Acute GI Bleeding Research Articles

1937 A Deadly Diagnosis: Aortic Stent Causing Aorto-Esophageal Fistula

INTRODUCTION: An aorto-esophageal fistula (AEF) is a rare but life-threatening cause of upper gastrointestinal bleeding caused by an abnormal communication between the esophagus and aorta. Etiologies include foreign body ingestion, malignancy, post-operative trauma, and ruptured TAA. We present the fatal case of a patient with profound anemia who suffered catastrophic consequences secondary to graft-esophageal fistula. CASE DESCRIPTION/METHODS: A 66-year-old male with history of percutaneous thoracic endovascular aortic repair 3 months prior presented with complaints of 2 weeks of dizziness, nausea, and intermittent dark stools. EGD/colonoscopy 2 months ago were negative for acute GI bleed. Upon evaluation, the patient was mildly tachycardic with positive orthostatic vital signs and fever of 100.4 F. Rectal exam did not demonstrate gross blood. Labs were remarkable for Hgb 6.8 with repeat 5.9, WBC 14, and BUN 14. CTA chest was done to investigate tachycardia and identified an enlarging distal aortic endoleak with stable short segment dissection. Vascular surgery was consulted but felt the endoleak was chronic. CT A/P ruled out retroperitoneal hematoma and he was treated with transfusions and beta blocker therapy. Following recurrent melena, our EGD revealed two areas concerning for aortic stent erosion into the esophagus at 34 and 36 cm from incisors with trace oozing, locating the source of hemorrhage. Vascular surgery reevaluated the patient with plan for graft removal and reconstruction of thoracic and abdominal aorta. Unfortunately, before advancing to surgery he decompensated after large volume hematemesis. Vasopressors were initiated for hemorrhagic shock but life-sustaining measures were eventually discontinued to respect family wishes. The etiology of his acute symptomatic anemia and massive hemorrhage was suspected to be graft-esophageal fistula. DISCUSSION: AEF is an unusual post-operative complication of prosthetic aortic repair. Secondary AEF can develop after open or endovascular repair of the aorta, occurring in 1.9% of patients post-endovascular aortic repair. Pathophysiology remains unclear but it is thought to arise from erosion of graft material into esophagus, graft infection with abscess rupture, or anastomotic pseudoaneurysm. Our case emphasizes the importance of raising clinical suspicion not only for hematemesis but for new onset fever with elevated inflammatory markers in the appropriate clinical setting as well as the need for emergent surgical intervention to avoid fatal outcomes.

2031 Metastatic Neuroendocrine Tumor of Unknown Primary Presenting as Acute Gastrointestinal Bleed With Hemorrhagic Shock

INTRODUCTION: Neuroendocrine tumors (NETs) are often localized, however up to 50% of cases can be metastatic, with 13% having an unknown primary . Most NETs are identified during work up of related symptoms or functional syndrome (i.e. carcinoid) or found incidentally. We present a case of metastatic NET of unknown primary origin presenting as acute hemorrhagic shock from gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 21-year-old male presented with hematochezia, abdominal pain and nausea and was admitted to the ICU for hemorrhagic shock with a drop in hemoglobin from 14.5 to 8.2. EGD showed 15 mm, necrotic, oozing duodenal ulcer without visible blood vessel, treated with Hemospray. Recurrent episode of bleeding necessitated IR-guided GDA embolization. CT imaging initially identified, and later MRI confirmed three complex hepatic lesions in both right and left lobes of the liver . IR-guided liver biopsy showed low-grade, well-differentiated metastatic NET, Ki-67 1%. Gastrin and chromogranin A levels were elevated at 166 pg/mL and 223 ng/mL respectively. Otreotide scan found enhancement in the liver consistent with metastatic NET, without identification of a primary site. He was started on octreotide infusions. Additional work-with CT chest and pelvis, repeat EGD/EUS and colonoscopy were negative for primary tumor. He underwent laparotomy with left lateral segment partial hepatectomy, microwave ablation of the remaining liver lesion and cholecystectomy. DISCUSSION: NETs are typically indolent cancers involving the small intestine, appendix, colon/rectum, pancreas or lung. Common sites of metastasis include the liver, peritoneum, lymph nodes and lungs. The majority of metastatic NETs have an identifiable primary site, but it is important to recognize that many can have an unknown origin. Understanding the primary site of NETs is an important prognostic factor in overall survival. In general, metastatic disease is associated with a poorer prognosis, particularly in the setting of unknown primary origin. This case illustrates that patients with NETs can have a variable initial presentation, including acute GI bleeding from peptic ulcer disease. In addition, this case shows that despite appropriate diagnostic testing including biochemical markers, anatomic and functional imaging studies, endoscopic procedures and tissue biopsies, the primary site of metastatic NETs can go unidentified, which can effect definitive treatment options.

