Small Bowel Enteroscopy Has a High Diagnostic and Therapeutic Yield in the Evaluation of Recurrent Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices

Abstract

Introduction: The evaluation of gastrointestinal bleeding (GIB) in patients with continuous-flow left ventricular assist devices (CF-LVADs) is burdensome and potentially harmful due to the need for endoscopic procedures which require bowel preparation, sedation, and often the reversal of anticoagulation with subsequent prolonged hospital stays. There are limited data assessing the diagnostic and therapeutic yield of various endoscopic procedures in the evaluation of GIB in this patient population. Objective: Our aim was to evaluate the efficacy of endoscopic procedures in CF-LVAD patients hospitalized for initial and recurrent GIB episodes by measuring the rate at which these procedures led to a diagnosis and subsequent therapeutic intervention. Methods: Medical records were retrospectively reviewed for all patients implanted with CF-LVADs from 1/2010 through 12/2016 who were then hospitalized for GIB. We recorded the procedures performed to manage GIB, including esophagogastroduodenoscopy (EGD), colonoscopy, small bowel enteroscopy, and video capsule endoscopy. The number of times a procedure identified and therapeutically intervened upon the source of GIB was recorded to calculate the diagnostic and therapeutic yield of the procedure. Results: Of the 207 patients implanted with a CF-LVAD during the study period, 49 (24%) required hospitalization for GIB after a mean follow up of 40 months. There were a total of 90 GIB hospitalizations, with 41 (46%) hospitalizations for recurrent GIB. The diagnostic and therapeutic yield of EGD and colonoscopy was similar between initial and subsequent GIB episodes; however, the diagnostic and therapeutic yield of small bowel enteroscopy approximately doubled in patients with recurrent GIB episodes (Table). Video capsule endoscopy was able to identify the potential source of bleeding in one-third of cases but did not result in a therapeutic intervention. Conclusions: Hospitalization for GIB occurred in 24% of CF-LVAD patients after 40 months of implantation. Approximately half of GIB hospitalizations were for recurrent episodes of bleeding. EGD and colonoscopy have similar efficacy in the management of initial and subsequent GIB episodes. Small bowel enteroscopy has a high therapeutic yield with recurrent GIB, suggesting that small bowel pathology such as arteriovenous malformations are a common cause of recurrent bleeding with CF-LVAD support. Given the high morbidity of GIB in CF-LVAD patients, improved diagnostic and therapeutic algorithms should be developed to allow for more efficient treatment of bleeding in this patient population.