Common Cause Of Gastrointestinal Bleeding Research Articles

Diagnostic imaging in determining the signs of possible bleeding from gastric varicose veins (literature review)

Annotation. Gastric varicose veins are one of the common causes of gastrointestinal bleeding in patients with portal hypertension. Bleeding of this localization has a greater percentage of death and difficulty in achieving hemostasis than bleeding from esophageal varices. This paper discusses the etiology and main aspects of the pathophysiology of portal hypertension, the mechanisms of bleeding, which play an important role in the prevention of complications prevention. The venous outflow from the stomach, variants of porto-systemic collateral anastomoses and types of varicose veins of the stomach itself are presented in sufficient detail. The advantages and disadvantages of diagnostic imaging in the assessment of gastric varicose veins and the possible prediction of the risk of bleeding are demonstrated.Aim: to analyze the data of foreign and domestic literature on varicose veins of the stomach, to identify criteria that determine the risks of bleeding according to the methods of diagnostic imaging.Results. Analysis of foreign and domestic literature showed that the problem of diagnosing gastric varicose veins is extremely relevant and requires special consideration of all its various aspects. There are many diagnostic methods with certain advantages and disadvantages. But, in our opinion, the possibilities of non-invasive methods, especially computed tomography, in the diagnosis of varicose veins of the stomach and the prognosis of bleeding from them are underestimated and require further study.

An Exceptional Presentation of “Watermelon Stomach” in a 30- Year-Old Cirrhotic Male

Gastric antral vascular ectasia (GAVE) is an unusual cause of chronic upper gastrointestinal bleeding commonly described in elderly females, with associated autoimmune diseases, and in cirrhotic males. The entity is characterized by angioectasia in the pyloric antrum, giving its classic streaky “watermelon stripe” appearance. This report highlights the rare presentation of a 30-year-old male with liver cirrhosis, who presented with anemia and fatigability. Diagnosis of GAVE was made using endoscopy, and trials of argon plasma coagulation were administered. Following this, an antrectomy was performed since there was a further drop in hemoglobin. The patient made a full recovery with no subsequent dependence on blood transfusions. GAVE can be mistakenly underdiagnosed as a treatable cause of occult gastrointestinal bleeding. This report mandates caution on endoscopy for younger patients with an upper gastrointestinal bleed while taking other more common causes of gastrointestinal bleeding (peptic ulcers, esophageal varices, and non-steroidal anti-inflammatory drugs [NSAID]-induced gastritis) into account.