2208 Autoinflammation in an Immunocompromised Lymphoma Patient With Sepsis

INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare autoinflammatory, typically pediatric condition, often triggered by infectious or malignant diseases in the immunocompromised patient. In this case, we describe the coincidence of HLH and bacterial sepsis in an adult NK/T cell lymphoma (NKTCL) patient. CASE DESCRIPTION/METHODS: A 38-year-old man presented with weight loss, fevers, night sweats and jaundice. Dermatological findings, including petechiae on the chest and extremities as well as an oropharyngeal soft palate erosion, were biopsied and revealed extranodal small cell NKTCL. Treatment was initiated according to the SMILE protocol yet soon complicated by fever and hypotension, which made an empiric antibiotic therapy with meropenem and amikacin necessary. Initial blood tests showed transaminitis, an acute drop in hemoglobin and thrombocytopenia. This, in combination with progressive hypotension and abdominal pain, raised suspicions of an acute GI bleed, but an esophagogastroduodenoscopy was unremarkable. Abdominal ultrasound, chest X-ray and abdominal CT, also yielded no evidence for bleeding, but confirmed the disease’s progression and led to treatment expansion by pembrolizumab. An increased EBV load, hypofibrinogenemia, hypertriglyceridemia, lactic acidosis and elevated ferritin levels in combination with the described clinical findings finally led to the diagnosis of HLH, complicated by disseminated intravascular coagulopathy (DIC), and were treated with steroids and plasma products. In the days thereafter, the patient’s fever spiked to 39.8°C and abdominal pain increased. Blood cultures were positive for MRSA and an infection with Parainfluenza virus was diagnosed. Anti-infectious treatment was adjusted accordingly. Decompensating electrolyte disturbances due to renal failure tachycardia and hypotension required catecholamine-treatment and the patient was transferred to the ICU where he deceased six days after initial admission. DISCUSSION: The complexity of the phenotypical diagnosis as well as the current lack of time-tested therapeutics pose major challenges in the treatment of HLH. Here we describe the history and death of a NKTCL patient, whose diagnosis and treatment was complicated by DIC and bacterial sepsis. We want to highlight the importance of a quick diagnosis and the rapid treatment of HLH. Further research is needed to advance diagnostic tools, optimize current therapeutic approaches and prevent comorbidities.

TC-325 hemostatic powder versus current standard of care in managing malignant GI bleeding: a pilot randomized clinical trial

TC-325 (Hemospray; Cook Medical, Winston-Salem, NC, USA), an endoscopic hemostatic powder, exhibits possible benefits in patients with malignant GI bleeding. Our aim is to assess feasibility and determine estimates of efficacy of TC-325 compared with standard of care (SOC) in terms of initial hemostasis and recurrent bleeding rates in comparable groups of patients with malignant GI bleeding. Adult patients presenting with acute malignant upper or lower GI bleeding were randomized to TC-325 or SOC. Measured outcomes included feasibility of recruitment and randomization in the urgent care setting, immediate hemostasis, recurrent bleeding, need for additional treatment modalities, and mortality. A preplanned 20 patients (upper GI source in 85%) were randomized 1:1 to TC-325 or SOC (25% women, age 67.2 ± 15.9 years, oozing in 95%) over 20 months. Immediate hemostasis was achieved in 90% of patients treated initially with TC-325 versus 40% in the SOC group (P= .057). Overall, 83.3% crossed over to TC-325, with hemostasis then achieved at index endoscopy in 80%. Overall, hemostasis at index endoscopy (before or after crossover) was obtained in 87.7% of patients treated with TC-325. Recurrent bleeding over the next 180 days was 20% in the TC-325 group compared with 60% in the SOC group (P= .170). This pilot trial demonstrates the feasibility of TC-325 in malignant GI bleeding and provides results to help inform a larger randomized trial. Although not powered for such, results suggest that use of TC-325 is a very promising modality in malignant GI bleeding in achieving immediate hemostasis and may even result in decreased subsequent recurrent bleeding. (Clinical trial registration number: NCT02135627.).

Magnetically assisted capsule endoscopy in suspected acute upper GI bleeding versus esophagogastroduodenoscopy in detecting focal lesions

Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed. We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined. Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P= .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P= 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge. MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.).

Mo1293 – Clinical Outcomes in Patients with Acute Kidney Injury and Upper Non-Variceal Gi Bleeding

Mo1293 – Clinical Outcomes in Patients with Acute Kidney Injury and Upper Non-Variceal Gi Bleeding

Double-balloon enteroscopy–facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos)

Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.

