieulafoy lesion with spurting bleeding, which was clipped. We report a rare case of cecal Dieulafoy lesion with only 13 other published cases. Our case was complicated by hemoptysis creating an interesting diagnostic dilemma. In patients bleeding from both oral and anal orifices, a brisk upper gastrointestinal bleed-as well as independent causes involving the gastrointestinal and respiratory tracts-should be considered.

Fifteen-minute consultation: Rectal bleeding in children

Bleeding per rectum in children is an infrequent presentation associated with a wide range of differential diagnoses, from benign to life-threatening. Irrespective of the underlying aetiology, it is typically a worrisome symptom for caregivers. Published data are limited, particularly for the UK population, from which to provide clear evidence-based guidance for assessment and management of infants, children and young people presenting with bleeding per rectum. In this Fifteen-Minute Consultation, we therefore explore the common aetiologies and combine opinions from acute paediatrics, paediatric gastroenterology and paediatric surgery to offer a structure for a diagnostic approach and initial management of lower gastrointestinal bleeding in infants, children and young people.

Upper Gastrointestinal Bleeding: Evaluation and Diagnosis

Upper gastrointestinal bleeding is a common medical emergency that requires prompt diagnosis and intervention. Patients may be hemodynamically stable or unstable depending on bleeding severity and vital signs. Immediate resuscitation and timely diagnosis are paramount to reducing mortality in this extremely vulnerable patient population. Upper gastrointestinal bleeding can be classified into two categories: variceal bleeding and nonvariceal bleeding, both of which can be life-threatening. This article aids bedside practitioners in understanding the pathogenesis of an upper gastrointestinal bleed to identify potential diagnoses. Furthermore, to ensure the proper diagnostic tests are prescribed, the algorithm provides guidance on collecting a pertinent medical history, discusses common presenting symptoms, and identifies the top risk factors for several disease processes that might present as an upper gastrointestinal bleed. A diagnostic algorithm that includes a myriad of the most common differential diagnoses of an upper gastrointestinal bleed is presented as a tool for bedside clinicians to utilize when encountering this serious gastrointestinal phenomenon.

Safety and efficacy of venous thromboembolism prophylaxis in patients with cirrhosis: A systematic review and meta-analysis

BACKGROUND & AIMS

Patients with cirrhosis are considered in a haemostatic balance, though weaker than in normal subjects. In these patients, however, the use of pharmacological prophylaxis for venous thromboembolism (VTE) remains controversial. Therefore, in this study, we aimed to assess the safety and efficacy of VTE prophylaxis in patients with cirrhosis.

METHODS

We conducted a systematic review of studies reporting the occurrence of bleeding and VTE events in patients with cirrhosis, and controls, undergoing VTE prophylaxis. Meta-regression analysis was conducted to further explore the determinants of heterogeneity in the study of the occurrence of either bleeding or VTE events.

RESULTS

In a total of 10 studies, including 5712 patients, of which 2330 undergoing VTE prophylaxis, bleeding (n = 5513) and VTE events occurred in 8.2% and 2.8% patients respectively. A total of 2963 and 3162 patients were included from low-risk of bias studies in bleeding and VTE analysis respectively: while administration of VTE prophylaxis did not seem to reduce VTE (OR = 1.07, CI 0.39-2.96, p = .89), importantly prophylaxis was not associated with increased bleeding risk (OR = 0.56, CI 0.20-1.59, p = .27). Meta-regression analysis showed that no parameter significantly influenced the heterogeneity of data regarding bleeding or VTE events.

CONCLUSIONS

In patients with cirrhosis, current evidence is insufficient to advise for or against the use of VTE prophylaxis, mainly due to lack of quality and homogeneity of available data. However, its use does not appear to be associated with a significant bleeding risk. Adequately designed studies are required to provide a measure of its overall utility.

