Etiology Of Bleeding Research Articles

Non-tumor Related Gastrointestinal Bleeding in U.S. National Hospitalized Cancer Patients

Introduction: Gastrointestinal bleeding (GI) is a known cause of morbidity and mortality. Cancer patients are at a higher risk of bleeding due to bone marrow suppression after chemotherapy, radiation therapy, or metastatic involvement of the bone marrow. The etiologies of bleeding are comparable to that seen in the general population. We aimed to determine and compare the etiologies of GI bleeding in cancer vs non-cancer hospitalized patients. Methods: We used the national inpatient sample (NIS) for the year 2008 to determine etiologies of GI bleed in cancer patients including those with metastatic disease. We used ICD-9-CM codes to extract data of hospitalized individuals in the U.S. for the year 2008. Logistic regression analysis was used to determine statistical significance between the cancer and non-cancer groups for various characteristics and etiologies of bleeding at 95% confidence interval (CI). Results: There were 119,328 inpatient hospitalizations for overt GI bleeding which were divided into cancer and non-cancer inpatient groups and we compared patient demographics, insurance status, type and size of the hospital between the 2 groups (Table 1). Cancer group consisted of significantly higher number of older males (p=<0.001) and had more number of co-morbidities (p=<0.001), than non-cancer group. Cancer group had significantly higher number of cases of leukopenia and thrombocytopenia than the non-cancer group (p=<0.001) and had higher in-hospital mortality (p=<0.001). The prevalence of etiologies of GI bleed among cancer and non-cancer is described in table. While non-malignant causes of GI bleed were significantly higher among non-cancer patients, the prevalence of diverticulosis, hemorrhoids, and non-radiation colitis differed marginally between the 2 groups.Table 1: Comparison of Etiologies of Gastrointestinal Bleeding Between Cancer and Non-cancer GroupsConclusion: Cancer patients who present with GI bleeding tend to be older males with higher incidence of leukopenia and thrombocytopenia. The prevalence of non-tumor related causes of GI bleeding is appreciably higher among patients with cancers and warrants appropriate work-up to treat reversible etiologies as amongst non-cancer population.

Overt Gastrointestinal Bleeding and Predictors of Rebleeding in Hematologic Malignancies

Introduction: GI bleeding in patients with hematologic malignancies is not well studied. These patients tend to have lower platelet counts and/or dysfunctional platelets which are strong predisposing factors for bleeding distinguishing them from other groups. We aim to determine the various etiologies for GI bleeding and predictors of rebleeding in this group of patients. Methods: We performed a retrospective chart review of all individuals who underwent EGD and colonoscopy for overt bleeding between 2009 to 2011, at our institution. We studied the etiologies of GI bleeding and the incidence and risk factors for rebleeding among patients with hematologic malignancies. The study population was followed for rebleeding after their index bleeding episode. The predictors of rebleeding were determined using competing risk regression with death as a competing event. Results: The study population consisted of 79 patients with an index bleed, of which 50 underwent EGD and 44 underwent colonoscopy (15 had both). Amongst these, 13 (17%) had hematemesis, 31 (39%) had melena and 35 (44%) had hematochezia at presentation. The mean age of the patients was 61 years [58-64 at 95% CI], male:female ratio% was 57:43 and 72% were Caucasians. There were 40 patients with leukemia (51%), 28 with lymphoma (35%) and 11 with multiple myeloma (14%). The etiologies for bleeding have been described in tables 1 and 2. The median follow up time was 7.5 months (0.3 - 55.3) during which 16 patients had a rebleeding episode. The incidence of rebleeding was 1.2% [0.7-1.9 at 95% CI] per patient month. Patients with multiple myeloma were 3.5 times more likely to rebleed after adjusting for demographics, platelet count, INR and WBC count. Conclusion: In patients with hematologic malignancies, the presence of multiple myeloma and with underlying thrombocytopenia increases the risk of recurrent GI bleeding.Table 1: Etiology of Overt Gastrointestinal Bleeding Among Patients With Primary Hematologic Malignancies Who Underwent EGDTable 2: Etiology of Overt Gastrointestinal Bleeding Among Patients With Primary Hematologic Malignancies Who Underwent Colonoscopy

Porto-Arterial Fistula Creation as a Complication of TIPS Procedure Causing Occult GI Bleeding