03:27 PM Abstract No. 241 Effects of time to visceral angiography for gastrointestinal bleeding on angiographic success

Gastrointestinal bleeding (GIB) is a complex problem with a multitude of etiologies requiring a multidisciplinary approach to treatment. There is varying data regarding the role of urgent endoscopy (EGD), colonoscopy, CT, nuclear medicine tests, or conventional angiogram in the acute setting. This retrospective review was conducted to evaluate the effect of time to angiogram on angiographic outcomes. The RRSB at University of Rochester approved this retrospective cohort study. Visceral angiograms performed from Jan 2012 to Dec 2015 were evaluated. Index angiograms for GIB were identified. Exclusion criteria included recent abdominal surgery (30 days), empiric embolization, or incomplete arteriograms. Multiple factors were included in the analysis, age, gender, angiogram time, EGD, colonoscopy, anti platelet use, anticoagulant use, INR, CT, and Tc99m RBC scan (RBC Scan), among others. 118 angiograms were included in the final analysis. 44 angiograms resulted in identification and embolization of a bleed. (average age 67.4 yrs, 65% male) 74 angiograms failed to identify a bleed. 74 (average age 70.6yrs, 52% male) In cases with a positive RBC scan in the preceding 24 hours, successful identification and embolization was significantly statistically correlated with a shorter time to angiogram 4.6 hrs compared to 9.6 hrs for unsuccessful angiograms (p=.026). Patients with a bleed identified on EGD or colonoscopy prior to successful angiogram had a shorter time to angiogram 9.1 vs 10 hours for non-diagnostic angiograms, although not significant. CTA examinations were excluded due to low sample size. 92% of active bleeds seen on RBC scan and 93% of directly visualized bleeds corresponded to the embolized location. Visceral arteriography is a key tool in the identification and treatment of acute GI bleeding. Successful angiograms had a, statically significant, shorter time to angiogram from positive RBC scan compared to inconclusive angiograms. Angiography should be performed as soon as possible after a positive RBC scan. Successful embolization after EGD did not have a strong time dependence, likely owing to several factors.

Lactic Acid Is an Independent Predictor of Mortality and Improves the Predictive Value of Existing Risk Scores in Patients Presenting With Acute Gastrointestinal Bleeding

BackgroundThere are validated clinical risk scores for risk stratifying patients presenting with acute upper gastrointestinal bleed (GIB), including Glasgow-Blatchford score (GBS), Pre-endoscopic Rockall score (RS-PE) and post-endoscopic complete Rockall Score (RS-C), and AIMS65. Several studies have explored the predictive value of lactic acid (LA) in the context of GI bleeding, but the prognostic role of LA and its incremental value in combination with existing clinical risk scores is not well defined.MethodsWe conducted a retrospective analysis of consecutive patients presenting to the emergency department of a single large academic tertiary care center from January 2014 to December 2015 with a charted diagnosis of acute GIB, inclusive of both upper and lower sources. We evaluated the independent role of LA as well as three clinical risk scores for predicting in-hospital mortality in these patients.ResultsOut of 704 patients admitted with acute GI bleeding, 366 patients had LA measured on presentation to the emergency department. The mean LA level, GBS, RS-PE and RS-C were found to be significantly higher in non-survivors, while there was no difference in the mean AIMS65 score between survivors and non-survivors. A multivariate logistic regression analysis showed that LA level was an independent predictor of in-hospital mortality. The area under the curve (AUC) for the receiver operator characteristic for RS-C, RS-PE, and GBS were 0.742, 0.675, and 0.652, respectively. When integrating LA into the above risk scores, the AUC for RS-C, RS-PE, and GBS showed statistical significance improvements to 0.780 (P = 0.04), 0.774 (P = 0.012), and 0.706 (P = 003), respectively.ConclusionsIn unselected patients with GIB who presented to the emergency department, LA is an independent predictor of in-hospital mortality. Integration of LA into RS-C, RS-PE, and GBS risk scores improved their ability to predict in-hospital mortality. The modified LA-based RS-PE (L-Rockall pre-endoscopic) score demonstrated predictive value comparable to the post-endoscopic RS-C.

