Evaluation Of Gastrointestinal Bleeding Research Articles

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

THU377 Arterio-enteric Fistula, A Rare Complication After Pancreatic Transplant

Abstract Disclosure: A.M. Herrera Chancay: None. A. Calderon: None. A. Manavalan: None. Introduction: Areterio-enteric (AE) fistula is a rare but life-threatening complication of a failed pancreas transplant and most often presents with a gastrointestinal (GI) herald bleed. This case illustrates the importance of the prompt recognition and appropriate evaluation of GI bleeding in patients with a failed pancreas transplant and highlights the challenges associated with the management of an AE fistula. Case Description: A 53-year-old man with history of T1D complicated by retinopathy, neuropathy, nephropathy, end-stage renal disease (ESRD) and failed combined pancreas-renal transplant, presented to our hospital with diabetic ketoacidosis secondary to insulin pump malfunction. His course was complicated by a GI bleed. He was initiated on proton pump inhibitors but endoscopy was deferred due to resolution of bleeding. The patient was discharged from the hospital with plans for outpatient endoscopy however, he returned to the emergency room with hematemesis, malena and hemorrhagic shock complicated by cardiac arrest. Emergent endoscopy was performed but the source of bleeding could not be visualized due to large clots and fresh blood. A CT angiogram revealed brisk bleeding from the right common iliac pancreatic transplant graft. Coil embolization was attempted but unsuccessful and the patient was ultimately treated with two stents to the right iliac artery with subsequent resolution of bleeding. The patient was ultimately discharged home in stable condition. Conclusion: During pancreas transplant, the donor pancreas and duodenum are connected by a Roux en Y anastomosis to the small bowel of the recipient. The donor pancreas is placed in the right iliac fossa followed by anastomosis of the recipient right common iliac artery with the donor Y graft (Consisting of the iliac artery, its bifurcation, and the splenic and superior mesenteric arteries). AE fistula is an extremely rare complication of pancreatic transplant with only about 30 reported cases. This occurs in the setting of transplant failure, possibly due to the increased local inflammation. Endoscopy is often unsuccessful in locating the bleeding source. Angiography and stenting of the bleeding vessel seem to offer the most success and should be considered in patients with failed pancreas transplant presenting with GI bleeding. Presentation: Thursday, June 15, 2023

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

S653 Assessing the Appropriateness of Computed Tomographic Angiography in Acute GI Bleeding

Introduction: Acute gastrointestinal bleeding (GIB) is a common cause for hospital admission with significant mortality. Multidetector computed tomographic angiography (CTA) has emerged as an important tool in the evaluation of GIB. CTAs are indicated for lower GIB in hemodynamically unstable patients or for those who cannot otherwise prepare for colonoscopy [1], however no firm guidelines exist to ensure they are ordered in the appropriate clinical context. Excessive use of CTAs can lead to avoidable contrast and radiation exposure and increased cost of care without enhancing management. Methods: We performed a retrospective analysis of all CTAs ordered for hospitalized patients in 2018 and 2019 at Albert Einstein Medical Center, a 548-bed tertiary care hospital in Philadelphia. For each patient, we looked for signs of hypotension, defined in our study as mean arterial pressure (MAP) < 70 at admission or just prior to the scan. We also evaluated the subsequent hospital course for each patient to determine what intervention, if any, was performed. Results: A total of 526 CTAs were ordered for GIB in a two-year period. Among these, 70% failed to show active bleeding. 473 (89.9%) CTAs were ordered for patients without documented hypotension while 10.1 % of patients had at least one MAP < 70. Among non-hypotensive patients, 30% of CTAs positively identified acute bleeding compared to 32% in hypotensive patients. Among non-hypotensive patients, 65% had no intervention, 24% underwent endoscopy and 9.5% underwent catheter embolization with interventional radiology. Among hypotensive patients, 52.8% had no intervention, 28% underwent endoscopy and 13.2% underwent embolization. Among the 17 hypotensive patients with positive scans, four underwent embolization, five underwent endoscopy and six had no intervention or required surgery. Conclusion: Most CTAs for GIB at our hospital were ordered in normotensive patients. Patients with bleeding identified on CTA were more than two times more likely to undergo endoscopy than embolization, suggesting most CTAs do not significantly alter management. Our data suggests that contrast and radiation exposure from these scans, along with additional cost of care, may be avoided. Additional research to establish appropriateness criteria for CTAs in GIB is warranted.Table 1.: Mortality in MDS patients with GI bleed (OR).