Introduction: Arterio-venous fistulas are abnormal connections of the portal vein to the hepatic artery. These entities are often a result of congenital malformations. After an extensive literature search, there have been no reported cases of portal vein-hepatic artery fistula formations after transjugular intrahepatic portosystemic shunt (TIPS) procedure causing GI bleeding. We are reporting the first known case of a porto-arterial fistula post-TIPS procedure causing GI bleeding. The patient is a 55-year-old male with a past medical history of hepatitis C cirrhosis with hepatocellular carcinoma and prior esophageal varices who presented with altered mental status. Labs on admission showed: Alb 1.5, TB 3.3, DB 0.9, AST 57, ALP 144, ALT 32, Na 134, K 5.3, BUN 23, Cr 1.2, H/H 10.8/32.0, Plt 87, and INR 1.9. The patient was treated for acute hepatic encephalopathy with lactulose and rifaximin and his mental status returned to baseline by hospital day 2. On hospital day 8, the patient became hypotensive and had episodes of hematemesis. An EGD was performed that revealed 4 large columns of esophageal varices, 1 with active bleeding. Band ligation was performed with 2 bands placed, but the patient continued to bleed and hemostasis was achieved after sclerotherapy was performed. The patient was then planned for an elective TIPS placement. On hospital day 19, a TIPS was placed without any immediate complications. On hospital day 22, the patient again had hematemesis and a second EGD was performed which revealed blood in the duodenum. A duodenoscope was inserted and blood was seen coming from the ampulla. A celiac angiogram was performed which revealed an arteriovenous fistula between the portal vein and the left hepatic artery. Subsequent embolization was performed. On hospital day 24, the patient expired. TIPS are placed to reduce portal systemic hypertension. TIPS are performed at many tertiary centers and have become the treatment of choice for recurrent variceal bleeding and refractory ascites. Common complications of TIPS include abdominal cavity hemorrhage, puncture of the biliary tract, puncture of the gallbladder, and subcapsular hematoma of the liver. To our knowledge, this is the first reported case of an arteriovenous fistula formation between the portal vein and hepatic artery post-TIPS procedure causing severe GI bleeding. This etiology of GI bleeding should be considered in the differential diagnosis in a patient who is experiencing GI bleeding post TIPS placement.Figure 1

Aortoesophageal Fistula

Introduction: A 83-year-old man with past medical history significant for non-small cell lung cancer in remission status post-surgical resection 9 years ago presented with hematemesis. Aortoenteric fistula is an uncommon etiology of gastrointestinal bleeding. Considering the most common site for aortoenteric fistulas is the third or fourth portion of the duodenum, aortoesophageal fistulas are rarer, representing less than 10% of aortoenteric fistula cases. In the U.S., the most frequent clinical setting where primary aortoesophageal fistulas are observed is the expansion of thoracic aortic aneurysms. Secondary causes include aortic graft complications (51% cases), ingested foreign bodies (19% cases), infiltrating esophageal neoplasms, esophageal ulcerations, trauma, and mediastinal radiation therapy. First described by Chiari in 1914, characteristic symptoms include mid thoracic pain, sentinel upper arterial hemorrhage, and rapid exsanguination. CT scanning is often an adequate diagnostic modality revealing aortic fistulas, phlegmons and active extravasation (Figure 2). Endoscopy may reveal a graft, an ulcer with adherent clot, or an extrinsic pulsatile mass (Figure 1). A recent case review recommended urgent management of the aortic tear with endovascular aortic repair (EVAR) and subtotal esophageal resection followed by gastroesophageal reconstruction. Previous literature has suggested a mortality rate of approximately 40% with surgical intervention and a mortality rate approaching 100% without intervention. Though rarely seen, it is important to consider aortoesophageal fistulas in cases of gastrointestinal bleeding, particularly in the presence of aortic aneurysms.Figure 2Figure 1