Complete Rockall score in predicting outcomes in acute upper gastrointestinal bleeding

Background: Acute upper GI bleeding is a common medical emergency with a hospital mortality of approximately 10%. Higher mortality rate is associated with rebleeding. Complete Rockall scoring system identifies patients at higher risk of rebleed and mortality.
 Methods: This is a descriptive hospital based study conducted in Gastroenterology unit of College of Medical Sciences and Teaching Hospital, Bharatpur, Nepal from January 2012 to December 2014. It included 200 patients at random presenting with manifestations of UGI bleed. Complete Rockall score was calculated in each patient and its correlation with mortality and rebleed was determined. Scores of >5 has been considered as one category as it comprises of patients with very high risks and scores of 0-4 as another category of low or lesser risks for the purpose of comparison of different risk factors.
 Results: Males were predominant (71%). Age ranged from 14 to 90 years, mean being 50.43+17.75 years. At presentation 110 patients (55%) had both hematemesis and malena, 56 patients (28%) had only malena and 34 patients (17%) had only hematemesis. Shock was detected in 21%, severe anemia and high blood urea were found in 31% and 41% respectively. Median hospital stay was 6.5+3.10 days. Comorbidities were present in 83.3%. Complete Rockall score ranged from 0 to 9, mean being 4.30+2.19. One hundred and thirteen (56.5%) had complete Rockall score <4 and 87 (43.5%) >5. Rebleeding was found in 16 (8%) patients. One hundred and eighty eight patients (94%) recovered and discharged from the hospital and 12 patients (6%) expired. The correlations between high Rockall scores (>5) and the occurrence of rebleeding (p=0.001) and mortality (p=0.001) were statistically significant.
 Conclusion: Acute Upper GI bleeding is a medical emergency. Predictors of mortality in this series were high complete Rockall score >5, esophageal varices with Child Pugh score C, massive initial bleed as well as rebleed and multiple comorbidities.
 Keywords: acute upper gastrointestinal bleed, complete Rockall score, comorbiditis, rebleed, mortality
 
 
 

Comparison of clinical prediction tools and identification of risk factors for adverse outcomes in acute lower GI bleeding

Limited data exist on prediction of adverse outcomes in patients with acute lower GI bleeding (LGIB). The purpose of our study was to compare the ability of existing validated clinical risk scores to predict relevant outcomes in LGIB. We performed a prospective observational study of patients admitted with LGIB who underwent colonoscopy at a single center between April 2016 and September 2017. Seven risk scores were calculated at admission (Strate, NOBLADS, Sengupta, Oakland, Blatchford, AIMS65, and Charlson Comorbidity Index). The risk of severe LGIB was determined via univariable and multivariable logistic regression. Area under the receiver operating characteristic curve (AUC) analysis was used to compare the scores. We included 170 patients admitted with LGIB requiring colonoscopy. Fifty-two percent (n= 89) fit criteria for severe bleeding. Patients with severe bleeding had lower admission hemoglobin levels (8.6 g/dL vs 11.1 g/dL; P= .0001), were more likely to have blood transfusions (85% vs 36%; P< .0001), intensive care unit stays (49% vs 19%; P< .0001), and had a longer length of stay (6 days vs 4 days; P= .0009). The Oakland score was best for prediction of severe bleeding (AUC, .74), Blatchford score for blood transfusion (AUC, .87), and Strate score for in-hospital recurrent bleeding (AUC, .66) and endoscopic intervention (AUC, .62). The strongest individual predictors of severe bleeding were low admission hemoglobin (odds ratio, 1.28 per 1-g/dL decrease; P= .0015; 95% confidence interval, 1.10-1.49) and low albumin (odds ratio, 2.56 per 1-g/dL decrease; P= .02; 95% confidence interval, 1.16-5.56). Admission albumin and hemoglobin levels were the strongest predictors of severe bleeding. No singular clinical risk tool had the best predictive ability across all outcomes.

Bleeding Related Episodes, Thrombotic Events and Platelet Counts Among Immune Thrombocytopenia Patients Receiving Second Line Therapy