S2498 Endoscopic Treatment of a Dieulafoy’s Lesion in the Appendiceal Orifice

Introduction: A Dieulafoy’s lesion, typically a large caliber submucosal artery that erodes gastrointestinal (GI) mucosa, is a less common cause of GI bleeding. While these vascular abnormalities may occur throughout the GI tract, appendiceal Dieulafoy’s lesions are exceedingly rare, with described cases often resulting in surgical intervention. We present a case of a Dieulafoy’s lesion in the appendiceal orifice leading to massive GI bleeding which was successfully diagnosed and treated endoscopically. Case Description/Methods: A 75-year-old female with end stage renal disease, hypertension, hyperlipidemia, and heart failure with preserved ejection fraction presented with abdominal pain and rectal bleeding for 2 weeks duration. At onset, she was admitted to an outside hospital where computed tomography (CT) angiography showed aortoiliac and mesenteric atherosclerosis without evidence of large vessel occlusion. Esophagogastroduodenoscopy did not reveal a bleeding source. She reported infraumbilical abdominal pain and continued rectal bleeding and was transferred to our medical center. Upon arrival, the patient was hemodynamically stable with active rectal bleeding on exam. Laboratory analysis revealed hemoglobin of 6.9 grams per deciliter, platelet count of 101 per milliliter, blood urea nitrogen of 6.6 milligrams/deciliter (mg/dl), and creatinine of 6 mg/dl. She was treated with 3 units of packed red blood cell and a proton pump inhibitor. Colonoscopy showed a Dieulafoy’s lesion at the appendiceal orifice. Hemostasis was achieved with placement of 2 hemoclips (Figure). She was discharged 6 days after colonoscopy without recurrence of bleeding. Discussion: Only 6 cases of appendiceal Dieulafoy’s lesions have been reported in the literature and all were treated with laparoscopic appendectomy (Table 1). To our knowledge, this is the first reported case of an appendiceal Dieulafoy’s lesion that was successfully treated with endoscopic placement of hemoclips. There is no data comparing the efficacy of endoscopic intervention versus laparoscopic appendectomy in treating appendiceal Dieulafoy’s lesions; however, this case highlights that therapeutic endoscopy may be both safe and effective. Further reports are needed to inform recognition and optimal approach to appendiceal Dieulafoy’s lesions. Furthermore, in cases where hemostasis is achieved endoscopically, longer term follow-up may inform if appendectomy can be safely avoided.Figure 1.: Successful hemostasis of a Dieulafoy’s lesion at the appendiceal orifice after placement of 2 hemoclips. Table 1. - Previously reported Appendiceal Dieulafoy’s Lesions% and Outcomes Case Report Patient Clinical presentation and course Endoscopic hemostasis attempted? Management? Xue et al, 2020 21 F Massive hematochezia with lower abdominal pain and LOC* N Laparoscopic appendectomy Choi et al, 2016 72 M Hematochezia with associated mild abdominal pain and bloating sensation, previous melena from duodenal ulcer N Laparoscopic appendectomy and cecum wedge resection Johnson et al, 2014 51 M RLQ# pain, Acute appendicitis with incidental finding of Dieulafoy’s lesion on mid-distal appendiceal wall N Laparoscopic appendectomy Reynolds et al, 2013 68 M Massive hematochezia with perfusion requirement N Laparoscopic appendectomy Lee et al, 2011 22 M Severe lower GI† bleed N Laparoscopic appendectomy So et al, 1995 42 M Melena and dizziness N Laparoscopic appendectomy %In all previously reported cases, a Dieulafoy’s lesion was diagnosed using colonoscopy to visualize blood emerging from the appendiceal orifice, then subsequent resection revealing an ulcerated appendiceal mucosal lesion and microscopy and histopathology demonstrating tortuous vasculature penetrating the circumferential and longitudinal muscular wall of the appendix. Abbreviations: *Loss of consciousness, #Right lower quadrant, †Gastrointestinal.

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Role of octreotide in small bowel bleeding.

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

CLINICAL CHARACTERISTICS AND CAUSES OF GASTROINTESTINAL BLEEDING IN CHILDREN

Abstract: Background: Gastrointestinal bleeding (GI) is a complication of many diseases, caused by injury at the gastrointestinal tract or outside the gastrointestinal tract, causing bleeding from mild to severe severity, which can even cause shock and death. The causes of gastrointestinal bleeding vary by age. Objectives: To describe the clinical, subclinical and common causes of non-infectious gastrointestinal bleeding in children. Subjects and methods: Patients from 2 months to 15 years old admitted to Pediatrics Department I, Pediatric Center, Hue Central Hospital from February 2020 to February 2021 with a diagnosis of gastrointestinal bleeding. The study was carried out by cross-sectional descriptive research method. Results: The study included 116 patients, 7 children in the group of 2 months - < 1 year old (6.0%), 36 children in the group 1 - < 6 years old (31%), 36 children in the group 6 - < 11 years old (31.1%) and 37 children in the group of 11-15 years old (31.9%). The mean age was 7.6 ± 4.6. Peptic ulcer disease is the most common cause of GI bleeding, accounting for 37%; 12.9% cases unknown cause. Most of the patients had mild and moderate GI bleeding, about 60.3% and 23.3%; severe bleeding 8.6% and very severe 7.8%. The most common cause of GI bleeding in the group of 2 months - < 1 year old is Mallory-Weiss syndrome and milk protein allergy (22.2%), in the group of 1-5 years old is anal fissure (41.6%) and in children over 6 years old is peptic ulcer disease. Conclusion: The most common causes of gastrointestinal bleeding depend on the age and have different clinical features depending on the cause. Key words: gastrointestinal bleeding in children, melena, hematemesis, hematochezia.