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Dual-energy CT evaluation of gastrointestinal bleeding.

Gastrointestinal bleeding is a common cause for hospital admissions and is an important cause of morbidity and mortality. Although endoscopy is accepted as the standard initial diagnostic modality for the evaluation of gastrointestinal bleeding, multiphasic computed tomography (CT) imaging has become an alternative diagnostic tool. Dual-energy CT with post-processing techniques may have additional advantages over single-energy computed tomography in evaluation of gastrointestinal bleeding. In this article, we discuss the role of dual-energy CT in the evaluation of gastrointestinal bleeding with potential advantages over conventional CT and limitations.

Octreotide: Prevention of Recurrent Gastrointestinal Bleeding in LVAD Patients

Background Gastrointestinal (GI) bleeding is a common complication of continuous flow Left Ventricular Assist Device (LVAD) therapy leading to frequent hospitalizations, invasive GI procedures, and reduction of antithrombotic therapies. There is a need for ongoing investigation of GI bleed prevention in LVAD patients in order to understand mechanisms, predictors and optimal medical therapy. Currently, very few pharmacological methods have been found to provide reliable decreased GI bleeding with minimal side effects. Octreotide has shown efficacy in treating and preventing GI and variceal bleeding through decreasing splanchnic blood flow. Our goal was to reduce burdensome GI bleeding events while maintaining maximally tolerated anticoagulation therapy to prevent thrombotic events. Methods The Advanced Heart Failure Team at Moses Cone Hospital has placed over 70s LVADs since inception, May 2013. These patients are a combination of HeartMate II, III and 2 Heart Ware devices. While most LVAD patients are maintained on warfarin with INR goal 2-2.5 and aspirin 81mg daily without difficulty, we have had eight patients with recurrent GI bleeding. This is a single center pre/post evaluation of GI bleeding with use of Octreotide IM 20mg LAR given once a month for a minimum of 6 months. LVAD patients were enrolled after recurrent GI bleeding was diagnosed despite discontinuation of aspirin and reduction of INR goal. To date eight patients have been initiated on our octreotide injection protocol. Results Despite removal of aspirin and reduction in INR goal, these 8 patients suffered recurrent GI bleeding. With the initiation of octreotide injections, the number of GI bleeds was decreased by one half, with 16 bleeds prior to initiation and seven bleeds post. Six of the bleeds occurred in one patient, another patient re-bled once after a year of therapy. Six patients have not re-bled since initiation of octreotide. Treatment time ranged from 2-14 months with an average of 6 months. Though all patients remain off aspirin, all patients have been able to maintain anticoagulation with an INR target in the range of 1.5-2.5 with only one thrombotic event (TIA) diagnosed in this cohort since the initiation of octreotide. Only one patient stopped treatment after two doses due to intolerable diarrhea. Discussion In our cohort, IM octreotide was well tolerated and there was a noticeable decrease in recurrent GI bleeding. Despite our small numbers, these results are encouraging, as it has led to a decreased need for blood transfusions, GI procedures and hospitalization due to GI bleeding.

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit.

Background and study aims Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. Patients and methods We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. Results This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. Conclusions This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.

Capsule Endoscopy in Left Ventricular Assist Device Patients: Retrospective Review of Efficacy and Necessity