Interesting Case of “Downhill” Varices

Introduction: Here we describe a case of a 34-year-old gentleman with an extensive past medical history including but not limited to ERSD on hemodialysis, SVC syndrome, recent left femoral neck fracture s/p total hip arthoplasty on coumadin for post-operative DVT prophylaxis who presented with massive hematochezia and was noted to have an incidental finding of “downhill varices.” Patient had massive hematochezia at admission with unstable hemodynamics. His physical exam was notable for facial edema and mild diffuse abdominal tenderness. His labs revealed acute anemia and a therapeutic INR at 2.66. After adequate resuscitation, he underwent emergent endoscopy. EGD showed extensive esophageal varices extending from the proximal to the distal esophagus without active / recent stigmata of bleeding and no evidence of blood in the stomach or duodenum. Patient had persistent hematochezia during the endoscopy and a follow-up sigmoidoscopy was limited due to presence of frank blood. Due to persistent unstable bleeding, patient went to the OR for exploration and underwent a subtotal colectomy with end ileostomy. Pathology revealed ulceration in the cecum and ascending colon consistent with ischemic colitis. He did not have any further episodes of bleeding after the surgery. While the etiology of the gastrointestinal bleed in this case was ischemic colitis, the finding of varices on endoscopy was unexpected and intriguing. He did not have a known history of cirrhosis or non-cirrhotic portal hypertension and subsequent work-up for these etiologies was also unrevealing. He did however have a known history of superior venacaval (SVC) thrombosis which is a rare but known cause for esophageal varices. These varices differ from the “uphill varices” in etiology, clinical behavior and management. These varices develop when obstruction in the SVC, forces blood back into the right atrium via collateral mediastinal pathways to the inferior vena cava, causing a retrograde direction of blood flow rather than as a result of portal hypertension wherein blood is forced into the inferior vena caval system (1). These varices are a rare cause of variceal bleeding (<0.1% of all acute esophageal variceal bleeds). However when they do bleed, treatment includes treatment of the underlying cause of vascular obstruction and “proximal” rather than “distal” banding in the setting of active hemorrhage. There is no role for beta-blockage for primary prophylaxis in this case.

Hemosuccus Pancreaticus: A Rare Cause Of GI Bleed

Introduction: Hemosuccus pancreaticus, a rare etiology of upper gastrointestinal bleeding, is bleeding from the papilla of Vater through the pancreatic duct into the duodenum. Case Report: A 64-year-old man with history of chronic pancreatitis presented with epigastric abdominal pain of 2 weeks’ duration. Patient underwent a CT scan, which showed partially occluding thrombus of the confluence of the superior mesenteric vein and splenic vein along with changes of chronic pancreatitis. Due to drop in hemoglobin while in hospital, patient underwent red cell tag study, which was positive for bleeding with activity at second portion of duodenum. Patient later underwent EGD showing periampullary area with oozing of blood without any definitive localized lesion. For further evaluation of periampullary area, he had EGD with side-viewing duodenoscope, which confirmed the finding of blood oozing from the ampula. Mesenteric angiogram showed a 1.9-cm splenic artery pseudoaneurysm and minimal intimal irregularity and active extravasation from the inferior pancreaticoduodenal artery. Patient had splenic artery aneurysm coiling, which took care of his gastrointestinal bleeding. Discussion: Hemosuccus pancreaticus is rare entity and often difficult to diagnose. Multiple etiologies can be considered as a culprit, with the most common one being arterial pseudoaneurysm formation secondary to chronic pancreatitis. In patient with known pancreatic disease who presents with upper GI bleeding and abdominal pain, upper endoscopy or appropriate radiological procedure can help to establish accurate diagnosis. Angiographic embolization and surgery are the options for the management and transcatheter intervention is the treatment of choice for the clinically stable patients. Additional innovative treatments have been discussed in literature, but more studies will be needed to confirm the safety and therapeutic effectiveness of those treatment options.

