Safety of endoscopy in patients undergoing treatments with antiangiogenic agents: A 5-year retrospective review

BACKGROUND

Antiangiogenic agents (AAs) are increasingly used to treat malignant tumors and have been associated with gastrointestinal (GI) bleeding and perforation. Elective surgeries and endoscopy are recommended to be delayed for 31 d until after AAs treatment. Data regarding the safety of endoscopy while on antiangiogenic agents is extremely limited. No guidelines are in place to address the concern about withholding these anti-angiogenic drugs.

AIM

To evaluate the risks of endoscopy in patients on antiangiogenic agents from 2015 to 2020 at our institution.

METHODS

This is a single centered retrospective study approved by the institutional review board statement of the institution. Patients that underwent endoscopy within 28 d of antiangiogenic agents’ treatment were included in the study. Primary outcome of interest was death, and secondary outcomes included perforation and GI bleeding. Data were analyzed utilizing descriptive statistics. Fifty-nine patients were included in the final analysis and a total of eighty-five procedures were performed that were characterized as low risk and high risk.

RESULTS

Among the 59 patients a total of 85 endoscopic procedures were performed with 24 (28.2%) categorized as high-risk and 61 (71.8%) procedures as low-risk. Of the total number of patients, (50%) were on bevacizumab and the rest were on imatinib (11.7%), lenvatinib (6.7%) and, ramucirumab (5%). The average duration between administration of AAs and the performance of endoscopic procedures was 9.9 d. No procedure-related adverse events were noted among our study population. We did observe two deaths with one patient, on lenvatinib for metastatic hepatocellular carcinoma, who had persistent bleeding despite esophageal variceal banding and died 4 d later from hemorrhagic shock. Another patient was diagnosed with acute myeloid leukemia died 24 d after an esophagogastroduodenoscopy with biopsy after transition to comfort care.

CONCLUSION

As per this single center retrospective study, the rate of endoscopic procedure-related adverse events and death within 28 d of AA administration appears to be low.

Persistent Helicobacter pylori Infection: An Insight to the Limitations of Current Clinical Practice

The discovery of the pathological role of Helicobacter pylori in various disease states, such as peptic ulcer disease (PUD) and Mucosa Associated Lymphoid Tissue (MALT) lymphoma, was ground-breaking in the field of gastroenterology. Given the potentially dire clinical implications of chronic H. pylori infection, it is important to achieve complete eradication. More importantly, the rising prevalence of H. pylori antimicrobial resistance, similar to other pathogens world-wide, is of particular concern. Despite evidence supporting the growing threat of antimicrobial resistance, clinically, it is also important to survey just how much of the failed treatment is truly a reflection of resistance versus poor treatment adherence. In this report, we detail the case of a 64-year-old female who was previously given six treatment courses for persistent H. pylori infection. Successful eradication was achieved with rifabutin triple therapy consisting of high-dose amoxicillin and strict adherence monitoring by a clinical pharmacist. This case highlights the importance of patient education, medication reconciliation, and close monitoring to ensure successful treatment of persistent H. pylori infection.

Giant Colonic Lipoma Presenting as Intermittent Colonic Obstruction With Hematochezia

Colonic lipomas are rare benign, non-epithelial tumors of mesenchymal origin. They are often solitary lesions of submucosal origin found in the proximal colon and typically measure less than 2 cm in size. Giant colonic lipomas are greater than 4 cm and present with non-specific gastrointestinal symptoms such as abdominal pain, abdominal distention, constipation, or gastrointestinal bleeding. Traditionally, giant colonic lipomas have been surgically rather than endoscopically resected due to concerns for bowel wall perforation and life-threatening hemorrhage. However, in recent years, advances in endoscopic tools and hemostatic techniques have lessened these risks. The following case details the successful endoscopic resection of an intermittently obstructing giant colonic lipoma (6 cm) located in the descending colon utilizing the loop-assisted-snare resection technique. 

Acute Gastric Hemorrhage due to Gastric Cancer Eroding Into a Splenic Artery Pseudoaneurysm: Two Dangerously Rare Etiologies of Upper Gastrointestinal Bleeding

Splenic artery pseudoaneurysms (SAPs) are rare causes of upper gastrointestinal bleeding (UGIB), with less than 250 reported cases in the literature. The highest incidence of SAPs is in patients with a history of acute or chronic pancreatitis or splenic artery trauma. SAP in the setting of gastric malignancy is an exceedingly rare finding. We present the unusual hospital course of an 82-year-old male with advanced gastric cancer presenting with UGIB secondary to a visceral communication between his known gastric malignancy and a SAP.