Background&#x0D; Capsule endoscopy (CE) is mainstream in the evaluation of obscure gastrointestinal bleeding (GIB) in the general population. However, the diagnostic and therapeutic impact of CE in LVAD patients susceptible to transient bleeding remains largely unexplored. This study aimed to assess the benefits of CE in the evaluation of LVAD associated GIB.&#x0D; Methods&#x0D; Retrospective review of patients implanted with a continuous flow LVAD who underwent inpatient capsule endoscopy (CE) between January 2014 and May 2017 at our center. Identification of lesions with high bleeding potential or presence of frank blood were considered abnormal findings on CE study.&#x0D; Results&#x0D; Twenty-five inpatients who underwent 41 CE were identified. All patients presented with GIB and had preceding negative upper endoscopy and colonoscopy in the past 4 weeks. On the first capsule in each patient, 19 had interpretable images, abnormal findings were detected in 5 patients (high risk lesion in 3, frank blood in 2), four of these underwent an enteroscopy and only 2 (8%) patients had confirmation of the capsule findings with APC treatment (true positive). Excluding patients with malfunction, LVAD interference and poor bowel prep, 14 patients had negative/equivocal CE, of which 4 underwent enteroscopy due to continued bleeding and 2 of these patients had treatable culprit lesions (false negative). A total of 17 (68%) patients were discharged without any therapeutic intervention irrespective of the success or findings on CE due to clinical stabilization. Twenty patients (80%) had recurrence in a mean 154 days. As expected, repeat capsules in the same admission increased the diagnostic yield (p=0.031). Only nine patients (36%) had capsule-image evidence of reaching the cecum while 4 patients (16%) had retention which had to be retrieved without further complication.&#x0D; Conclusions&#x0D; This study demonstrated that evaluation of GIB with CE is feasible and safe but was associated with a low diagnostic yield and low conversion to therapeutic intervention. With a true positive yield of 4% in our cohort, the efficacy and cost-effectiveness of CE in the LVAD population is debatable. The role of CE in LVAD patients may need to be reevaluated. An identification of patients who would benefit from a capsule-first approach would allow optimum utilization of resources and reduce healthcare expenditure.

Small Bowel Enteroscopy Has a High Diagnostic and Therapeutic Yield in the Evaluation of Recurrent Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices

Introduction: The evaluation of gastrointestinal bleeding (GIB) in patients with continuous-flow left ventricular assist devices (CF-LVADs) is burdensome and potentially harmful due to the need for endoscopic procedures which require bowel preparation, sedation, and often the reversal of anticoagulation with subsequent prolonged hospital stays. There are limited data assessing the diagnostic and therapeutic yield of various endoscopic procedures in the evaluation of GIB in this patient population. Objective: Our aim was to evaluate the efficacy of endoscopic procedures in CF-LVAD patients hospitalized for initial and recurrent GIB episodes by measuring the rate at which these procedures led to a diagnosis and subsequent therapeutic intervention. Methods: Medical records were retrospectively reviewed for all patients implanted with CF-LVADs from 1/2010 through 12/2016 who were then hospitalized for GIB. We recorded the procedures performed to manage GIB, including esophagogastroduodenoscopy (EGD), colonoscopy, small bowel enteroscopy, and video capsule endoscopy. The number of times a procedure identified and therapeutically intervened upon the source of GIB was recorded to calculate the diagnostic and therapeutic yield of the procedure. Results: Of the 207 patients implanted with a CF-LVAD during the study period, 49 (24%) required hospitalization for GIB after a mean follow up of 40 months. There were a total of 90 GIB hospitalizations, with 41 (46%) hospitalizations for recurrent GIB. The diagnostic and therapeutic yield of EGD and colonoscopy was similar between initial and subsequent GIB episodes; however, the diagnostic and therapeutic yield of small bowel enteroscopy approximately doubled in patients with recurrent GIB episodes (Table). Video capsule endoscopy was able to identify the potential source of bleeding in one-third of cases but did not result in a therapeutic intervention. Conclusions: Hospitalization for GIB occurred in 24% of CF-LVAD patients after 40 months of implantation. Approximately half of GIB hospitalizations were for recurrent episodes of bleeding. EGD and colonoscopy have similar efficacy in the management of initial and subsequent GIB episodes. Small bowel enteroscopy has a high therapeutic yield with recurrent GIB, suggesting that small bowel pathology such as arteriovenous malformations are a common cause of recurrent bleeding with CF-LVAD support. Given the high morbidity of GIB in CF-LVAD patients, improved diagnostic and therapeutic algorithms should be developed to allow for more efficient treatment of bleeding in this patient population.