UGI Bleeding in the AIDS Patient: Not Your Usual Ulcer

Introduction: Gastrointestinal Kaposi’s sarcoma (KS) is an entity that is often missed as a possible etiology of upper gastrointestinal bleeding in immunocompromised patients. We present a case of upper gastrointestinal tract bleeding from Kaposi’s sarcoma lesions in the stomach. Case Report: A 45-year-old man with Hx of AIDS (CD4 9) on HAART, ESRD on dialysis, HTN, CHF, chronic HBV, left internal jugular vein thrombus on warfarin, presented with altered mental status. A month prior to presentation, he was evaluated for chronic diarrhea and colonoscopy at that time was grossly normal with normal mucosal biopsies. On admission, the patient’s labs were significant for leukocytosis with bandemia and INR of 5.1. The patient was started on broad spectrum antibiotics. CT showed circumferential thickening of the whole colon, compatible with pancolitis. C difficile GDH antigen was positive and he was started on metronidazole. Subsequently, he developed melena with dark red clots, worsening mental status, and sepsis. Hb dropped from 9 gm on admission to 3.6 gm. EGD was performed and showed serpiginous, bulging, erythematous lesions of varying size/shape throughout the entire stomach. The lesions were friable and oozing moderate amounts of blood. Multiple biopsies were taken. Pathology showed mild chronic inflammation, negative for intestinal metaplasia or H. pylori, and no evidence of Kaposi’s sarcoma. Due to strong suspicion for KS, repeat EGD with deeper biopsies was performed. The clinical case was discussed with pathology department, and at this time, biopsies revealed Kaposi’s sarcoma with small focus of abnormal endothelial lined spaces with atypical endothelial cells positive for HHV8, indicative of KS. Upon second review, analysis of the previous pathology specimens also revealed KS due to a strong suspicion. Discussion: Kaposi’s sarcoma is the most common tumor among HIV infected individuals. The HIVinduced damage of the mucosa-associated immune system (decreased CD4cells in lamina propria) leads to more opportunistic infections and the development of malignant tumors. Although most cases of gastrointestinal KS are asymptomatic, advanced lesions may occasionally result in severe and life-threatening hemorrhage. Due to tumor growth in the submucosa, biopsies are diagnostic less than 25% of the time. In the setting of strong clinical suspicion for Kaposi’s, this case illustrates that multiple biopsies and deeper biopsies may be needed to establish the diagnosis, as well as the importance of discussing the clinical suspicion of a lesion with the pathology team. KS should always be considered as a strong differential diagnosis in the lesions of the gastrointestinal tract in an immunocompromised host.

A Risk Scoring System to Predict In-hospital Mortality in Patients With Cirrhosis Presenting With Upper Gastrointestinal Bleeding

We aimed to develop a simple and practical risk scoring system to predict in-hospital mortality in cirrhotics presenting with upper gastrointestinal (GI) bleeding. Extensive clinical data were captured in patients with documented cirrhosis who underwent endoscopic evaluation for upper GI bleeding between January 1, 2003 and June 30, 2011 at Parkland Memorial Hospital. Predictors of mortality were identified by multivariate regression analysis. A total of 884 patients with cirrhosis admitted for upper GI bleeding were identified; 809 patients survived and 75 died (8.4%). The etiology of bleeding was similar in both groups, with bleeding attributed to esophageal varices in 59% of survivors and 60% of non-survivors (ulcer disease and other etiologies of bleeding accounted for the other causes of bleeding). Mortality was 8.6% and 8.3% in patients with variceal bleeding and nonvariceal bleeding, respectively. While survivors and those who died were similarly matched with regard to gender, age, ethnicity and etiology of cirrhosis, patients who died had lower systolic blood pressures, higher pulse rates and lower mean arterial pressures at admission than patients who survived. Non-survivors were more likely to be Childs C (61% vs. 19%, P<0.001). Multivariate regression analysis identified the following 4 predictors of in-hospital mortality: use of vasoactive pressors, number of packed red blood cells transfused, model for end-stage liver disease (MELD) score, and serum albumin. A receiver operating characteristic curve including these 4 variables yielded an area under the receiver operating characteristic (AUROC) curve of 0.94 (95% confidence interval, 0.91-0.98). Classification and Regression Tree analysis yielded similar results, identifying vasoactive pressors and then MELD>21 as the most important decision nodes for predicting death. By comparison, using the Rockall scoring system in the same patients, the AUROC curve was 0.70 (95% confidence interval, 0.64-0.76 and the comparison of the University of Texas Southwestern model to the Rockall model revealed P<0.0001). A validation set comprised of 150 unique admissions between July 1, 2011 and July 31, 2012, had an AUROC of 0.92, and the outcomes of 97% of the subjects in this set were accurately predicted by the risk score model. Use of vasoactive agents, packed red blood cell transfusion, albumin, and MELD score were highly predictive of in-hospital mortality in cirrhotics presenting with upper GI bleeding. These variables were used to formulate a clinical risk scoring system for in-hospital mortality, which is available at: http://medweb.musc.edu/LogisticModelPredictor.

What to do when she’s bleeding through

This article reviews the current understanding and management of abnormal uterine bleeding (AUB) in adolescents. The readers will learn a practical approach to the evaluation and treatment of mild-to-severe uterine bleeding. In 2011, a new classification system was proposed to standardize the terminology used to describe AUB. This system is based on the pattern and etiology of bleeding and has been adopted by other organizations. The term dysfunctional uterine bleeding has been replaced by AUB. The negative effect of AUB on adolescents' quality of life is now well established. The levonorgestrel-releasing intrauterine system is considered a first-line treatment for heavy menstrual bleeding and should be considered, especially in those adolescents who may also need contraception. AUB is a common adolescent complaint that can vary from mild to life-threatening if not recognized and treated promptly. This article reviews the appropriate assessment and management of AUB and proposes a practical algorithm that can be used in an office or hospital setting.