Angiodysplasia and its correlation to serum magnesium level in patients with chronic kidney disease stage 5D under maintenance hemodialysis

Background Angiodysplasias (ADs) are vascular ectasias not associated with any familial syndrome, cutaneous lesions, or systemic vascular disease. They are the most common vascular malformations of the gastrointestinal tract in the general population with a prevalence of 0.82%. Most AD occurring in the general population are detected in patients older than 60 years of age, although presentation in patients with chronic kidney disease (CKD) can be earlier. The aim was to correlate AD with serum magnesium level in patients with CKD stage 5D under maintenance hemodialysis.Patients and methods This study included 60 patients with CKD stage 5D on maintenance hemodialysis. Upper and lower gastrointestinal tract endoscopy was done for all patients in Kafr Elsheikh University Hospital in a cross-sectional ‘prospective study,’ and all laboratory investigations were done.Results The mean age of patients with CKD was 49.03±14.66 years. There was a statistically significant increase in Mg among patients with AD and those without AD. This study showed that there were statistically significant negative correlations between Mg and parathyroid hormone.Conclusion AD is one of the common causes of gastrointestinal bleeding in all population and is the most common cause of bleeding in patients with CKD. Hypermagnesemia is associated with AD in patients with CKD.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms.

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Effect of fenugreek (Trigonella foenum-graceum L.) seeds powder on gastrointestinal bleeding in mechanically ventilated patients: A double-blind, randomized controlled clinical trial

Stress ulcers are common in mechanically ventilated patients. They are the most common cause of gastrointestinal bleeding and are primarily associated with increased the consumption of non-steroidal anti-inflammatory drugs. Despite advanced treatment, it has a high in-hospital mortality rate. This study assessed the effect of fenugreek ( Trigonella foenum-graceum L.) seeds on gastrointestinal bleeding in mechanically ventilated patients. In this double-blind, randomized controlled clinical trial, 60 mechanically ventilated patients hospitalized in intensive care units were equally distributed into intervention and control groups. The intervention group received 3 mg fenugreek seeds powder twice daily with a gavage solution for five days, in addition to routine treatment. The control group received only the gavage solution and routine treatment. The gastrointestinal bleeding and abdominal pain at admission and during the five days were assessed. Data were analyzed using SPSS software V. 16, and the significance level was set at 0.05. Gastrointestinal bleeding at admission was similar in both groups. The number of mechanically ventilated patients with gastrointestinal bleeding decreased on the third, fourth, and fifth days, but the difference was insignificant. The Cochran test results showed that the rate of stress-induced gastrointestinal bleeding in the control group increased significantly (P = .04). The decrease in gastrointestinal bleeding in the intervention group was not statistically significant ( P = .08). The use of this drug reduces the gastrointestinal side effects of ventilated patient. Despite this, reducing gastrointestinal bleeding and similar mechanical ventilation complications in patients entirely dependent on the treating team is an important achievement.

Clinical research progress on colorectal polyps in children

Colorectal polyps is common cause of gastrointestinal bleeding in children.In recent years, with the increasing application of colonoscopy and genetic testing in pediatrics, the understanding of colorectal polyps has been deepened.Children′s colorectal polyps, although mainly juvenile polyps, have some polyps syndrome.Gene mutation plays an important role in polyps syndrome, which is prone to relapse and malignant in the gastrointestinal tract.We need to follow up regularly, while there is still no consensus in China.Therefore, this paper describes the research progress of common colorectal polyps in children, including epidemiological characteristics, pathogenesis, clinical manifestations, diagnosis, treatment, association with tumors and follow-up. Key words: Children; Colorectal polyps; Treatment; Relapse

2657 Novel Use of Radiofrequency Ablation in the Treatment of AVMs of Small Bowel Mucosa

INTRODUCTION: Radiofrequency ablation (RFA) is a well-authorized treatment in a number of gastrointestinal conditions such as dysplastic Barrett’s, gastric antral vascular ectasia and biliary stricture. We are presenting a case series focused on the use of RFA in the treatment of small bowel AVMs through small bowel enteroscopy, using a novel through the scope radio frequency ablation catheter. CASE DESCRIPTION/METHODS: Cases: This case series encompasses five cases using a new through the scope radio frequency ablation caterer to treat AVMs found in the small bowel and cecum. The age for these patients ranged from 56 to 72 years old, with two being males and three being females. Our patients presented for various reasons, including abdominal pain, abnormal CT findings, and gastrointestinal bleeding. Colonoscopies and endoscopies on these patients were unremarkable. All patients underwent single balloon enteroscopy, and multiple arteriovenous malformations (AVMs) were found. AVMs were successfully ablated using a novel through the scope radio frequency ablation catheter (RFA-SB). AVMs in these patients were found in the cecum, jejunum, ileum and stomach. 12 J/cm2 energy was applied with each paddle application. All patients recovered well after the procedure and follow up CBC showed improvement in their hematocrit. No immediate or late procedure related complications were reported. DISCUSSION: AVMs are one of the common causes of gastrointestinal bleeding. Ablation of AVMs in the small bowel has typically utilized argon plasma coagulation (APC) as a treatment modality. This case series looks at the use of a new RFA-SB as a new treatment modality for small bowel AVMs. This series is novel, due to the length of the new RFA catheter, as it is able to pass through a 200 cm small bowel enteroscope with better maneuverability and providing a uniform therapy than traditionally used APC technique without healthy tissue damage and achieving satisfactory hemostasis.

Intensive Care Tactics for Reducing Gastrointestinal Bleeding in the Context of Portal Hypertension

Introduction.Gastrointestinal bleeding is currently one of the most significant pathologies indicating lethality. Factors in the incidence of gastrointestinal bleeding include the spread of gastrointestinal diseases caused by eating disorders, Helicobacter Pylori infection and routine use of anticoagulants. The various causes leading to the development and level of bleeding in the gastrointestinal tract require a differentiated therapeutic approach. In addition to surgical haemostasis, pharmacological support is also required. In the article, we consider medicamentous therapeutic approaches to bleeding due to phlebeurysm, which is one of the most common causes of gastrointestinal bleeding. This problem is very relevant due to the spread of hepatitis and alimentary toxicity having cirrhosis as the outcome.Materials and methods.The review considers the priority methods for treatment of patients with gastrointestinal bleeding, depending on the etiopathogenetic factors.Conclusion.Adequate pharmacotherapy of bleeding from varicose veins of the esophagus is more important than surgical interventions, both for prevention and for haemostasis and subsequent control of the development of re-bleeding. Obviously, the use of vasoactive drugs improves the prognosis and effectiveness of endoscopic ligation of esophageal varicose veins, balloon tamponade, portosystemic shunting, and beta-blockers play a significant role in primary and secondary prevention.

Von Willebrand Disease and Gastrointestinal Bleeding: A National Inpatient Sample (NIS) Study