Colon in and Polyp Out

Introduction: Tagged red blood cell (RBC) scan has a limited but unique role in the evaluation of overt gastrointestinal bleeding. We present a case where a patient was offered total colectomy at an outside hospital solely based on a tagged RBC scan that suggested a major colonic bleed, when in fact the bleeding was from a duodenal polyp on enteroscopic evaluation. Case Report: 87 year old man with a history of Billroth II surgery for a bleeding peptic ulcer in the 1980s was transferred for further evaluation of gastrointestinal bleeding. He had history of dark stools for 3 weeks. At outside facility, a tagged RBC scan was performed that identified the bleed was localized to his left upper quadrant. An endoscopy was not performed, instead a colectomy was offered. Upon his refusal to surgery, he was transferred to our facility. On our examination, the patient had melena. An esophagogastroduodenoscopy was performed that revealed Billroth II anatomy and a 2cm bleeding polyp with a thick stalk in the afferent limb. A snare-cautery polypectomy was performed. The pathology revealed that the polyp was a benign polypoid duodenal vascular malformation. The tagged RBC scan was later reviewed with radiology, which showed two areas of tracer activity. One was near the mid-abdomen, which corresponded to the polypectomy site, and the other was in the left upper quadrant, which was suspicious of a simultaneous colonic bleed. The next day a colonoscopy was performed which showed only melenic stool in the splenic flexure without evidence of an active bleed. Discussion: Tagged RBC scan has many merits but it does have significant drawbacks as well. Chief among them are non-localization and erroneous localization of bleeding. In a retrospective studyinvolving80 patients, tagged RBC scans were positive in 36% of overt GI bleed cases and negative in 64% cases. Among the positive cases, 10% were determined to be “incorrect positive” and led to incorrect surgeries in 5 out of 8 cases, 15% cases were “truly positive”, and 11% were “unconfirmed positive”. This led to a positive predictive value of 41%. Among the negative cases (64%), 21% were “false negatives” and 34% were “unconfirmed negative”. Its accuracy diminished proximally, with more false negatives reported, when bleeding was in the gastroduodenal region. Conclusion: Results of RBC scan should be interpreted with caution with endoscopic correlation.Figure 1Figure 2Figure 3

Gastric Metastasis from Clear Cell Renal Cell Carcinoma Presenting with Gastrointestinal Bleeding: A Case Report

Introduction: Renal cell carcinoma (RCC) is the most common cancer originating from the kidney, it is responsible for 80 to 85 % of all primary renal neoplasms. The most common sites of metastasis include lungs, bones, liver, and brain. However, Gastric metastases from RCC are exceedingly. Hematogenous metastases to the stomach in general are rare with incidence in autopsy 0.2-9%. Breast cancer, malignant melanoma and lung cancer as the most common cancers metastasizing to the stomach. There are only few cases in literature of RCC gastric metastasis, most of them are of clear cell type. It can be diagnosed even many years after removal of the primary cancer which indicates slow growing potential. Case report: 67-year-old male patient with past medical history of polycystic kidney disease, live donor renal transplant in 2002, and metastatic left sided renal cell carcinoma treated with radical nephrectomy and resection of pulmonary metastasis in 2014. He presented with multiple episodes of black tarry stool for the last 2 days. He was on aspirin and ticagrelor. Initial laboratory workup showed Hemoglobin 8.8 g/dl; platelet count 344*1000/cmm; and INR 1.2. The patient was admitted for stabilization and further evaluation of gastrointestinal bleeding. The patient was started on pantoprazole infusion and ordered 2 units of PRBCs. His aspirin and ticagrelor were held. Esophagogastroduodenoscopy (EGD) showed a 2.5 to 3.0 cm polypoid mass in the gastric fundus. The polyp was 90% removed with a polypectomy snare and cautery. Bleeding occurred after the procedure and hemostasis was achieved by local epinephrine injection, and application two Cook hemostasis clips. Histologic examination demonstrates tumor composed of nests and fascicles of cells with abundant clear cytoplasm and moderately pleomorphic nuclei with prominent eosinophilic nucleoli. Immunohistochemical staining was most consistent with metastatic clear cell renal cell carcinoma, and it was comparable with right lung biopsy resected in 2014.Figure 1Conclusion: Gastric involvement in renal cell carcinoma is rare even-though it's reported. The possibility of gastrointestinal involvement should always be considered in any patient with history of cancer who presents with gastrointestinal symptoms. Immunohistochemistry is also very useful in the diagnostic workup and in many cases it is possible to make a diagnosis in the absence of access to the primary tumor.Figure 2

Do medicine residents triage patients with gastrointestinal bleeding appropriately?