Gastrointestinal Bleeding in Acute Ischemic Stroke: Recent Trends from the Fukuoka Stroke Registry

Background: Gastrointestinal (GI) hemorrhage is a potentially serious complication of acute stroke, but its incidence appears to be decreasing. The aim of this study was to elucidate the etiology of GI bleeding and its impact on clinical outcomes in patients with acute ischemic stroke in recent years. Methods: Using the database of the Fukuoka Stroke Registry, 6,529 patients with acute ischemic stroke registered between June 2007 and December 2012 were included in this study. We recorded clinical data including any previous history of peptic ulcer, prestroke drug history including the use of antiplatelets, anticoagulants, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), and poststroke treatment with suppressing gastric acidity. GI bleeding was defined as any episode of hematemesis or melena on admission or during hospitalization. The cause and origin of bleeding were diagnosed endoscopically. Logistic regression analysis was used to identify risk factors for GI bleeding and its influence on deteriorating neurologic function, death, and poor outcome. Results: GI bleeding occurred in 89 patients (1.4%) under the condition that 66% of the total patients received acid-suppressing agents after admission. Multivariate analysis revealed that GI bleeding was associated with the absence of dyslipidemia (p = 0.03), a previous history of peptic ulcer (p < 0.001), and the severity of baseline neurologic deficit (p = 0.002) but not with antiplatelet drugs, anticoagulants, and NSAIDs. The source was the upper GI tract in 51% of the cases; causes included peptic ulceration (28%) and malignancies (12%), and other or unidentified causes accounted for 60%. GI bleeding mostly occurred within 1 week after stroke onset. Hemoglobin concentration fell by a median value of 2.5 g/dl in patients with GI bleeding. Among them, 28 patients underwent blood transfusion (31.5%). After adjustment for confounding factors, GI bleeding was independently associated with neurologic deterioration (OR 3.9, 95% CI 2.3-6.6, p < 0.001), in-hospital death (OR 6.1, 95% CI 3.1-12.1, p < 0.001), and poor outcome at 3 months (OR 6.8, 95% CI 3.7-12.7, p < 0.001). These associations were significant irrespective of whether patients underwent red blood cell transfusion. Conclusions: GI bleeding infrequently occurred in patients with acute ischemic stroke, which was mostly due to etiologies other than peptic ulcer. GI bleeding was associated with poor clinical outcomes including neurologic deterioration, in-hospital mortality, and poor functional outcome.

Abstract 209: The Safety of Emergent Bedside Gastrointestinal Endoscopy in Patients with Moderate and Severe Aortic Stenosis in the Cardiac Intensive Care Unit

Purpose: Recent advances in the management of aortic stenosis (AS) including the availability of percutaneous valve therapies have resulted in the evaluation of patients with increased co-morbidities. AS is associated with an increased risk of Gastrointestinal (GI) bleeding which is further increased by antithrombotic and antiplatelet treatment that often accompany hospitalization. The aim of our study was to determine the safety of emergent bedside endoscopies in patients with moderate to severe AS in the Cardiac Intensive Care Unit (CICU) setting presenting with acute GI bleeding. Objective and Methods: We identified all patients with moderate to severe AS who were admitted to the CICU at the Cleveland Clinic and experienced GI bleeding requiring emergent bedside endoscopies between Jan 2011 and Jan 2013. Data collection included demographics, indication for admission to the CICU, indication for bedside endoscopy, etiologies of GI bleeding, and intra procedural as well as post procedural hemodynamic instability and respiratory distress. AS was defined as moderate for aortic valve area (AVA) in the range 1.5-1.00 cm square and severe for AVA &lt; 1.00 cm square. Result: 17 patients (10 males) with a mean age 78.4 ± 10.6 years were identified. Overall 4 patients had moderate AS while 13 had severe AS. The peak gradient across the aortic valve was 53.8 ± 24.8 with a mean AVA 0.74 ± 0.25 cm square. Indication for urgent bedside endoscopies included episodes of acute melena, hematemesis, acute anemia of an undetermined etiology, in addition to evaluation of acute anemia in the perioperative period. 88% of patients were on either antiplatelet or anticoagulation or both. The patients underwent a total of 20 bedside endoscopies: 16 upper endoscopies and 4 colonoscopies. IV fentanyl and midazolam were used for sedation in patients not previously intubated. The etiologies of GI bleeding were peptic ulcer disease (n=5), hemorrhagic gastritis (n=5), esophagitis with esophageal ulcer (n=3), GI angiodysplasias (n=3), and diverticulitis (n=1). None of the patients developed acute hemodynamic instability or acute respiratory distress during or after the endoscopy. Conclusion: The etiologies of acute bleeding in patients with AS are diverse. Emergent bedside GI endoscopies done in the CICU for the diagnosis and management of acute GI bleeding is a safe procedure in patients with moderate to severe AS.

