Evaluation Of Gastrointestinal Bleeding Research Articles

Safety of Gastrointestinal Endoscopic Procedures Performed on Patients with Ventricular Assist Devices (VADs): A Single Center Experience

Purpose: VADs support many cardiac patients as a bridge to recovery, cardiac transplantation, or as a destination therapy. Patients with VADs frequently require gastrointestinal (GI) endoscopic procedures. Indications most commonly include colon cancer screening for transplant clearance, and the evaluation of GI bleeding, which is common in this population due to the use of multiple anticoagulant/antiplatelet use. However, these patients are perceived as particularly high risk for endoscopy, due to hemodynamic instability, anticoagulation/antiplatelet use, and the presence of other comorbidities. We present a single center experience of 83 patients with VADs who underwent a variety of endoscopic procedures. We have focused primarily on evaluating the safety of these procedures in LVAD patients, in terms of complications and mortality. Methods: A retrospective chart review of all patients with Ventricular Assist Devices (VADs) who have undergone colonoscopy, esophagogastroduodenoscopy (EGD), push enteroscopy, PEG placement, endoscopic ultrasound (EUS), double balloon endoscopy or video capsule endoscopy at the University of Rochester Medical Center from 2002 until 2009. The procedure reports and charts were analyzed to evaluate for any complications that occurred during the procedure or within 24 hours. Specific endoscopic interventions performed included cold mucosal biopsy, jumbo forceps biopsy, cold snare, hot snare, and FNA. Results: A total of 170 patient charts were reviewed, representing all patients in which VADs have been placed at our institution between 2002 and 2009. Only patients in which a GI endoscopic procedure was performed at our institution were further analyzed. A total of 104 procedures were performed in 83 VAD patients. There were no deaths related to endoscopic complications. The only significant complication occurred in a single patient who underwent EUS with FNA (enlarging perigastric lymphadenopathy), in whom anticoagulation could not be held for the customary interval. That patient developed a perigastric hematoma and anemia following the procedure, but recovered with conservative management. Conclusion: Our experience suggests that gastrointestinal endoscopic procedures can be performed safely in patients with VADs, despite the hemodynamic alterations, comorbidities, and anticoagulation/antiplatelet issues which make this population more challenging.

The Role of Endoscopy in the Evaluation of Gastrointestinal Bleeding in Patients with Ventricular Assist Devices

Introduction: Data available in patients with ventricular assist devices (VAD) regarding the incidence, etiology and endoscopic diagnosis of gastrointestinal bleeding (GIB) is limited. The purpose of this study is to better characterize GIB in patients with VAD and to evaluate endoscopic outcomes. Methods: The charts of all patients who had VAD placement at The Ohio State University Medical Center (OSUMC) from 4/2000 to 7/2008 were screened for GIB retrospectively. Patients with documented GIB underwent full data extraction.

The role of computerized tomography in the evaluation of gastrointestinal bleeding following negative or failed endoscopy

Gastrointestinal bleeding remains an important cause for emergency hospital admission with a significant related morbidity and mortality. Bleeding may relate to the upper or lower gastrointestinal tracts and clinical history and examination may guide investigations to the more likely source of bleeding. The now widespread availability of endoscopic equipment has made a huge impact on the rapid identification of the bleeding source. However, there remains a large group of patients with negative or failed endoscopy, in whom additional techniques are required to identify the source of bleeding. In the past, catheter angiography and radionuclide red cell labeling techniques were the preferred 'next step' modalities used to aid in identifying a bleeding source within the gastrointestinal tract. However, these techniques are time-consuming and of limited sensitivity and specificity. In addition, catheter angiography is a relatively invasive procedure. In recent years, computerized tomography (CT) has undergone major technological advances in its speed, resolution, multiplanar techniques and angiographic abilities. It has allowed excellent visualization of the both the small and large bowel allowing precise anatomical visualization of many causes of gastrointestinal tract (GIT) bleeding. In addition, recent advances in multiphasic imaging now allow direct visualization of bleeding into the bowel. In many centers CT has therefore become the 'next step' technique in identifying a bleeding source within the GIT following negative or failed endoscopy in the acute setting. In this review article, we review the current literature and discuss the current status of CT as a modality in investigating the patient with GIT bleeding.