Background: Gastrointestinal specialists depend on internal medicine (IM) teams to accurately identify acute gastrointestinal bleeding (GIB). We evaluated whether IM residents’ assessment of GIB correlated with the impressions of GI specialists during consultations at an inner-city university teaching hospital. Methods: A questionnaire was distributed to house staff requesting GIB consultations and to the GI fellows performing the consults between August 2011 and April 2012. Residents and fellows were asked to assess GIB, specifically melena, using a stool color card and digital rectal examination (DRE) findings. Fellow DRE findings served as controls for stool color identification. Results: Eighty-seven GI consults were eligible for the study. Residents and fellows completed 81 and 86 questionnaires, respectively. A total of 76 questionnaires were included for analysis. A DRE was performed by medical staff before calling a consult in 65% of cases compared with fellows (97% of cases, P = 0.0001). Residents more frequently labeled stool as melena (42%) in patients as compared with fellows (12%, P = 0.0001). Residents inaccurately identified melenic stools in 22 patients (11 based on stool color and 11 based on DRE findings). Residents were more likely to label a consult as emergent than fellows (13.5% vs 4%, P < 0.05). Conclusion: Residents are less likely to perform DRE during an evaluation for GIB and to accurately identify melena based on stool color or DRE findings. There appears to be a need to educate residents on the appropriate terminology for stool color and the importance of DRE to accurately triage patients with acute GIBs.

Predictors of double balloon endoscopy outcomes in the evaluation of gastrointestinal bleeding.

To identify patients' characteristics associated with double balloon endoscopy (DBE) outcomes in investigation of obscure gastrointestinal bleeding (OGIB). Retrospective study performed at an academic tertiary referral center. Evaluated endpoints were clinical factors associated with no diagnostic yield or non-therapeutic intervention of DBE performed for OGIB evaluation. We included fifty-five DBE between August 2010 and April 2012. The mean age of the sample was 67 with 32 males (58.2%). Twenty-four DBE had no diagnostic yield and 30 DBE did not require therapy. Non-diagnostic yield was associated with performing two or more DBE studies in one day [odds ratio (OR): 13.72, P = 0.008], absence of blood transfusions within a year of the DBE (OR: 7.16, P = 0.03) and absence of ulcers or arteriovenous malformations (AVMs) on prior esophagogastroduodenoscopy (EGD) or colonoscopy (OR: 19.30, P = 0.033). Non-therapeutic DBE was associated with performing two or more DBE per day (OR: 18.579, P = 0.007), gastrointestinal bleeding episode within a week of the DBE (OR: 11.48, P = 0.003), fewer blood transfusion requirements prior to DBE (OR: 4.55, P = 0.036) and absence of ulcers or AVMs on prior EGD or colonoscopy (OR: 8.47, P = 0.027). Predictors of DBE yield and therapeutic intervention on DBE include blood transfusion requirements, previous endoscopic findings and possibly endoscopist fatigue.

Sa1641 Factors Associated With Negative Findings or No Therapy on Double Balloon Endoscopy in the Evaluation of Gastrointestinal Bleeding

Obscure GI bleeding (OGIB) is a challenging diagnostic problem for gastroenterologists. Double balloon endoscopy (DBE) offers both diagnostic and therapeutic value in this setting. However, it is invasive, complex, and time-consuming.

Mo1964 Efficacy and Safety of Endoscopic Studies in 207 Pediatric and Young Adult Patients: A Japanese Single Children's Hospital Experience