Knowledge and Awareness About Gastric Cancer Among the General Population in Al-Baha City, Saudi Arabia

Background Gastric cancer is a significant health concern worldwide, and its incidence varies across different populations. This study aimed to assess the level of knowledge and awareness of gastric cancer among the general population in Al-Baha City, Saudi Arabia.  Methodology This is a cross-sectional study that was conducted among the residents of Al-Baha city older than 18 years. The study was conducted based on a questionnaire that has been developed by a previous study. Data were initially recorded in an Excel sheet before being exported to the SPSS program, version 25 for data analysis. Results The survey included 426 respondents from Al-Baha city, Saudi Arabia, with 56.8% being females and the majority being in the age groups (21-30 years). Alcohol consumption (mean=4.5, SD= 0.77), smoking cigarettes or Shisha (mean= 4.38, SD=0.852), family history of gastric cancer (mean= 4, SD=1.008), a past medical history of gastric cancer (mean= 3.99, SD=0.911), stomach ulcer (mean=3.76, SD=0.898), and consumption of smoked food (mean= 3.69, SD=0.956) are the most widely recognized risk factors. The most highly recognized symptoms are gastrointestinal bleeding (mean= 4.03, SD=0.875), abdominal lump (mean= 3.94, SD=0.926), weight loss (mean= 3.93, SD=0.963), recurrent nausea and vomiting (mean=3.76, SD=0.956), and abdominal pain (mean= 3.57, SD=0.995). The study also identified several subgroups of the population that may benefit from targeted educational programs, including individuals in the age group of 41-50 years and those in non-medical occupations. Conclusion The study found that participants had a moderate level of knowledge about the risk factors and symptoms of gastric cancer, with significant variability among different subgroups of the population. Further research is needed to investigate the prevalence and risk factors of gastric cancer in Saudi Arabia and other similar populations, to develop effective prevention and management strategies for this disease.

Effect of Patient Age on Timing of Inpatient Esophagogastroduodenoscopy and Outcomes for Non-variceal Upper GI Bleeds

Background Esophagogastroduodenoscopy (EGD) is typically performed within 24 hours of presentation for patients admitted to a hospital for patients presenting with a non-variceal upper gastrointestinal bleed (UGIB). To date, no studies have been performed to identify the impact of patient age on the timing of inpatient EGD and patient outcomes in non-variceal UGIB. Our aim was to assess the differences in the timing of EGD, blood transfusion requirements, development of hemorrhagic shock, development of acute renal failure, mortality, length of stay, and total hospital charges for patients aged 18-59 and those aged 60 and older. Methods Admissions for non-variceal UGIB were identified from the National (Nationwide) Inpatient Sample (NIS) database from 2016 and 2017. Patients who initially presented with hemorrhagic shock were excluded. Patients were divided into two age groups, those aged 18-59 and those aged 60 or older. We classified EGDs as early and delayed. Since the NIS database identifies days as midnight to midnight, we categorized early EGDs as those performed on day 0 and day 1. Delayed EGD were categorized as those performed on days 2 and 3. Multivariate logistic regression was performed on propensity-matched data to compare EGD timing, blood transfusion requirements, development of post-hospitalization hemorrhagic shock, development of acute renal failure, and mortality. The following patient and hospital variables were used in regression models: race, sex, insurance status, income quartile, mortality risk score, illness severity score, admission month, admission day, type of admission, region, bed size, and hospital teaching status. Finally, weighted two-sample T-tests were used to compare the length of stay and total hospitalization cost. Results A total of 12,449 weighted cases of inpatient non-variceal UGIB were included in this study. Patients aged 60 and older were more likely to die during the hospitalization (OR= 1.661, 95%CI: 1.108-2.490, p= 0.014), require blood transfusion (OR= 1.257, 95%CI: 1.131-1.396, p<0.001), and develop acute renal failure (OR= 1.672, 95%CI: 1.447-1.945, p<0.001). Patients aged 60 and older were also less likely to receive an early EGD (OR= 0.850, 95%CI: 0.752-0.961, p= 0.009). Total hospital costs (95%CI: -1397.77 - -4005.68, p<0.001) and length of stay (95%CI: -0.428 - -0.594, p<0.001) were both lower in patients aged 18-59 years. There was no difference in the development of post-hospitalization hemorrhagic shock between the two groups (OR= 0.984, 95%CI: 0.707-1.369, p= 0.923). Conclusions Patients aged 60 and older were less likely to have an early EGD and more likely to have worse outcomes. They had increased rates of inpatient mortality, blood transfusion requirements, development of acute renal failure, increased total hospital costs, and longer lengths of stay. There were no differences in the development of post-hospitalization hemorrhagic shock between the two groups.

Outcomes in Patients Admitted for Upper Gastrointestinal Bleeding and COVID-19 Infection: A Study of Two Years of the Pandemic

Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures.

METHODS

We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019.

RESULTS

Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic.

CONCLUSIONS

COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment.