Common Cause Of Gastrointestinal Bleeding Research Articles

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.

Cyanoacrylate to the Rescue: Successful Treatment of Duodenal Variceal Bleeding by Glue Injection

Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. However, the incidence is low and a good treatment method has not been well established yet. We have successfully treated a patient with duodenal variceal bleeding secondary to liver alcoholic cirrhosis after the patient was found to be a poor candidate for transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old male with a recently diagnosed alcoholic cirrhosis presented with hematemesis of 24 hours in duration, and acute post-hemorrhagic anemia. After resuscitation, the patient was taken for emergent upper endoscopy. Four columns of Grade 1-esophageal varices, which easily collapsed with insulfation and had no stigmata of recent bleed. A single 3cm duodenal varix with a single umbilication was seen in the second portion of the duodenum. The ampulla was situated distant from the varix. The varix was examined with a duodenoscope as well as EUS probe. Examination suggested that lesion was consistent with a vein. Thereafter, 4 cc of lipiodol and indermal was injected in 1 cc aliquots followed by 3 cc of sterile water. The varix was noted to be hard after the glue injections. Transient bleeding was seen from the varix, which was self-limited. Polyermized glue was seen to extruding from the umbilicated region of the varix. Retroflexion showed no further gastric varices (fundic or cardia). Follow up radiology demonstrated no migration of the cyanoacrylate injection. Duodenal variceal bleeding is not a common cause of gastrointestinal bleeding. It is important to always consider duodenal variceal bleeding in patients with portal hypertension. Although an effective treatment method has not been established yet, successful management of duodenal variceal bleeding can be expected by using glue injection.

Predictive Role of Admission Lactate Level in Critically Ill Patients with Acute Upper Gastrointestinal Bleeding

BackgroundThe predictive role of lactate in critically ill patients with acute upper gastrointestinal bleeding (UGIB) remains to be elucidated. ObjectiveThe primary objective of this study was to assess the value of lactate level on admission to predict in-hospital death in patients with UGIB admitted to the intensive care unit (ICU). The secondary objective was to assess whether lactate level adds predictive value to the clinical Rockall score in these patients. MethodsThis was a retrospective cohort study that included 133 patients with acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and presence of UGIB on admission to the ICU. ResultsMean age was 55.4 years old and 64.7% were male. The most common cause of gastrointestinal bleeding was peptic ulcer disease, followed by erosive esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level in survivors and nonsurvivors was 2.0 (interquartile range [IQR] 1.2–4.2 mmol/L) and 8.8 (IQR 3.4–13.3 mmol/L; p < 0.01), respectively. The receiver operating characteristic (ROC) area to predict in-hospital death for clinical Rockall score and lactate level (0.82) was significantly higher than the ROC area for the clinical Rockall score alone (0.69) (p < 0.01). ConclusionsIn patients admitted to the ICU with acute UGIB, lactate level on admission has a high sensitivity but low specificity for predicting in-hospital death. Lactate level adds to the predictive value of the clinical Rockall score. Given its high sensitivity, lactate level can be used in addition to other prediction tools to predict outcomes in patients with UGIB.

Gastrointestinal Bleeding due to Meckel's Diverticulum in an Elderly Patient

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract (1). It mostly occurs in children while it is also the most common cause of lower gastrointestinal bleeding in childhood. While the most common cause of gastrointestinal bleeding in adult patients is peptic ulcer, it is usually diverticulosis and angiodysplasia in older adults. In this report, we aim to present the case of an elderly adult patient who underwent operation due to acute lower gastrointestinal system (GIS) bleeding the etiology of which was determined to be Meckel's diverticulum. A sixty-five-year-old man was admitted to our emergency department with rectal bleeding. There was widespread abdominal tenderness with no defence or rebound on physical examination. We had fresh blood during the rectal examination. The hemoglobin level was 6 g/dl. In the colonoscopy, we observed that the entire colon was filled with blood but the source of bleeding could not be determined. We also failed to determine the source of bleeding in the upper gastrointestinal gastroscopy. Despite the blood transfusion the patient remained hemodynamically unstable and thus was taken to the operation room in emergency conditions. The exploration revealed a Meckel's diverticulum 80cm from the ileocecal valve. We observed fluid that could be related to the bleeding in the distal of the diverticula, in the ileum, and all over the colon lumen. The intraluminal section in the proximal of the diverticulum showed an externally usual picture. We opened the small intestine and Meckel's diverticulum with enterotomy and determined the active source of bleeding in the diverticulum. We then applied small bowel resection to include the diverticulosis followed by an end-to-end anastomosis. The patient returned to normal hemodynamically during the postoperative follow-up. The hematochezia stopped completely on the 4th postoperative day. The hemoglobin levels were stable as well. The patient was discharged in good health on postoperative day 6. Meckel's diverticulum is the most common cause of lower gastrointestinal bleeding in childhood. In adults, it usually causes mechanical intestinal obstruction. It should be kept in mind that Meckel's diverticulum may be the reason behind acute bleeding in adults and elderly patients while it may even cause acute lower gastrointestinal bleeding in the same patient groups (2). It will also be beneficial for surgeons and patients to remember that Meckel's diverticulum may result in GIS bleeding in older patients.