INTRODUCTION: Immune Thrombocytopenia (ITP) is a disease of immune-mediated destruction of platelets and suppression of platelet production. ITP has been historically treated with corticosteroids and/or immune globulins as first-line agents. There are several second-line treatments available, should patients fail to respond to initial treatment or relapse after it is tapered. This study utilizes a national electronic health record (EHR) database to understand clinical outcomes with use of second-line treatments including: thrombopoietin receptor agonists (specifically, eltrombopag and romiplostim), rituximab, and splenectomy.METHODS: Utilizing the Optum EHR database, we identified patients who initiated a second-line treatment from Jan. 1, 2009 to Sep. 30, 2016 for primary or unspecified ITP. Additionally, patients included in the analysis had the following characteristics: 18 years or older; previous treatment with corticosteroids or immune globulin products; and active in the database for at least 6 months prior to and 12 months post initiation of a second-line treatment. Evaluated outcomes included: (1) platelet counts; (2) bleeding related episodes (BREs); and (3) thrombotic events (TEs), including stroke, transient ischemic attack, myocardial infarction, deep vein thrombosis, and pulmonary embolism. All outcomes were evaluated over the 12-month period following the initiation of second-line treatment. BREs and TEs were defined using ICD codes, collapsed to first three characters, indicating a form of bleeding or thrombotic events. Chi-square test and t-test were used to evaluate differences among the four treatment cohorts (eltrombopag, romiplostim, rituximab, and splenectomy).RESULTS: 2,047 patients met the inclusion criteria and used the second-line treatments as follows: eltrombopag, N=110 (5.4%); romiplostim, N=189 (9.2%); rituximab, N=1,488 (72.7%); splenectomy, N=260 (12.7%). The mean age was 60.8 years (standard deviation [SD]: 17.4), with 52.4% female and mean Charlson comorbidity score of 2.1 (SD: 2.1). Compared with platelet counts at the initiation of second-line treatments (collected within +/- 14 days of initiation of second-line treatments), mean platelet counts achieved during the 12 months post initiation of a second-line treatment increased in all treatment cohorts, ranging from an increase of 63,000/μL for rituximab to an increase of 157,000/μL for splenectomy. Mean platelet counts achieved during the 12 months post initiation of a second-line treatment differed significantly across treatment cohorts, ranging from 102,000/μL for eltrombopag to 240,000/μL for splenectomy (p<0.001) (Table 1). The proportion of patients who experienced BREs differed across the treatment cohorts, ranging from 25.5% for eltrombopag to 36.5% for romiplostim (p=0.038) (Table 2). Most common BREs observed included acute posthemorrhagic anemia, GI hemorrhage, hematuria, hemoptysis and hemorrhage, and rectal hemorrhage. TEs were observed in all treatment cohorts ranging from 11.6% for eltrombopag to 15.7% for splenectomy (p=0.744). (Table 2).CONCLUSIONS: This retrospective real world evidence study compares mean platelet response and burden of both BREs and TEs in ITP patients treated with different second-line treatments. Although there were significant differences in mean platelet counts achieved with the second-line treatments, TEs were observed with similar incidence across all treatments. Patients who received splenectomy had the highest mean platelet counts and also the highest proportion of patients who experienced TEs, though differences in TEs did not reach statistical significance. Incidence proportion of patients with BREs was lower in patients treated with eltrombopag than in patients treated with other second-line treatments. Such differences in outcomes may be useful when selecting treatment in the second-line setting. [Display omitted] DisclosuresSaid:Novartis Pharmaceuticals Corporation: Employment. Lal:Optum: Employment. Andrade:Optum: Employment. Nezami:Novartis Pharmaceuticals: Employment. Graves:Novartis: Employment. Roy:Novartis: Employment. Cuker:Kedrion: Membership on an entity's Board of Directors or advisory committees; Synergy: Consultancy; Genzyme: Consultancy; Spark Therapeutics: Research Funding.

Successful hemostasis of active lower GI bleeding using a hemostatic powder as monotherapy, combination therapy, or rescue therapy

Acute lower GI bleeding is a frequent cause of hospital admission. The objective of this study was to evaluate the safety and performance of a hemostatic powder (TC-325/Hemospray) in the treatment of nonvariceal lower GI bleeding. Patients were enrolled into this prospective, multicenter, single-arm study at 4 tertiary care centers in Canada. Fifty patients with active lower GI bleeding of multiple different causes (52 bleeding sites) underwent topical endoscopic application of hemostatic powder. The primary endpoint was powder-related adverse events within 30 days of the index procedure. Secondary endpoints were initial hemostasis as well as recurrent bleeding and mortality within 30 days of the index procedure. Most patients (96%) had a single bleeding site, and most bleeding (73%) was due to polypectomy. Overall, the powder was applied as monotherapy in 13 bleeding sites (25%), as combination therapy in 22 bleeding sites (42.3%), and as rescue therapy in 17 bleeding sites (32.7%). Hemostasis was achieved in 98% of patients. No patient experienced a powder-related adverse event. Five patients (10%) developed recurrent bleeding within 30 days. One patient (2%) died within 30 days of powder application, but the death was not directly related to hemostatic powder use. The hemostatic powder is a safe and effective option for patients with lower GI bleeding of varying causes, and in particular, postpolypectomy hemorrhage. The hemostatic powder is effective as monotherapy, part of a combination approach, or as a rescue therapeutic option for the treatment of nonvariceal lower GI bleeding. (Clinical trial registration number: NCT02099435.).