Background:Von Willebrand disease (VWD) is a common congenital bleeding disorder, caused by defective or deficient von Willebrand factor (VWF), and characterized by mucosal bleeding. Among these, recurrent gastrointestinal (GI) bleeding may be serious and life-threatening,requiring hospitalization in 30%. Diagnosis and management remain challenging, and the prevalence and correlates of GI bleeding in VWD are not well understood.Methods. We conducted a cross-sectional study using discharge data from the National Inpatient Sample (NIS) between January 1, 2009 and December 31, 2014 to identify factors associated with GI bleeding in VWD. NIS is the largest publicly available inpatient database in the U.S. developed by Healthcare Cost and Utilization Project (HCUP), containing a 20% stratified sample of U.S. hospital discharges. Discharges of individuals with and without VWD were evaluated by age, race, gender, primary and secondary diagnoses, length of stay, insurance, and discharge status. International Classification of Diseases, 9thedition, Clinical Modification (ICD9-CM) codes were used to classify de-identified discharge data by causes of GI bleeding, medications, blood products, and comorbidities. Discharge-level weights from the NIS database were used to produce estimates representative of all U.S. community hospitals. We compared GI bleeding prevalence between patients with and without VWD, and among those with VWD, the demographics (age, gender, race), length of stay, inpatient mortality, payor, medical comorbidities, and potential causes of and risk factors for GI bleeding. Categorical variables were compared by Rao-Scott chi-square test, and continuous variables by weighted simple linear regression. Independent factors associated with GI bleeding in VWD were determined by a weighted multivariable logistic regression model.Results:Individuals with VWD and GI bleeding were younger than those without GI bleeding, 58.5 yr vs 45.2 yr, and were more likely male, 42.3% vs 25.9%, and Black, 12.3% vs 7.5%, each p<0.0001. Overall, the prevalence of upper GI bleeding (UGI) was greater than lower GI bleeding (LGI) in VWD, 57.4% vs 44.4%; but these rates were significantly higher in non-VWD, 65.5% vs 35.6%, each p<0.001. The most common cause of GI bleeding in VWD was angiodysplasia, 36.5% (LGI 19.7%, UGI 16.3%) which was significantly more common than in non-VWD, 9.5% (LGI, 4.1%, UGI, 4.9%), p<0.0001. By contrast, the next most common causes of GI bleeding in VWD were ulcer disease, 10.8%; diverticulitis, 9.7%; and gastritis/ duodenitis, 8.9%, each less common than in non-VWD, 20.7%, 16.7%, and 12.5%, p<0.01. The most common ulcer type was gastric ulcer, 6.5% vs 14.1%, respectively, p<0.0001.Among VWD patients, those with GI bleeding were more likely than those without GI bleeding to receive aspirin, 3.3% vs 2.0% (p=0.030), platelet transfusion, 4.0% vs 2.1% (p=0.0012), and coagulation factor, 7.8% vs 4.6% (p=0.0003). Comorbidities were also more common in VWD with GI bleeding, including surgery, 73.4% vs 57.6%; hypertension, 36.7% vs 29.1%; hyperlipidemia, 24.6% vs 16.9%; GERD, 19.3% vs 16.1%; smoking, 17.1% vs 10.7%); diabetes, 15.0% vs 10.9%; chronic kidney disease, 12.2% vs 6.3%; hepatitis C, 9.2% vs 3.2%; thrombocytopenia, 7.6% vs 3.9%; liver disease, 7.5% vs 2.6%; aortic valve disease, 5.5% vs 2.0%; and vascular assist device, 2.2 vs 0.4%, each p<0.0001. Severity of illness, 1.5 vs 0.9, p<0.0001, and inpatient mortality, 2.4% vs 1.2%, p=0.011 were higher in VWD with GI bleeding than without GI bleeding.In a multivariable model, variables significantly associated with GI bleeding in VWD were angiodysplasia, OR=104.06 [95% CI: 75.14, 144.11]; diverticulitis, OR=16.66 [11.85, 23.42]; hepatitis C, OR=2.17 [1.40, 3.36]; Black race, OR=1.80 [1.31, 2.47]; male gender, OR=1.61 [1.29, 1.99]; and smoking, OR=1.40 [1.04, 1.88].Conclusion.The most significant correlates of GI bleeding in VWD are angiodysplasia, diverticulitis, hepatitis C, Black race, male gender, and smoking. Identification of VWD at high risk for GI bleeding with consideration for factor prophylaxis after the first GI bleed, may help reduce the morbidity of recurrent GI bleeding in VWD. [Display omitted] DisclosuresRagni:Bioverativ: Consultancy, Research Funding; CSL Behring: Research Funding; MOGAM: Membership on an entity's Board of Directors or advisory committees; Shire: Research Funding; SPARK: Consultancy, Research Funding; Alnylam: Membership on an entity's Board of Directors or advisory committees, Research Funding; Biomarin: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novo Nordisk: Research Funding; Sangamo: Research Funding.

Clinical characteristics and risk factors of active bleeding in colonic angiodysplasia among the Taiwanese

Colonic angiodysplasia (AGD) is a common cause of gastrointestinal bleeding. However, information on the characteristics and prevalence of colonic AGD is limited. We determined the clinical features of and risk factors for active bleeding in colonic AGD in a Taiwanese population. From February 2007 to December 2016, 13,047 patients undergoing 16,760 colonoscopies at the Tri-Service General Hospital were included in this study. Eighty-four patients were diagnosed with AGD. We conducted a retrospective study by analyzing the medical records of these patients. The clinical features and endoscopic findings were evaluated. Furthermore, we distinguished colonic AGD into bleeding and non-bleeding types and identified the risk factors for bleeding in colonic AGD. In our study, the prevalence of colonic AGD was 0.6% among all patients who received colonoscopy. Among patients with colonic AGD, we found that many were aged; in all, 58.3% of patients with colonic AGD were older than 65 years. More than half of the patients had hypertensive cardiovascular disease (53.6%) and the AGD lesions were predominantly located in the left-sided colon (41.7%). We analyzed several factors to identify those associated with bleeding colonic AGD. Our results indicated that age (p<0.001), hypertension (p=0.020), atrial fibrillation (p=0.027), and in-patient status (p=0.006) were significant factors associated with active bleeding lesions. On multivariate analysis, old age was the only significant risk factor. Angiodysplastic lesions in Taiwanese patients were predominantly identified in the left-sided colon. Old age was an independent risk factor associated with active bleeding in colonic angiodysplasia.

ANGIODYSPLASIA OF THE SMALL INTESTINE AND COLON: A REPORT OF THREE CASES.

INTRODUCTION: Angiodysplasia is a rare lesion (0.82% prevalence) characterised by enlarged, abnormally dilated blood vessels in the mucous or submucous sheath of the gastrointestinal tract. This condition clinically manifests with acute or chronic bleeding from the gastrointestinal tract. Typically the diagnosis is based on endoscopic findings and histological characteristics of the distorted vascular structures. Angiodysplasia is quite a common finding in elderly patients. However, the reasons for the anomaly observed with advancing age are yet to be revealed. CASE REPORT: The aim of this report is to highlight three cases of intestinal angiodysplasia histologically confirmed in patients at 47, 60 and 66 years of age. Histological examination using light microscopy revealed different in size and shape dilated, filled with blood vessels surrounded by oedematous, inflamed stroma in the mucosal and submucosal layer of the intestine. CONCLUSION: Angiodysplasia is considered to be the second most common cause of gastrointestinal bleeding. This makes an adequate histologically confirmed diagnosis of this anomaly crucial for a patient`s quality of life.

Assessing Readmissions for Gastrointestinal Bleeding in Patients With Left Ventricular Assist Devices Treated With Octreotide

Introduction: Left ventricular assist device (LVAD) implantation has been associated with a high rate of gastrointestinal bleeding (GIB) that results in costly hospital readmissions for monitoring, transfusions, and endoscopy. Angiodysplasia (AVM) is a common cause of GIB found in these patients. Our institution's heart failure (HF) team has attempted to use octreotide to treat obscure or refractory GIB secondary to AVM in LVAD recipients. We set out to assess the clinical outcomes and hospitalization frequency of these patients. Methods: Retrospective analysis of LVAD patients with one or more admissions to a single academic center for GIB and history of octreotide use (March 2012-November 2016). Patients identified in a HF database of LVAD patients hospitalized for GIB. Medication reconciliation records interrogated for octreotide orders. The hospitalization in which octreotide was initiated was defined as the index stay and used as a marker to compare data before and after therapy. Patients excluded if death occurred during index stay. Number of readmissions within days 30, 60, and 90 from discharge or last octreotide dose were assessed. Results: 128 patients were identified (17 met criteria; one excluded due to death). Among 16 patients (mean age 67.5±7.4, 4 females): one patient treated with only intramuscular (IM) octreotide (dose 20mg, every 4 weeks), 5 patients with only subcutaneous (SQ) injections (dose 50-100mcg, every 8-12 hours), and 10 patients with combination IM and SQ (similar ranges). Most common endoscopic results were AVMs (35.6%) and no findings (37.9%). Mean number of admissions were 2.43 ±2.78 before index stay and 1.75 ±2.3 afterward (P=0.45), not significantly different. However, time between admissions lengthened after octreotide therapy (88.9 ±122.4 vs 216.6 ±313.8 days; P<0.05). Average length of stay per admit shortened after therapy trending towards statistical significance (10.3 ±8.9 vs 7.0 ±5.0; P=0.06). Number of endoscopies performed (P=0.08), admit Hgb (P=0.47) and INR (P=0.89) were not changed by octreotide. Readmissions in 30 and 60 days following index stay decreased significantly (P<0.05), but not in 90 days (P=0.9). Conclusion: Our study reveals that octreotide therapy for GIB in LVAD patients can lengthen the intervals between admissions and lower readmissions for GIB in 30 and 60 days. Octreotide shows potential to improve clinical outcomes but results need to be validated in a prospective study.

A Rare Cause of Gastrointestinal Bleeding: Metastatic Renal Cell Carcinoma

This is a case of metastatic renal cell carcinoma to the small bowel as a cause of GI bleed. A 60-year-old man with known renal cell carcinoma metastatic to the lung s/p right nephrectomy, was admitted with anemia. He reported fatigue and melena for one week. He denied hematemesis, hematochezia, hematuria, epigastric pain, reflux symptoms, and did not use NSAIDs. Physical exam was notable for normal vital signs, conjunctival pallor, a soft non-tender abdomen, and rectal exam was negative for melena. Labs were significant for hemoglobin 6.8 (baseline 10), MCV 101, normal BUN, baseline creatinine 1.6. Upper endoscopy revealed a large ulcerated mass in the first portion of the duodenum with stigmata of recent bleeding. There were no additional abnormalities or sources for bleeding found during the procedure. Pathology from the mass confirmed metastatic renal cell carcinoma. The patient had a good response to blood transfusion and was discharged in stable condition. He underwent systemic therapy with ipilimumab and nivolumab. Hemoglobin remained stable without further GI bleeding. While malignancy is an uncommon cause of gastrointestinal bleeding (GIB) in the general population, it is the most common cause of GIB in oncologic patients (5% vs 23%). Patients with primary GI malignancies comprise a large proportion of those with tumor related bleeding. In contrast, those with malignancy outside of the GI tract are most likely to bleed from causes similar to that of the general population. In a retrospective study of 147 oncologic patients with an identified source of GIB, common sources of GIB in those with malignancies outside of the GI tract included ulcers, erosive disease, and varices. Only 10.9% percent of this group had malignancy related bleeding. A more recent study describing the epidemiology of GIB due to malignancy found that of the 71 GI bleeds due to tumors, only 5 cases (7%) were due to metastatic disease. Renal cell carcinoma is metastatic in 25-30% of patients at the time of diagnosis with common sites including the lung, liver, bone and brain. Metastatic disease to the small bowel is exceedingly rare, with only a few cases reported in the literature. Presenting symptoms are variable and can include abdominal pain, intussusception, obstruction, and GI bleed. Metastasis to the duodenum is thought to arise from primary tumors of the right kidney given the close proximity, as in our patient who underwent right nephrectomy.Figure: duodenal mass.Figure: duodenal mass.Figure: duodenal mass.

Novel Use of Thalidomide in Recurrent Gastrointestinal Tract Bleeding in Patients with Left Ventricular Assist Devices: A Case Series

Bleeding is an important and common complication of left ventricular assist devices (LVADs). One of the common causes of gastrointestinal bleeding is arteriovenous malformations. However, the source of bleeding is often hard to identify. Thalidomide is efficacious in treatment of gastrointestinal (GI) bleeding in non-LVAD patients. We report our experience of the use of thalidomide in the treatment of GI bleeding in four patients with LVAD. Four patients who had recurrent GI bleeding from May 2009 to December 2014 were started on thalidomide. All of them responded to treatment and had no further gastrointestinal bleeding while on thalidomide. One patient developed constipation, requiring thalidomide to be stopped. Another patient developed symptomatic neuropathy, that resolved with reduction of dosage. Thalidomide appears safe and efficacious in LVAD patients with recurrent gastrointestinal bleeding.

Characterization of gastrointestinal hemorrhage and prediction of mortality in Asian patients with alcoholic hepatitis.

Gastrointestinal bleeding (GIB) often accompanies alcoholic hepatitis (AH). The study aimed to investigate clinical characteristics of GIB in AH patients and to identify risk factors for mortality in AH patients with GIB. Data from 329 patients hospitalized with AH in a single center during 1999-2014 were retrospectively analyzed. Patients with AH were dichotomized into GIB and non-GIB groups. The GIB group was further divided into portal hypertensive bleeding (PHB) and non-PHB groups. Clinical characteristics and survival outcomes were compared between the groups. Risk factors for mortality were analyzed using Cox regression. Among the 329 AH patients, 132 experienced GIB at admission or during hospitalization. The most common cause of GIB was an esophageal varix. The GIB group had worse survival outcomes than the non-GIB group (log-rank test, P = 0.034). The PHB group had worse survival outcomes than the non-PHB group (log-rank test, P = 0.001). On multivariate analysis, alcohol consumption, ascites, encephalopathy, infection, Maddrey's discriminant function, and the model for end-stage liver disease (MELD) score independently predicted mortality in the entire AH cohort. The MELD score (hazard ratio, 1.085; 95% confidence interval, 1.052-1.120; P < 0.001) and PHB (hazard ratio, 2.162; 95% confidence interval, 1.021-4.577; P = 0.044) were significant prognosticators for patients with AH and GIB. The presence of PHB and a higher MELD score adversely affected survival in AH patients with GIB. Accordingly, prompt endoscopic examination for exploring the etiologies of GIB may alert physicians to predict the risk of death in AH patients with GIB.