213 Comparative Effectiveness of Radiofrequency Ablation and Argon Plasma Coagulation for Treatment of Gastric Antral Vascular Ectasia: a Systematic Review and Meta-Analysis

Gastric antral vascular ectasia (GAVE), while a less common cause of gastrointestinal bleeding, may result in iron deficiency anemia and a requirement for frequent transfusion therapy. The current standard endoscopic treatment for GAVE is argon plasma coagulation (APC), though studies have shown mixed results to date. Recently, radiofrequency ablation (RFA) has emerged as an attractive alternative for the treatment of GAVE; however, data comparing the efficacy and tolerability of these 2 endoscopic modalities is lacking.

Unusual cause of massive upper gastrointestinal bleeding: a pancreatic arteriovenous malformation.

Upper gastrointestinal bleeding is one of the most common emergencies in gastroenterology. The common causes of the upper gastrointestinal bleeding include peptic ulcer disease, gastric erosive mucosal disease and portal hypertension. Gastrointestinal arteriovenous malformation is a less common cause of gastrointestinal bleeding and these arteriovenous malformation are most commonly located in the large and small intestine. Pancreatic arteriovenous malformation is a rare condition in which there is tumor-like formation or vascular anomaly built up via an aberrant bypass anastomosis of the arterial and venous systems in the pancreas. Splenic artery is most commonly involved (42%), followed by gastroduodenal artery (22%) and small pancreatic arteries (25%). Clinically it may present as gastrointestinal hemorrhage which is occasionally fatal. Other presentations are abdominal pain, pancreatitis, duodenal ulcer, jaundice, and portal hypertension. We present a rare case of pancreatic arteriovenous malformation presenting as massive upper gastrointestinal bleeding. Since early surgery is a life saving treatment for such cases, hence, a high index of suspicion should be maintained especially when massive bleeding is detected from the medial wall of second part of duodenum.

Increased Resource Utilization in Left Ventricular Assist Device Patients with Gastrointestinal Bleeding Compared to Medical Controls

There is significant interest in the cost of left ventricular assist device (LVAD) therapy for treatment of end-stage heart failure. However, little is known about the costs of caring for gastrointestinal (GI) bleeding after LVAD, a common complication. Resource utilization for evaluation and management of GI bleeding patients with an LVAD is higher than in a group of medical inpatients without LVAD. Consecutive patients who were hospitalized for GI bleeding at our medical center from 2006 to 2011 were identified. Procedures, blood product transfusion, length of stay and direct hospital cost represent resource utilization. Of 670 consecutive patients admitted for GI bleeding, 24 were those with an LVAD implant. This LVAD group tended to require higher numbers of diagnostic and therapeutic procedures (3 vs. 1; p=0.02) and red blood cell transfusion (75% vs. 49%; p=0.001) compared to those in the non-LVAD group. Furthermore, LVAD patients had longer length of hospital stay (7 vs. 2 days; p<0.0001) and greater direct admission cost ($9,765 vs. $4,594; p<0.0001) (Table). Further evaluation of the LVAD group found that dominant expenses were room and board charges ($2,961, 30%) and procedures ($2,296, 24%). Arteriovenous malformation (AVM) was the most common cause of GI bleeding (n=16, 67%) in patients with LVAD. This patient subgroup required more red blood cell transfusion (94%) compared to 38% of LVAD patients with non-AVM bleeding (p=0.003). Furthermore, AVM bleeders were likely to experience longer hospital stay (8 vs. 4 days; p=0.53) and accrued higher hospital expenses ($11,101 vs. $4,919; p=0.13), although these differences did not reach statistical significance (Table). The cost of management of GI bleeding following LVAD is higher than in a group of non-LVAD medical controls, and is particularly high for the subgroup with bleeding from AVM.Table (287)Procedures, Blood Product Transfusion, Length of Stay and Direct Hospital Cost in Study patients and LVAD Patients with AVM bleeding with non-AVM BleedingNon LVAD patients n=646LVAD patients n=24P valueaAVM bleeding n=16Non-AVM BleedingP value**Procedures0.9±0.73.3±2.00.022.0±1.716±0.90.63PRC, %49750.00194380.003LOS, days2[3-5]7[2-9]<0.00018[5.9]4[2-9]0.53Direct cost, $4,634[2,611-8,177]9,765[5,563-16,693]<0.000111,101[6,671-17,544]4,919[3,601-7,016]0.13*Comparison between patients with and without LVAD.**Comparison between patients with AVM and non-AVM bleeding.Abbreviations:AVM=arteriovenous malformation; FFP=fresh frozen plasma; LOS=length of stay, LVAD=left ventricular assist devices; RBC=red blood cell. Open table in a new tab

Letter: the irony of oral iron – not an underdog for post‐gastrointestinal bleeding anaemia

Bager et al.1 reported a randomised controlled trial comparing oral (100 mg twice daily ferrous sulphate for 3 months) or intravenous (1000 mg ferric carboxymaltose, single-dose infusion) iron supplementation and placebo for anaemia after nonvariceal upper gastrointestinal (GI) bleeding. Peptic ulcers were the most common sources of bleeding (70%). Patients in the placebo group prematurely discontinued the study medication because 25% of patients were still anaemic at the end of the 13-week follow-up period and, therefore, required rescue therapy. The study shows that either oral or intravenous were significantly more effective than placebo to overcome anaemia, and iron stores were more effectively replenished with intravenous iron when compared with oral. On reading the abstract, one may tend to think the results were foreseeable, but this study deserves a higher consideration. The first important conclusion we can draw is that no patient should be discharged after upper GI bleeding without iron supplementation whenever anaemia is present. Although logical, this protocol is not applied in routine daily practice, and had been seldom addressed in the literature. Intravenous iron did not lead to better results at week 1, 4 or 13 when compared with oral supplementation, even though only 56% had complete adherence to oral therapy. At the very least, these findings seem counterintuitive. Whether the efficacy of oral iron was related to higher intestinal absorption because of few patients on proton pump inhibitor therapy (17%), even though peptic ulcer was the most common cause of GI bleeding, remains unknown. In addition, oral iron is notably cheaper. This study highlights the importance of iron supplementation after post-bleeding anaemia, with a clear cost-effective advantage for oral administration, but with similar results for the intravenous route in case of oral iron intolerance. The results are especially relevant given that restrictive transfusion strategies for upper GI bleeding (transfusion when haemoglobin level <7 g/dL) have been associated with better outcomes for nonvariceal upper GI bleeding2. In this context, most patients will be expected to be anaemic at discharge, and this study sheds light on the optimal short-term clinical management regarding iron supplementation. Declaration of personal and funding interests: None.

Common Causes of Gastrointestinal Bleeding Diagnosed by Endoscopy/Colonoscopy at Hospital Sultanah Bahiyah, Alor Setar, Malaysia

Acute gastro-intestinal bleeding is potentially a life-threatening abdominal emergency and has been a common cause of hospitalization.1 It is always fascinating as well as informative to know the various causes of upper and lower gastro-intestinal bleeding prevalent in a particular region. It helps us in early diagnosis and prompt management of the case in thatarea. Keeping this in mind we started a project to see the common causes of gastro-intestinal bleeding as confirmed by direct endoscopy methods in patients admitted in Hospital Sultanah Bahiyah, Alor Setar, Malaysia between

Management of portal hypertensive gastropathy and other bleeding.

A major cause of cirrhosis related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Less common causes of gastrointestinal bleeding are peptic ulcers, malignancy, angiodysplasia, etc. Upper gastrointestinal bleeding has been classified according to the presence of a variceal or non-variceal bleeding. Although non-variceal gastrointestinal bleeding is not common in cirrhotic patients, gastroduodenal ulcers may develop as often as non-cirrhotic patients. Ulcers in cirrhotic patients may be more severe and less frequently associated with chronic intake of non-steroidal anti-inflammatory drugs, and may require more frequently endoscopic treatment. Portal hypertensive gastropathy (PHG) refers to changes in the mucosa of the stomach in patients with portal hypertension. Patients with portal hypertension may experience bleeding from the stomach, and pharmacologic or radiologic interventional procedure may be useful in preventing re-bleeding from PHG. Gastric antral vascular ectasia (GAVE) seems to be different disease entity from PHG, and endoscopic ablation can be the first-line treatment.

Angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

Angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.

An Unusual Cause of Gastrointestinal Bleeding: Gastric Fundic Gland Polyps

The most usual causes of iron deficiency anemia are related to the digestive disease: acute or chronic blood loss (due to cancer or polyp of colon or stomach, peptic ulcer, nonsteroidal anti-inflammatory drugs use, inflammatory bowel disease, vascular lesions) or reduced iron absorption (in celiac disease, small bowel bacterial overgrowth, Whipple’s disease, lymphangiectasia, gastrectomy and gastric atrophy, gut resection or bypass). Fundic gland polyps are not common causes of gastrointestinal bleeding, but in this case we were able to proof that the bleeding was the result of these unusual large polyps. What is reported here is a case of occult gastrointestinal bleeding caused by torsion of sessile polyps in the patient who received chronic low-dose acetylsalicylic acid therapy. The patient was successfully treated with endoscopic resection of largest polyps. This report could be useful in cases of sporadic fundic gland polyps and unrecognized cause of bleeding or iron deficiency anemia; especially in instances in which anticoagulant or low-dose aspirin therapies were applied.

Reply

Thank you for your comments. Gastrointestinal bleeding (GIB) is not rare in patients with chronic renal failure. The common causes of GIB in these patients include gastroduodenal ulcers, erosive esophagitis/gastritis/duodenitis, and angiodysplasia (angioectasias) bleeding. In Taiwan, only one tenth of about 45,000 chronic renal failure patients underwent regular peritoneal dialysis (PD); others underwent hemodialysis (HD). Using the same database and study design (CMAJ 2011;183:E1345–E1351; Am J Med 2013;126:264.e25–32), we analyzed data from 2239 PD patients, 2328 HD patients, 2267 chronic kidney disease (CKD) patients, and 4574 controls with age and gender matching in a 1:1:1:2 ratio. Cox proportional hazard regression analysis showed that CKD (hazard ratio [HR], 3.99; 95% confidence interval [CI], 2.24–7.13) had similar risk of peptic ulcer bleeding with PD (HR, 3.71; 95% CI, 2.00–6.87). HD was most risky (HR, 11.96; 95% CI, 7.04–20.31). Regarding the issue of nonpeptic ulcer, nonvariceal bleeding, Cox regression analysis also showed that CKD (HR, 3.01; 95% CI, 1.84–6.23) had similar HR of nonpeptic ulcer, nonvariceal bleeding with PD (HR, 3.13; 95% CI, 1.87–6.41). HD also carried a greater risk (HR, 10.26; 95% CI, 6.14–17.55) than CKD and PD. In fact, HD patients are older, have worse self-care ability and performance status, and have more comorbidities than PD patients. Moreover, the use of heparin during HD seems to exaggerate bleeding risk in patients with an existing GI lesion. In facing chronic renal failure patients with risk of GIB, PD rather than HD may be a strategy to decrease GIB. Thank you for your comments. Gastrointestinal bleeding (GIB) is not rare in patients with chronic renal failure. The common causes of GIB in these patients include gastroduodenal ulcers, erosive esophagitis/gastritis/duodenitis, and angiodysplasia (angioectasias) bleeding. In Taiwan, only one tenth of about 45,000 chronic renal failure patients underwent regular peritoneal dialysis (PD); others underwent hemodialysis (HD). Using the same database and study design (CMAJ 2011;183:E1345–E1351; Am J Med 2013;126:264.e25–32), we analyzed data from 2239 PD patients, 2328 HD patients, 2267 chronic kidney disease (CKD) patients, and 4574 controls with age and gender matching in a 1:1:1:2 ratio. Cox proportional hazard regression analysis showed that CKD (hazard ratio [HR], 3.99; 95% confidence interval [CI], 2.24–7.13) had similar risk of peptic ulcer bleeding with PD (HR, 3.71; 95% CI, 2.00–6.87). HD was most risky (HR, 11.96; 95% CI, 7.04–20.31). Regarding the issue of nonpeptic ulcer, nonvariceal bleeding, Cox regression analysis also showed that CKD (HR, 3.01; 95% CI, 1.84–6.23) had similar HR of nonpeptic ulcer, nonvariceal bleeding with PD (HR, 3.13; 95% CI, 1.87–6.41). HD also carried a greater risk (HR, 10.26; 95% CI, 6.14–17.55) than CKD and PD. In fact, HD patients are older, have worse self-care ability and performance status, and have more comorbidities than PD patients. Moreover, the use of heparin during HD seems to exaggerate bleeding risk in patients with an existing GI lesion. In facing chronic renal failure patients with risk of GIB, PD rather than HD may be a strategy to decrease GIB. Causes of Gastrointestinal Hemorrhage in Patients with Chronic Renal FailureGastroenterologyVol. 145Issue 4PreviewLuo JC, Leu HB, Hou MC, et al. Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients. Am J Med 2013;126:e25–32. Full-Text PDF

Gastrointestinale Blutungen im fortgeschrittenen Lebensalter

Peptic ulcer disease is a common cause of gastrointestinal bleeding, independent of the patient's age. With advancing age, an increase of lower gastrointestinal bleeding (diverticula, angiodysplasia) has been observed. The administration of non-steroidal anti-inflammatory drugs and aspirin is an important risk factor for upper and lower gastrointestinal bleeding, thus in patients aged 65 years and more a concomitant therapy with proton pump inhibitors is recommended in order to prevent ulcer bleeding. Even in very old individuals endoscopy should be used for the diagnosis of gastrointestinal bleeding, providing the opportunity for definite endoscopic bleeding therapy. In elderly patients with comorbidities and recurrent bleeding after endoscopic therapy or continuous blood loss, surgery or transarterial embolisation should be considered in good time.

Colorectal polyps in childhood

Colorectal polyps are a common cause of gastrointestinal bleeding in children. This review updates the information on colorectal polyps and summarizes the recent advances in genetics, diagnosis, and treatment of polyps in the large intestine. A review of recent literature regarding colorectal polyps demonstrates an estimated detected prevalence of 6.1% overall and 12.0% among those with lower gastrointestinal bleeding during pediatric colonoscopy. Non-Caucasian races (e.g., black and Hispanic) are at higher risk for colorectal polyps in childhood. Recent data show juvenile polyps may recur in approximately 45% of children with multiple polyps and 17% of children with solitary polyps. A clinical trial showed that celecoxib, a cyclooxygenase (COX)-2 inhibitor, significantly reduced the number of colorectal polyps in children with familial adenomatous polyposis (FAP). Ethical challenges related to genetic tests for FAP have been newly examined. The utility of novel endoscopic techniques (e.g., enteroscopy) in Peutz-Jeghers Syndrome to prevent intussusception have been newly described. Although colorectal polyps in children are generally benign and easily removed, careful clinical evaluation and ongoing research are needed to identify the small proportion of children at risk for cancer. The current paradigm of using the polyp number at presentation as a primary determinant of subsequent surveillance may be inadequate for many patients.

Hepatic artery aneurysm rupture presenting as an upper GI bleed: A case report

Hepatic artery aneurysms (HAAs) are a rare but a clinically important phenomenon. The natural history of HAA is poorly understood, however, it is suggested that mortality following spontaneous rupture is as high as 40%. Statistics such as these sanction an aggressive approach to the management of the HAA, whenever detected. We present a case of a 42-year-old old male who presented with two episodes of hematemesis. He underwent esophagogastroduodenoscopy (EGD) twice with control of bleeding, only to rebleed, and become unstable. A computed tomography (CT) angiogram demonstrated a hepatic artery aneurysm, which appeared to involve the duodenal bulb. The patient was taken emergently to the operating room for surgical repair of the hepatic artery aneurysm. Hepatic artery aneurysms are a rare entity and even less common cause of gastro-intestinal bleeding.

Endoscopic Findings and Clinical Outcomes in Ventricular Assist Device Recipients with Gastrointestinal Bleeding

Gastrointestinal bleeding (GIB) is an important clinical problem in recipients of ventricular assist devices (VAD), although data pertaining to the endoscopic evaluation and management of this complication are limited in the medical literature. We sought to identify the most common endoscopic findings in VAD recipients with GIB, and to better define the diagnostic and therapeutic utility of endosopy for this patient population. Twenty-six subjects with VAD and overt GIB were retrospectively identified. Clinical and endoscopic data were abstracted for each subject on to standardized forms in duplicate and independent fashion. Raw data and descriptive statistics were reported. Non-peptic vascular lesions were the most common cause of GIB. A definitive cause of bleeding was identified by endoscopy in almost 60% of subjects. Endoscopic hemostasis was achieved in 14/15 patients in whom bleeding did not stop spontaneously. Rebleeding occurred in 50% of subjects and was successfully retreated or stopped spontaneously in all cases. Colonoscopy did not establish a definitive diagnosis or deliver hemostatic therapy in any case. Vascular malformations account for the overwhelming majority of bleeding lesions in VAD patients with GIB. Endoscopy seems to be a safe and effective tool for diagnosing, risk stratifying, and treating this patient population, although multiple endoscopies may be necessary before therapeutic success, and the incidence of rebleeding is high. A prospective multi-center registry is necessary to establish evidence-based management algorithms for VAD recipients with GIB.

High Contrast Imaging Improves the Visualization and Detection of Gastrointestinal Vascular Ectasias

Introduction: Vascular Ectasia (VE) of the gastrointestinal tract are a common cause of gastrointestinal bleeding, but can be difficult to detect during endoscopy due to factors including blood pressure, blood volume, hydration and drugs such as meperidine. The opiate antagonist, naloxone has been used to unmask otherwise unseen VE. New endoscopic imaging techniques have been developed to produce high contrast images (HCI) with the aim of enhancing the visualization of early neoplastic lesions. These may have additional value in detecting VE at endoscopy. Methods: We used the high contrast settings on endoscopes to visualize VE in patients undergoing elective endoscopy for recent gastrointestinal bleeding. The Fujinon EPX-4400 multi- band system was used in 4 patients; it produces an image using electronically selected wavelengths from blue, green and red components of light reflected from the mucosa. The system has 10 built in settings of which preset 4 (blue light at 405 nm, green light at 500 nm, red light at 520 nm) was used as it displays blood vessels as dark purple- black structures that contrast strongly against a brighter mucosa. We also used the Olympus narrow band system in one patient, which provides an image with a bluish hue, but at fixed wavelengths. VE were sought on forward advancement of the endoscope, to minimize trauma and suction artifacts. The imaging modes in both systems were switched between standard endoscopy and HCI in each field of view prior to advancing to the next area. Results: In 2 EGDs, 8 VE were seen with standard endoscopy, but 15 were found with HCI. In 3 colonoscopies, 3 VE were seen with standard endoscopy, but 8 were found with HCI. The VE that were visible under white light endoscopy became far more prominent under HCI. Overall, HCI revealed 4.4 ± 1.3 VE per procedure, and standard endoscopy 2.2 ± 1.0 VE per procedure; (p = 0.01). Conclusions: These early findings indicate the potential utility of high contrast imaging for the detection of VE in the gastrointestinal tract. The images are composed using reflected light with wavelengths that are well absorbed by hemoglobin in blood vessels, which are thus displayed as dark structures that contrast with the more reflective, brighter mucosal surface. The resulting HCI help facilitate imaging of vasculature and may unmask otherwise unseen VE.

Obscure bleeding in the gastrointestinal tract

Obscure bleeding is bleeding of unknown origin that persists or recurs after initial colonoscopy and endoscopy of the upper gastrointestinal tract. Obscure bleeding can have two forms: obscure occult bleeding (as maifest by recurrent iron-deficiency anaemia, faecal occult blood tests) and obscure overt bleeding (with recurrent passage of overt blood). Both forms can present diagnostic and management difficulties. This contribution outlines the causes and management of obscure gastrointestinal bleeding. It highlights the problems and accuracy of the various diagnostic techniques to localize obscure bleeding, with particular reference to bleeding of small-bowel origin and angiodysplasia. Patients with obscure gastrointestinal bleeding often require aggressive investigation to identify the source of bleeding. Any common cause of gastrointestinal bleeding can fall into the ‘obscure’ category if it is missed initially. Repeating initial investigations is sensible and has a definite diagnostic yield. Localization provides the opportunity for endoscopic treatment, thereby avoiding the morbidity and mortality associated with surgery in patients who often have significant comorbidity. Localization of the bleeding pre- or perioperatively also greatly reduces the risk of rebleeding if surgery is required. Medical therapy is a limited option.

Management principles of gastrointestinal bleeding

There is now a multitude of technologic and pharmacologic options available to clinicians caring for patients with gastrointestinal (GI) bleeding; however, drugs and technology are no substitute for understanding and properly executing the basic management principles of GI bleeding. This article focuses on the most common causes of GI bleeding and emphasizes the importance of the primary care provider's role in the management of these patients. Also, by answering questions we are commonly asked as gastroenterology consultants, we hope to provide insight into current diagnostic and therapeutic options and the most appropriate use of these options.