Utility of CT Angiography (CTA) in Diagnosis and Treatment of Acute Lower GI Bleeding (LGIB)

Introduction: To investigate the diagnostic performance of CTA in identifying the cause of acute lower GI bleeding and to determine the clinical features associated with positive test result of CTA. Acute Lower GI bleed warrants quick detection and localization of the bleed. Various studies have shown that CTA can detect active hemorrage at rate of 0.3 ml/min (compared to bleeding scan detection rate of 0.2 ml/min) Methods: Retrospective chart review study of all patients who had CTA performed for suspected acute LGIB in last 5 years in a community hospital in Brooklyn Results: 84 patients with mean age of 69 years were included. 41% were male and 59% were females. 49% were on antiplatelet therapy.29% had history of diverticulosis. Mean Hb value was 8.34 g/dL. Presenting complaints were lower GI bleeding in 86%, upper GI bleeding in 9.5%, abdominal pain with anemia in 4.5%. On abd CTA, 86% had no active bleeding and 14% had active bleeding. 9/12 had LGI and 3/12 had upper GI bleeding. EGD showed antral/duodenal ulcers in patients where CT had localized disease to upper GI tract. 5/9 with localized bleeding to lower GI tract had colonoscopy done. Colonoscopy showed diverticulosis in 3, mass in 1 and colitis in 1. CTA was negative in 44%, non-specific colitis 13%, diverticulosis in 15%. 20% patients had bleeding scan done. 11/17 had positive bleeding scan. In patients with positive bleeding scan,10/11 had initial negative CTA, 6/11 had EGD done which did not show active bleeding. 7 had colonoscopy done which did not show active bleeding. EGD was done in 41/84 patients. No active bleeding was identified in all patient who had EGD done. Conclusion: In patients with acute LGIB, CTA lacks sensitivity and was positive only in14% of the patients. Bleeding scan was more sensitive however, lacked specificity in localizing the bleeding. Patients who had positive CT scan for active bleeding, only one had active bleeding on Colonoscopy. All the patients who had CT evidence of diverticulosis, were found to have diverticulosis on colonoscopy.Diverticular bleeding is most common cause of LGIB. CTA should only be reserved for patients with continued bleeding despite usual standard of care and in patients in whom vascular intervention is needed. Majority of patients can be spared from radiation and IV contrast exposure from CTA. However, further large prospective studies are needed to define the role of CT in acute GI bleeding when other investigations are unable to provide a diagnosis.

Hepatocelluar Carcinoma Invading the Gallbladder - A Rare Cause of Hemobilia

Bleeding from the hepatobiliary tract (hemobilia) is a rare cause of acute upper GI bleed. It should be considered in any patient with recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a rare case of hemobilia due to hepatocellular carcinoma (HCC) invading the gall bladder wall. A 52- year old female with Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical examination was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (Fig A). She was aggressively transfused multiple blood products, placed on a proton pump inhibitor and started on octreotide. An emergent EGD was performed which identified blood oozing from the ampulla of vater; consistent with a diagnosis of hemobilia (Fig B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gall bladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with unknown exact incidence. Traumatic etiology accounts for 40-80 percent of all cases. In patients with HCC, invasion into the blood vessels is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-biliary duct invasion. 21 percent developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with quinke's Triad: acute upper GI bleed (100 percent), biliary colic (70 percent) and jaundice (60 percent). Diagnosis is by visualizing blood from the Ampulla of vater via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95 percent). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25 percent.1950_A Figure 1. A 3.1 cm oval shaped arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity of the gall bladder.1950_B Figure 2. EGD oozing from the ampulla of vater (A) and showing blood oozing within the second part of the duodenum (B).

Traumatic Nasogastric Tube Placement Causing Acute Upper GI Bleeding in a Black Esophagus: A Warning to Gastroenterologists and Clinicians