Prevalence and Predictors of Esophageal Varices in Patients With Primary Biliary Cirrhosis

Esophageal varices and bleeding are among the most feared complications of primary biliary cirrhosis (PBC). We aimed to determine the prevalence of esophageal varices in patients with PBC, to evaluate noninvasive markers of esophageal varices in this population, and to validate the results in an independent set of patients. Data were collected on all patients with PBC seen for the first time at the University of Florida (study group) and at Case Western Reserve University hospitals (cross-validation group) during 7 consecutive years. Logistic regression analysis was used to identify independent predictors of esophageal varices. The best cut-off values were calculated based on receiver operating characteristic curves. The diagnostic accuracy of the independent predictors of esophageal varices identified in the study group were retested in the cross-validation group. Of 210 patients with PBC seen at the University of Florida, 113 had an endoscopy and 49.6% (56 of 113) were found to have esophageal varices. After excluding 22 patients with a history of variceal bleeding, data on 91 patients were analyzed. Thirty-four patients had esophageal varices (37%). Multivariate analysis revealed that a platelet count of less than 140,000 (odds ratio, 7.6; 95% confidence interval, 1.6-37) and a Mayo risk score of 4.5 or greater (odds ratio, 10.6; 95% confidence interval, 1.8-62) were independent predictors of esophageal varices. The diagnostic accuracy of these predictors was confirmed in an independent set of patients. Among patients with PBC, a platelet count of less than 140,000 and/or a Mayo risk score of 4.5 or greater appears to identify those patients more likely to benefit from a screening endoscopy.

Primary Lymphoma of the Small Bowel Detected With Red Blood Cell Scintigraphy

Tc-99m-labeled RBC scintigraphy is an easy and noninvasive method in the evaluation of gastrointestinal bleeding. However, the detection of small bowel lesions with bleeding is often found to be difficult. Primary neoplasms of the small bowel are unusual and constitute 1% to 5% of all gastrointestinal tract neoplasms. In this study, we report a case of gastrointestinal bleeding resulting from primary gastrointestinal B-cell lymphoma in the small bowel, which was successfully detected with Tc-99m-labeled RBC scintigraphy.

Impact of Capsule Endoscopy in Obscure Gastrointestinal Bleeding: Defining Strict Diagnostic Criteria for a Favorable Outcome

Impact of Capsule Endoscopy in Obscure Gastrointestinal Bleeding: Defining Strict Diagnostic Criteria for a Favorable Outcome Nikos Viazis, Kostis Papaxoinis, Ioannis Theodoropoulos, Spiros Sgouros, John Vlachogiannakos, Prokopis Pipis, Costas Markoglou, Alec Avgerinos Background: The most frequent indication for capsule endoscopy is to diagnose the cause of obscure gastrointestinal bleeding. Objective: To determine the impact of capsule endoscopy on the outcome of patients subjected to the test for the evaluation of gastrointestinal bleeding of obscure origin. Methods: From September 2002 till June 2004, all patients referred to our Unit for capsule endoscopy for the investigation of obscure gastrointestinal bleeding were considered for entry into the study. We defined bleeding of obscure origin as bleeding that persists or recurs after a negative initial work up including gastroscopy, colonoscopy, small bowel barium follow through or enteroclysis and push enteroscopy. Capsule endoscopy was performed with the Given M2A video capsule system. Using strict diagnostic criteria, studies were classified as having positive findings, findings of uncertain significance and no findings. According to our final classification, findings were considered positive only if we thought they were the actual source of bleeding, while lesions suspected to be the source were classified as findings of uncertain significance. Outcome was defined as continued or complete resolution of bleeding, during the follow up period. Results: Ninety six patients (M/F: 53/43, mean age: 60.84 G 16.55 years old) were enrolled in the study. Positive findings, findings of uncertain significance and no findings were identified in 41.7%, 20.8% and 37.5% of our study population respectively. The most common lesions seen were angiodysplasias of the small intestine. Therapeutic intervention was possible in 82.5% of patients with positive findings and 35% of patients with findings of uncertain significance. Complete resolution of bleeding, after a mean follow up period of one year, occurred significantly more often in patients with positive findings (68.4%), as compared to patients with findings of uncertain significance and no findings (40.8%; p Z 0.009). Complete resolution of bleeding did not differ significantly in patients with any kind of findings (positive findings and findings of uncertain significance) as compared to patients with no findings (p Z 0.198). Conclusion: Capsule endoscopy increases the diagnostic yield in the work up of patients with gastrointestinal bleeding of obscure origin. Patients with strictly defined positive findings are those that will benefit from medical therapy and have a favorable outcome.

Endoscopic Approach to the Treatment of Gastrointestinal Bleeding

Gastrointestinal endoscopy is the primary diagnostic and therapeutic modality in the management of gastrointestinal bleeding. Esophagogastroduodenoscopy, small bowel enteroscopy, and colonoscopy are well-established standards for initial evaluation of gastrointestinal bleeding, and have been used effectively for diagnosis, prognosis, and therapy. Although thermal, injection, and mechanical methods have been the mainstay of endoscopic therapy, promising new technologies such as endoscopic ultrasound and wireless capsule endoscopy will further advance our ability to improve morbidity and mortality from severe gastrointestinal hemorrhage. Herein we review current standards and recent advances in the endoscopic management of upper, lower, and obscure gastrointestinal bleeding.

Videocapsule endoscopy renders obscure gastrointestinal bleeding no longer obscure

INTRODUCTION Hemorrhage arising from inaccessible areas of the gastrointestinal tract has long been an enigma in gastroenterology. The advent of the Given M2A videocapsule endoscope now permits direct visualization of small bowel mucosa. The purpose of this study is to compare the diagnostic yield of the Given M2A videocapsule endoscope to conventional push enteroscopy. METHODS Twenty consecutively referred patients (9 men aged 54.8 +/- 21.7 years, 11 women aged 65.6 +/- 16.6 years) who had previously had 1.6 +/- 0.8 EGDs, 1.6 +/- 0.8 colonoscopies, at least 1 normal small bowel radiographic study, and who had received 6.2 +/- 3.9 units of blood were studied. Patients underwent videocapsule endoscopy and subsequently push enteroscopy within 1 week. The endoscopist was blinded to the results of the videocapsule study. RESULTS Videocapsule endoscopy determined the source of bleeding in 12/20 (60%) of patients versus 15% for push enteroscopy (McNemara chi2, P = 0.02). Videocapsule endoscopy found a source of bleeding in 9/13 patients in whom enteroscopy was negative. Three patients had surgical resections for vascular ectasias (2) and a hamartoma (1) based on the videocapsule endoscopy results. CONCLUSION The Given M2A videocapsule endoscope has superior diagnostic utility for the evaluation of gastrointestinal bleeding when compared with standard push enteroscopy. The Given M2A videocapsule endoscope can be used to direct appropriate therapy in addition to avoiding the use of unnecessary conventional endoscopic and radiologic procedures.

Does push enteroscopy increase the diagnostic yield in the evaluation of gastrointestinal bleeding of unknown origin?

Does push enteroscopy increase the diagnostic yield in the evaluation of gastrointestinal bleeding of unknown origin?

Gastric antral vascular ectasia (watermelon stomach)

With the invention of fiberoptic endoscopy and now video endoscopy, evaluation of gastrointestinal bleeding has dramatically changed the understanding and treatment of vascular malformations. Gastric Antral Vascular Ectasia is one such rare entity that is known to cause acute or chronic blood loss. The term "watermelon stomach" represents the endoscopic appearance of bright red longitudinal stripes localized in the gastric antrum, thus, resembling the skin of a ripened watermelon. Definitive treatment of watermelon stomach is antrectomy. However, endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for patients who experience acute, recurrent or chronic gastrointestinal bleeding from these lesions. In this article, the author describes the characteristics, diagnosis, and treatment of this uncommon disorder.

Vascular Malformations of the Gastrointestinal Tract

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.