PTU-019 Antithrombotic Vs. Ulcer Effects In Non-variceal Bleeding In Users Of Antithrombotic Drugs

IntroductionThe use of antithrombotic drugs (ATDs) remains a considerable challenge in the aetiology and management of non-variceal upper gastrointestinal bleeding (NVUGIB). In the upper gastrointestinal tract, ATD use may result...

Features of Patients With Gastrointestinal Bleeding After Implantation of Ventricular Assist Devices

Ventricular assist devices (VADs) are used to treat patients with end-stage heart disease. However, patients with VADs frequently develop gastrointestinal (GI) bleeding. We investigated the incidence, etiology, and outcome of GI bleeding in patients with VADs. In a retrospective study, we analyzed data from 391 consecutive patients (mean age, 53.9 ± 14.2 years; 81% male) who underwent VAD implantation for end-stage heart disease from January 2000 through May 2012 at the Cleveland Clinic. Multivariable logistic regression analysis was used to identify factors independently associated with GI bleeding in patients with VADs. Sixty-two patients (15.9%) had GI bleeding. The risk of GI bleeding increased by 10% for every 5-year increase in age (P = .006). GI bleeding was also associated with lower body mass index (P = .046), current smoking (P = .007), and lower baseline levels of hemoglobin (P < .001). Bleeding was primarily overt (79%), and most patients presented with hematochezia (43.5%). Causes of bleeding were primarily vascular malformations (26.5%) and ulcers (26.5%). Patients who received VADs as their only therapy, rather than as a bridge-to-transplantation, were more likely to have GI bleeding (P = .008). Colonoscopy detected GI bleeding with the highest diagnostic yield; most bleeding was associated with colonic lesions (51.4%). Overall mortality was 39.4%, and 2 deaths were directly related to GI bleeding. On the basis of a large case series analysis, GI bleeding is common after implantation of VADs (15.9% of patients have at least 1 episode of bleeding). Episodes were mostly overt and predominantly from the lower GI tract; colonoscopy is the best method of detection.

Sa1883 Antithrombotic vs. Ulcer Effects in Non-Variceal Bleeding in Users of Antithrombotic Drugs

Introduction The use of antithrombotic drugs (ATDs) remains a considerable challenge in the aetiology and management of non-variceal upper gastrointestinal bleeding (NVUGIB). In the upper gastrointestinal tract, ATD use may result in bleeding by mucosal damage (ulcer effect) or through its basic antithrombotic effect. The clinical significance of these effects is unclear. In this controlled analysis, we AIMED to clarify the significance of the antithrombotic effect as compared with the ulcer effect in patients with NVUGIB using ATDs. Methods We previously found that ATD users tended to be older and to have higher comorbidity and different endoscopy findings. To overcome these confounding factors, we compared 202 patients with NVUGIB using ATDs (ATD Group) with 202 patients with NVUGIB but not using ATDs (Controls), having matched both groups in a pairwise manner for age, Charlson comorbidity score and a composite endoscopic score covering the oesophagus, stomach, and duodenum. Antithrombotic drugs included low-dose aspirin, clopidogrel, dipyridamole, warfarin, and heparin. Patients using NSAIDs were excluded. Characteristics of the groups were compared using the Wilcoxon signed rank test and McNemar’s test. Continuous variables are reported as median (IQR). Results The characteristics of the two matched study groups are shown in Table 1. Conclusion After matching for age, comorbidity, and composite endoscopy score, patients with NVUGIB and using ATDs had significantly lower haemoglobin level, higher Blatchford risk score, and were 1.5 times more likely to be transfused. These effects are most likely to be due to the antithrombotic activity of ATDs rather than ulcers alone, and they need to be considered in the management of NVUGIB. Disclosure of Interest A. Taha Consultant for: Almiral Pharma UK, Vifor Pharma UK, Horizon Pharma USA, C. McCloskey: None Declared, T. Craigen: None Declared, W. Angerson: None Declared.

175 The Association of Drugs and Specific Causes of Acute Lower Gastrointestinal Bleeding: a Prospective Study

Background: The association of drugs and upper gastrointestinal bleeding is well known. However, there is a scarcity of data on the role of drugs in acute lower gastrointestinal bleeding (ALGIB), especially concerning specific causes of ALGIB. Material and methods: The study was prospective, population-based and consisted of all patients who underwent colonoscopy during the year 2010 as well as from January 1st to the 30th of June, 2013, at the National University Hospital of Iceland. Drug intake of NSAIDs, low-dose aspirin (LDA) and warfarin prior to ALGIB was prospectively registered, moreover the indications and results of colonoscopies were recorded. Clinically significant bleeding was defined as one or more of the following: hemoglobin <100g/L, need for blood transfusion, circulatory shock, surgery or death from bleeding. An ageand gender-matched control group consisted of patients who underwent colonoscopy during the study period and did not have ALGIB. A two-tailed Fisher's exact test was used for univariate analysis, statistical significance was set at p <0.05. Variables with a p <0.15 were entered into to a stepwise multiple regression. Independent variables entered into the multiple regression were; NSAIDs, LDA, warfarin and age. Results: Overall, 1814 patients underwent 2040 colonoscopies, 253 (14%) had ALGIB. The mean age for bleeders vs. controls (n = 343) was 63 (±19.9) and 63 (±19.5), respectively. Males were 50% in both cohorts. The most common etiologies for bleeding were diverticulosis (20%), ischemic colitis (15%), hemorrhoids (13%) and inflammatory bowel disease (IBD) (12%). The use of NSAIDs, LDA and warfarin was associated with ALGIB (Table 1). Patients with diverticular bleeding were more likely to use all drugs compared to controls (Table 1). The use of LDA was strongly associated with bleeding caused by ischemic colitis (Table 1) and NSAID use was associated with most etiologies (Table 1). Those who had clinically significant bleeding were more likely to use LDA or warfarin (Table 1). In the logistic regression, NSAIDs, LDA and warfarin were all independently associated with ALGIB (OR (CI) 2.5 (1.49-4.12), OR 1.7 (1.15-2.46), OR 1.8 (1.062.97), respectively). NSAIDs and warfarin were independently associated with diverticular bleeding (OR 5.5 (2.52-12.2) and 2.6 (1.18-5.57), respectively). LDA was independently associated with bleeding from ischemic colitis compared to controls (OR 3.1 (1.52-6.17)). Finally, clinically significant bleeders were more likely to use warfarin compared to nonclinically significant bleeders (OR 3.2 (1.46-7.13)). Conclusions: Drugs seem to play a major role in diverticular bleeding. LDA has a strong association with bleeding caused by ischemic colitis and NSAID use seems to have a more overall effect compared to other drugs. Warfarin use increases the risk of clinically significant bleeding. Table 1.

Le cavernome portal : cause rare d’hémorragie digestive et d’ictère

IntroductionRupture of esophageal varices due to schistosoma induced portal hypertension remains the major etiology of non ulcer gastrointestinal bleeding in Madagascar. The author reports two cases of portal cavernoma, a rare etiology of gastrointestinal bleeding.We want to increase the knowledge of this pathology and to discuss its management in our centre.ObservationThe first patient had esophageal varices diagnosed 6 years ago and the second one had a history of jaundice of unclear etiology 6 years ago. Both were admitted for upper gastrointestinal bleeding. Upper gastrointestinal endoscopy showed stage III esophageal varices. Abdominal ultrasonography led to the diagnosis of portal cavernoma. The exploration of an associated portal biliopathy was not feasible in our centre due to the lack of transhepatic or retrograde endoscopic cholangiography and Magnetic Resonance Imaging. We medically managed the gastrointestinal bleeding. Betablocker drugs were prescribed to prevent the recurrence of any gastrointestinal bleeding.ConclusionPortal cavernoma is a rare but possible etiology of gastrointestinal bleeding and jaundice. Management of these two complications is difficult in our country due to the lack of investigation and therapeutic tools.

Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding.