Background: The life expectancy of the population is rising. The number of octogenarian (80 years or older) undergoing endoscopy evaluation is rising. The utility of double balloon enteroscopy (DBE) procedure in Octogenarians have not been previously reported. Aim: To determine the safety and diagnostic yield of DBE procedure in the octogenarians. Methods: We reviewed our large prospectively collected DBE database from 2006 to 2011. The octogenarian patients aged 80 years or older were included in our study analysis. Patients' demographics along with DBE procedure indication, findings, and complications were recorded. The safety and diagnostic yield of DBE procedure was calculated by the frequency statistics. Results: A total of 1218 DBE procedure were performed from 2006 to 2011 at our tertiary referral center. Out of these DBE procedures, 108 DBE (60 antegrade and 48 retrograde approaches) performed in 86 different patient encounters among 68 octogenarian (54.4% Male) were included in our study analysis. The average age of these patients was 84 (80-95) years and BMI was 26.2 (18.6-45.13) kg/m2. The most common indication for DBE was overt bleeding 29.6% (See table below). The most common finding during these DBE was bleeding AVM (arterio-venous malformation) among 38% (n=33) encounters. The overall diagnostic (pertinent positive findings) or therapeutic yield of DBE was found to be 91.86% (79/86 encounters). The diagnostic and therapeutic yield was found to be 91% (71/ 78 encounters) for evaluation of gastrointestinal bleeding and 100% (5/5 encounters) for evaluation of suspected mass or bowel stricture among octogenarian. There was no immediate (<48 hours) complications occurred in any of these patients. In 55.8% (n=48) of the total 86 encounters, the patients received capsule endoscopy procedure. Among them, capsule endoscopy found specific lesions in 58.3% (n=28) encounters, nonspecific findings in 35.4% (n=17) encounters and negative in only 6.3% (n=3) encounters. Conclusion: The diagnostic (pertinent positive findings) and therapeutic yield of DBE procedure was found to be more than 90% in the octogenarian patients. The DBE procedure in octogenarians was found to be safe without any complications. Indications and findings of DBE in Octogenarians (total n = 86 encounters)

Mo1963 Double Balloon Enteroscopy (DBE) in Octogenarians: Analysis of a Large Prospectively Collected Database

Background: The life expectancy of the population is rising. The number of octogenarian (80 years or older) undergoing endoscopy evaluation is rising. The utility of double balloon enteroscopy (DBE) procedure in Octogenarians have not been previously reported. Aim: To determine the safety and diagnostic yield of DBE procedure in the octogenarians. Methods: We reviewed our large prospectively collected DBE database from 2006 to 2011. The octogenarian patients aged 80 years or older were included in our study analysis. Patients' demographics along with DBE procedure indication, findings, and complications were recorded. The safety and diagnostic yield of DBE procedure was calculated by the frequency statistics. Results: A total of 1218 DBE procedure were performed from 2006 to 2011 at our tertiary referral center. Out of these DBE procedures, 108 DBE (60 antegrade and 48 retrograde approaches) performed in 86 different patient encounters among 68 octogenarian (54.4% Male) were included in our study analysis. The average age of these patients was 84 (80-95) years and BMI was 26.2 (18.6-45.13) kg/m2. The most common indication for DBE was overt bleeding 29.6% (See table below). The most common finding during these DBE was bleeding AVM (arterio-venous malformation) among 38% (n=33) encounters. The overall diagnostic (pertinent positive findings) or therapeutic yield of DBE was found to be 91.86% (79/86 encounters). The diagnostic and therapeutic yield was found to be 91% (71/ 78 encounters) for evaluation of gastrointestinal bleeding and 100% (5/5 encounters) for evaluation of suspected mass or bowel stricture among octogenarian. There was no immediate (<48 hours) complications occurred in any of these patients. In 55.8% (n=48) of the total 86 encounters, the patients received capsule endoscopy procedure. Among them, capsule endoscopy found specific lesions in 58.3% (n=28) encounters, nonspecific findings in 35.4% (n=17) encounters and negative in only 6.3% (n=3) encounters. Conclusion: The diagnostic (pertinent positive findings) and therapeutic yield of DBE procedure was found to be more than 90% in the octogenarian patients. The DBE procedure in octogenarians was found to be safe without any complications. Indications and findings of DBE in Octogenarians (total n = 86 encounters)

Mo1271 Comparison of Internal Medicine Residents to GI Fellows in the Assessment of Patients With GIB at an Inner-City University Teaching Hospital: Are Patients Triaged Appropriately?

