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Abstract

Because our study was a retrospective cohort study, the diagnosis of lower gastrointestinal (GI) bleeding was largely by exclusion rather than by direct confirmation of the source of bleeding. A lower GI investigation was not performed on every patient because some patients were too frail to undergo further endoscopic examination. Accordingly, presumed small bowel bleeding was a diagnosis of exclusion with no source of bleeding identified in the upper GI tract and the colon. Nevertheless, any misclassification of recurrent lower GI bleeding should be equally distributed between aspirin users and nonusers with the use of blinded adjudication. Therefore, we disagree that a possible or probable diagnosis of small bowel bleeding would confound our study outcome. All 14 patients who were diagnosed to have recurrent occult lower GI bleeding were hospitalized for transfusion to relieve symptomatic anemia. The adjudication committee identified 37 patients not fulfilling the criteria of recurrent lower GI bleeding—25 had upper GI bleeding and 12 had a decrease in hemoglobin for non-GI reasons.1Chan F.K. et al.Gastroenterology. 2016; 151: 271-277Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Because the number of patients using nonaspirin antiplatelet drugs was small, the results remain unchanged by comparing an aspirin-only group versus the no antithrombotic group. Whether the source of rebleeding was caused by the original culprit lesion or a different lesion is an interesting academic question, but we are not sure how it will inform clinical practice. Unlike upper GI bleeding, which mostly arises from a solitary peptic ulcer, we found that lower GI bleeding associated with aspirin often originates from multiple sites. In our study, for example, we found that more than one-half (4 of 7) of patients with diverticular bleeding developed recurrent diverticular bleeding despite initial success with endoscopic therapy. Unless one had tattooed the site of initial diverticular bleeding, it would be difficult to ascertain whether aspirin provoked recurrent diverticular bleeding from the same or a different diverticulum in the colon. The optimal timing of resuming aspirin after lower GI bleeding probably needs individualized decisions. A prospective study is ongoing to address this important clinical question. RE: Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal HemorrhageGastroenterologyVol. 152Issue 3PreviewWe read with interest the paper by Chan et al1 on the effects of resuming aspirin on clinical outcomes in patients with lower gastrointestinal bleeding (LGIB).1 In a retrospective study on patients who had LGIB on aspirin, the authors found that patients who resumed aspirin had a higher risk of recurrent bleeding, but a lower risk of serious cardiovascular events, cardiovascular mortality and, interestingly, mortality owing to sepsis, renal failure, or cancer. Full-Text PDF