Background and study aim: The novel over-the-scope clip (OTSC) allows for excellent apposition of tissue, potentially permitting hemostasis to be achieved in various types of gastrointestinal lesions. This study aimed to evaluate the usefulness and safety of OTSCs for endoscopic hemostasis in patients with upper gastrointestinal bleeding in whom traditional endoscopic methods had failed. Patients and methods: A retrospective case series of all patients who underwent placement of an OTSC for severe recurrent upper gastrointestinal bleeding over a 14-month period was studied. Outcome data for the procedure included achievement of primary hemostasis, episodes of recurrent bleeding, and complications. Results: Twelve consecutive patients (67 % men; mean age 59, range 29 – 86) with ongoing upper gastrointestinal bleeding despite previous endoscopic management were included. They had a mean ASA score of 3 (range 2 – 4), a mean hemoglobin of 7.2 g/dL (range 5.2 – 9.1), and shock was present in 75 % of patients. They had all received packed red blood cells (mean 5.1 units, range 2 – 12). The etiology of bleeding was: duodenal ulcer (n = 6), gastric ulcer (n = 2) Dieulafoy lesion (n = 2), anastomotic ulceration (n = 1), Mallory – Weiss tear (n = 1). Hemostasis was achieved in all patients. Rebleeding occurred in two patients 1 day and 7 days after OTSC placement. There were no complications associated with OTSC application. Conclusions: OTSC use represents an effective, easily performed, and safe endoscopic therapy for various causes of severe acute gastrointestinal bleeding when conventional endoscopic techniques have failed. This therapy should be added to the armamentarium of therapeutic endoscopists.

Myelodysplastic syndrome and associated coagulopathy

Myelodysplastic syndrome (MDS) is a primary bone marrow disorder whose hallmark is the development of peripheral cytopenias and a predilection toward the development of acute myeloid leukemia (AML). Patients often have hypercellular bone marrows with dysplastic features that may involve multiple lineages. An increased awareness of MDS has led to the reporting of a number of associated autoimmune and paraneoplastic conditions in the medical literature. We present the case of an elderly man who was transferred to our institution with persistent, refractory bleeding several weeks after the resection of a sebaceous cyst. Despite reoperation, treatment with topical and intravenous hemostatic agents, and transfusion of blood products, the patient's bleeding persisted. A comprehensive evaluation for the cause of his coagulopathy was undertaken. Bone marrow evaluation was consistent with MDS. A paraneoplastic consumptive coagulopathy or fibrinolytic process in conjunction with MDS-related platelet dysfunction was felt to be the most likely etiology of the patient's bleeding.

Abstract No. 344 - Transcatheter arterial embolization of acute upper gastrointestinal arterial bleeding with fuaile medical glue

To evaluate the clinical utility and safety of transcatheter arterial embolization with Fuaile Medical glue (FAL) for control of acute upper gastrointestinal arterial bleeding. The emergency FAL embolization was performed in 27 patients (male=19, female=8; mean age 58years,range 26-83 years) with acute upper gastrointestinal bleeding after endoscopic management had failed or endoscopic procedure were unacceptable. Transcatheter arterial embolization was performed using 1:1 mixtures of FAL and lipiodol. All of the etiology of bleeding was benign ulcer (n=27). Coagulopathy was present in 6 patients, and 14 patients were hemodynamically unstable before FAL embolization. The technical success rate was 100%. Recurrent bleeding occurred in 1 patients. Among these 27 patients, arteriography demonstrated pseudoaneurysm in 7 cases and active contrast extravasation in the remaining 20 cases. The bleeding locations were gastroduodenal arteries (n = 22), left gastric arteries (n = 3) and superior mesenteric arteries (2); all cases involved a solitary lesion. Complete hemostasis was achieved in all patients with coagulopathy (n=6). Ulcers induced by transcatheter arterial embolization were noted in 2 of 5 patients who underwent endoscopic examination post-procedure; the ulcers were successfully treated with conservative measures. None of the intestinal necrosis secondary to FAL embolization was found. Two patients were dead in 5 days, because disseminated intravascular coagulation (DIC) were occurred, But DIC was not the embolization related complication. Transcatheter arterial embolization with FAL is a good treatment option with a high rate of hemostasis and a low recurrent bleeding rate.

Epistaxis and catastrophic nasal bleeding

Epistaxis is the most common otolaryngologic emergency. Its severity may range from mild to life threatening. Management of acute epistaxis varies depending on its severity, etiology, and site of bleeding. Endoscopic control of epistaxis is considered a highly effective and cost-effective treatment. It is important for the surgeon to weigh the potential benefits and risks. Ligation and cauterization of the sphenopalatine artery and anterior and posterior ethmoidal arteries is discussed. A plan of action and control of catastrophic bleeding from the internal carotid artery or cavernous sinus are also discussed.