Comparison of Internal Medicine Residents to GI Fellows in the Assessment of Patients With GIB at an Inner-City University Teaching Hospital: Are Patients Triaged Appropriately? Priti Bijpuria*, Alexander Schlachterman, Scott Naples, Asyia S. Ahmad Gastroenterology, Drexel University, Philadelphia, PA Background: It is essential for physicians to accurately identify acute gastrointestinal bleeding (GIB) as urgent endoscopy may be indicated in patient with melena or hematemesis and for those patients with significant comorbidities such as coronary artery disease (CAD). GI specialists are dependent on primary medicine teams to accurately communicate patient information in the setting of GIB. There has been no study to date identifying the accuracy of internal medicine residents’ initial evaluation of GIB. Objective: To evaluate whether the accuracy of internal medicine (IM) residents’ assessment of GIB in patients correlates with the impression of GI specialists during consultation at an innercity university teaching hospital. Methods: Prospective study of inpatient GIB consultations requested from 8/2011 to 11/2011. A questionnaire was distributed to house staff requesting GIB consultations as well as to the GI fellows performing the consult. The questionnaire assessed physical exam, treatment, medications and past medical history. In addition, both the residents and fellows were asked to assess GIB, specifically melena, based on 1) stool color using a stool color card and 2) by rectal findings. Fellow digital rectal exam (DRE) findings served as a control for stool color identification. Results: There were 142 residents and 6 GI fellows eligible for this study. Thirty-nine GI consults have been evaluated to date. Of these consults, residents completed the questionnaire in 37 patients and fellows completed all 39 questionnaires. Residents were less likely to do a DRE to support their diagnosis of GIB 22 of 36 (61%) compared to fellows 34 of 38 (89%); p 0.006. When asked to characterize the stool of a presumed GIB, residents more frequently labeled stool as melena in 13 of 33 (39%) patients as compared with fellows in 3 of 38 (7.9%) patients; p 0.002. Residents inaccurately identified melanotic stools in ten patients. Four were incorrect based on the stool color and the other 6 were inaccurately labeled melena based on DRE findings that contradicted fellow findings. Finally, residents’ identified CAD in 14 of 29 patients (48%) whereas fellows identified CAD in only 7 of 34 patients (21%); p 0.03. Conclusion: Preliminary data indicates residents are less likely to perform DRE during evaluation for GIB and are less likely to accurately identify melena based on stool color or DRE findings. Surprisingly, residents were more likely than GI fellows to ascertain a history of CAD in GIB patients even though CAD is a significant comorbidity that impacts both the approach and timing of endoscopy. There appears to be a need to educate both residents and GI fellows on the appropriate triage of patients with acute GIBs. In addition, improved communication between services is necessary especially in high-risk patients.

Endoscopic Evaluation and Management of Gastrointestinal Bleeding in Patients with Ventricular Assist Devices

The optimal diagnostic approach and yield for gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) are unknown. We explored the etiology of bleeding and yield of upper and lower endoscopy, balloon-assisted enteroscopy, and video capsule endoscopy in the evaluation of GIB in patients with VADs. Methods. All VAD patients with overt gastrointestinal bleeding and drop in hematocrit from April 1, 2000 to July 31, 2008 were retrospectively reviewed. The endoscopic evaluation of each episode was recorded. Overall yield of EGD, colonoscopy, balloon-assisted, and video capsule endoscopy were evaluated. Results. Thirty-six bleeding episodes occurred involving 20 patients. The site of GIB was identified in 32/36 episodes (88.9%), and the etiology of bleeding was determined in 30/36 cases (83.3%). Five VAD patients underwent VCE. The VCE exams demonstrated a high yield with 80% of exams identifying the etiology of GIB. Endoscopic intervention was successful in 8/9 attempts. No adverse events were recorded. Two patients required surgical intervention for GIB. Conclusion. Upper, lower, video capsule, and balloon-assisted enteroscopies are safe and demonstrate a high yield in the investigation of gastrointestinal bleeding in VAD patients. Medical centers caring for VAD patients should employ a standardized protocol to optimize endoscopic evaluation and intervention.

Evaluation of Gastrointestinal Bleeding Following Implantation of Left Ventricular Assist Device (LVAD)

Evaluation of Gastrointestinal Bleeding Following Implantation of Left Ventricular Assist Device (LVAD)