Acute necrotizing esophagitis (Black Esophagus) is a rare and sometimes fatal syndrome, typically affecting older males, with a prevalence of up to 0.01% of all endoscopy cases. In our tertiary referral center, we describe the case of a 57-year-old male with a history of hypertension, diabetes mellitus type II, and renal cell carcinoma who presented for an elective partial nephrectomy. His post-operative course was complicated by gross hematuria requiring multiple blood transfusions, and he was found to have a AV fistula and pseudoaneurysm of his kidney. He then developed fevers and hypotension and was found to have bacteremia and a urinary tract infection. On post-op day 12, the patient became obtunded and a nasogastric tube was placed which aspirated copious coffee-ground materials. Overnight, the patient had frank hematemesis and was transferred to the ICU; an emergent EGD was performed. Diffuse esophagitis with necrosis was found in the mid and distal esophagus (Image 1A). His nasogastric tube was removed, which unveiled a pulsatile arterial bleed 4 cm proximal to the GE junction (Image 1B). Hemostasis was achieved with BICAP cautery (Image 1D). He was made strict NPO, IV PPI was started, and antifungals were added. A follow up EGD on post-op day 14 demonstrated a sharp demarcation of normal healthy esophageal mucosa in the proximal esophagus to necrotic black esophagus distally (Image 2B). A final endoscopy was performed 6 days later, with the majority of esophagus demonstrating signs of healing (Image 2 C,D). Black esophagus is thought to be due to a “two hit” phenomenon, where an initial event such as a low flow vascular state predisposes the esophageal mucosa to severe topical injury from acid reflux. With concomitant gastric outlet obstruction, accumulation of gastric fluids results in direct tissue injury and necrosis of the esophageal mucosa, with the distal third of the esophagus being most vulnerable to ischemic injury due to its relative hypovascularity. This elusive diagnosis should not be missed in critically ill patients with hemorrhagic or septic shock who develop upper GI bleeding during their hospitalization. We recommend that before urgent nasogastric tube placement for gastric decompression, a bedside endoscopy should be considered to rule out acute necrotizing esophagitis, as placement of a foreign body in a severely diseased esophagus could lead to direct tissue injury and significant GI bleeding as was the case in our patient.1723_A Figure 1. Initial EGD A. Necrotizing Esophagitis (Black Esophagus) - B. Active arterial bleeding in distal esophagus from NGT trauma C. Large clot burden in esophagus D. NG trauma s/p BICAP treatment1723_B Figure 2. A, B. EGD #2 (48 hours later) - distal esophageal necrosis (A) with proximal sharp demarcation from necrotic esophagus to normal mucosa (B). C, D. EGD #3 (8 days after initial EGD) - healthy, healing esophageal mucosa with viable granulation tissue

Donʼt Stop Looking: Lower Gastrointestinal Hemorrhage Secondary to Appendiceal Orifice Bleeding

The patient is a 53 year old male who presented to the hospital with anemia and gastrointestinal hemorrhage. The decision was made to pursue an endoscopic work up with upper endoscopy and a colonoscopy. The upper endoscopy was nondiagnostic, however a large amount of hematochezia noted during his colonoscopy. Further work up with a bleeding scan did not reveal active bleeding, prompting us to pursue a capsule endoscopy. There was an area of active bleeding noted in the distal small bowel which led to patient being scheduled for retrograde double balloon enteroscopy. During this procedure, diligent attention was made to irrigate and suction remaining blood throughout the colon. After the cecum was thoroughly cleaned, a slow ooze was noted emanating from the appendiceal orifice. Withdrawal of the scope did not reveal any other potential source of bleeding. The patient subsequently underwent an appendectomy resulting in successful treatment of his hemorrhage. The specimens from surgical pathology did not reveal any obvious abnormality. The patient was subsequently discharged without any signs of overt hemorrhage. Appendiceal orifice hemorrhage is a rare cause of lower gastrointestinal hemorrhage, as there are only few case reports noted in the literature. This type of bleeding can result from ulcers, erosions, angiodysplasias, or malignancy. Appendectomy is generally curative as it was in our patient's case. This case highlights the need to remain persistent while attempting to diagnose an acute lower GI bleed

A Rare Case of Massive Gastrointestinal Bleeding From a Rectal Dieulafoy Lesion

A Dieulafoy lesion (DL) is defined as a dilated sub-mucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. DL lesions of the rectum are a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. We present an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a DL of the rectum. An 84-year-old man with a medical history significant for End-stage renal disease(ESRD), and hypertension presented to our emergency department with multiple episodes of rectal bleeding mixed with bowel movements. On physical examination, he was hemodynamically stable, with rectal examination notable for bright red blood on the examining finger. His initial complete blood count showed a hemoglobin of 8.4 g/dL, with other normal indices. The patient was rapidly prepped for colonoscopy. Colonoscopy revealed an actively spurting Dieulafoy lesion in the distal rectum just proximal to the pectinate line associated with underlying friable mucosa. Hemostasis was achieved with injection of 3cc of 1:10000 epinephrine, and application of 3 hemostatic clips. He remained stable, with no subsequent rectal bleeding and was discharged home. DLs first described by Gallard in 1884, is a rare cause of gastrointestinal bleeding.They are believed to account for an estimated 1-2% of all cases of acute GI bleeding and can be associated with high mortality rate. The etiology of Dieulafoy lesions are unknown. Risk factors associated with their development include male gender, hypertension, and ESRD, which were present in our patient. With regards to location, DLs are most commonly encountered in the stomach and the gastroesophageal junction. DLs of the rectum is a rare entity, observed in a mere 2% of reported cases in the literature. Bleeding episodes of DL are usually self-limited, however, they are usually recurrent and can lead to profuse rectal bleeding. Diagnosis of DLs, both gastric and rectal, can often time be challenging for the clinician. Endoscopy is the gold standard for diagnosis, but is only successful in 70% of cases, requiring the need for repeat endoscopy to establish the diagnosis. Treatment of rectal DLs is best accomplished endoscopically using a combination of epinephrine injection with bipolar probe coagulation, hemoclip placement, or thermal coagulation. Rarely angiograph and surgery is indicated in failed endoscopic therapy.1991_A Figure 1. An actively bleeding dieulafoy lesion in the distal rectum, just proximal to the pectinate line.1991_B Figure 2. Hemostasis achieved with 3 hemostatic clips.

Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping

Very few prospective studies with over 100 samples have evaluated the long-term outcomes of endoscopic therapy for colonic diverticular bleeding (CDB). This study sought to elucidate the recurrent bleeding risk of endoscopic band ligation versus clipping for definitive CDB based on stigmata of recent hemorrhage (SRH). Patients emergently hospitalized for acute lower GI bleeding and examined by high-resolution colonoscopy were enrolled. Better visualization of SRH from a diverticulum was obtained using a water-jet device. Endoscopic band ligation or clipping was performed as first-line treatment, and patients were prospectively followed after discharge. No statistical difference was found between the ligation (n= 61) and clipping (n= 47) groups in baseline characteristics or follow-up period. The probability of 1-year recurrent bleeding was 11.5% in the ligation group versus 37.0% in the clipping group (P= .018). No patients required surgery or experienced perforation. One patient in the ligation group experienced diverticulitis the next day. In patients with recurrent bleeding within 7 days, the recurrent bleeding site was the same diverticulum, and ulceration was found in the ligation group on repeat colonoscopy. In patients with recurrent bleeding after 2 months, repeat colonoscopy identified that the recurrent bleeding site was different, and scar formation was seen in the ligation group. The left side of the colon was an independent predictor for recurrent bleeding in the ligation group but not in the clipping group. Band ligation for definitive CDB has better outcomes than clipping during long-term follow-up after endoscopic therapy, probably because of complete elimination of the diverticulum. CDB can recur at the same diverticulum in the short term but at a different diverticulum in the long term.

Mo1115 IS OVER-THE-SCOPE-CLIP AN EFFECTIVE RESCUE THERAPY FOR SEVERE ACUTE UPPER GASTROINTESTINAL BLEEDING EVEN IN VARICEAL ONES?

When repeated endoscopic therapy fails to achieve hemostasis for acute upper GI bleeding, current treatment options have been limited to surgery or angiography with embolization. Over-the-scope-clip (OTSC) has potency to achieve haemostasis of various bleeding GI lesions. We aimed that to critize the usefulness and safety of OTSC for achieve endoscopic hemostasis in patients who failed repeated endoscopic methods. Case series of patients who have serious upper GI bleeding undergoing endoscopic hemostasis using OTSC was evaluated. The OTSC-system was loaded on the scope and then the lesion was suctioned into the transparent cap before releasing the clip. Grasping forceps were not used. All patients underwent second look endoscopy after the procedure on first and fourth days. Primary hemostasis success, recurrent bleeding rate, complications, and 1-month follow-up clinical outcomes analyzed. During a 24-months period, 15 consecutive patients were evaluated (10 male) with a mean age of 31 (range 22-79) years, a mean hemoglobin of 9 (range 6 to 11) g/dl. All patients had received packed red blood cells with the mean being 3 (range 4- 9) units. All patients had failed hemostatic therapy using current available endoscopic methods. The mean number of endoscopies performed on these patients prior to OTSC was 3 (range 3-5). Reasons for bleeding in patients were as follows: Dieulafoy lesion (n=5), duodenal ulcer (n=3), anastomotic varices (n=2), fibrotic esophageal varices (n=2), fundic varices and anastomotic ulceration (n=1). All patients achieved immediate hemostasis. Re-bleeding occurred in only one patient (fundic varices) 72 hours after OTSC. Subsequently, this patient successfully treated with synthetic surgical glue injection. No adverse event related to OTSC application was observed. OTSC is a safe endoscopic treatment method that can be easily applied to control serious acute GI bleeding even in variceal ones when single or combined current endoscopic treatments are unsuccessful. Its use for fundic varices can be considered as a bridge to standardized synthetic surgical glue injection therapy, until its superiority would be demonstrated by prospective studies in this patient population