Evidence Of Gastrointestinal Bleeding Research Articles

A147 PRIMARY COLONIC MANTLE CELL LYMPHOMA: A RARE ENTITY

Abstract Background Mantle cell lymphoma (MCL) is an aggressive subtype of B-cell non-Hodgkin lymphoma (NHL), often diagnosed at later stages with secondary gastrointestinal (GI) involvement. Primary GI MCL is rare and is not often discussed in the literature. Aims To increase awareness of a rare condition that is likely to be encountered but can be challenging to diagnose. Methods Case report and review of the literature. Results Case Report A 78-year-old man with multiple untreated vascular risk factors including atrial fibrillation and type 2 diabetes presented with acute onset left hemiplegia, dysarthria, and imaging consistent with a left pontine stroke. As part of his workup he underwent a CT abdomen/pelvis identifying an 11 x 5 cm intraluminal mass in the transverse colon. Previous screening colonoscopies, for family history of colon cancer, were notable for tubular adenomas without high-grade dysplasia at 13, 12, 10, 7, and 2 years prior to admission. The patient had 16 pounds of weight loss without other constitutional symptoms, change in bowel habits or evidence of GI bleeding. Bloodwork was notable for microcytic anemia (Hemoglobin 91 g/L, MCV 75 fL), from a normal baseline one year prior, without other cytopenias. C-reactive protein (44 mg/L) and GGT (164 U/L) were elevated. Other liver enzymes, lactate dehydrogenase, and electrolytes were normal. Colonoscopy revealed numerous polypoid lesions throughout the entire colon and a large non-obstructive mass with submucosal appearance in the transverse colon. Biopsies were taken from the large mass and one of the smaller polypoid lesions. Histology showed a sheet-like infiltrate of small lymphocytes within the lamina propria. Immunohistochemical staining was positive for CD20, BCL2, Cyclin D1, equivocal for CD5, and negative for BCL6 and CD3. Ki67 index approached 30%. A diagnosis of colonic MCL was made. Literature Review Primary MCL of the GI tract is rare, accounting for only 1 to 4% of all GI malignancies. There is a male and Caucasian predominance with a median age of 68 years at diagnosis. Presenting complaints may include abdominal pain, anorexia, and GI bleeding. Typical endoscopic features are small nodular or polypoid tumors, between 2mm and 2 cm in size, along one or more segments of the GI tract referred to as multiple lymphomatous polyposis (MLP). A single colonic mass is infrequently seen, highlighting the importance of endoscopy for diagnosis, as subtle findings may be missed on radiographic evaluation. Biopsies for immunohistochemistry are essential to distinguish MCL from other NHLs, as almost all cases express cyclin D1. Despite aggressive immunochemotherapy, prognosis is often poor due to MCL’s rapid progression and early relapse. Conclusions Primary GI MCL is a rare entity. Awareness is essential as evaluation and management differ from lymphoma at other sites, and other GI malignancies. Funding Agencies None

Effects of High-Flow Transesophageal Dry Air on Core Temperature: A Novel Method of Therapeutic Hypothermia.

Therapeutic hypothermia (TH) is one of the few proven neuroprotective modalities in clinical practice. However, current methods to achieve TH are suboptimal. We investigated a novel esophageal device that utilizes high-flow transesophageal dry air to achieve TH via evaporating cooling. Seven Yorkshire pigs (n = 7) underwent hypothermia therapy using a novel esophageal device that compartmentalizes a segment of esophagus through which high-flow dry air freely circulates in and out of the esophagus. Efficacy (primary objective) and safety (secondary objective) were evaluated in all animals. Safety assessment was divided into two sequential phases: (1) acute safety assessment (n = 5; terminal studies) to evaluate adverse events occurring during therapy, and (2) chronic safety assessment (n = 2; survival studies) to evaluate adverse events associated with therapy within 1 week of follow-up. After 1 hour of esophageal cooling (mean airflow rate = 64.2 ± 3.5 L/min), a significant reduction in rectal temperature was observed (37.3 ± 0.2°C → 36.3 ± 0.4°C, p = 0.002). The mean rectal temperature reduction was 1 ± 0.4°C. In none of the seven animals was oral or pharyngeal mucosa injury identified at postprocedural visual examination. In the two animals that survived, no reduction of food ingestion, signs of swallowing dysfunction or discomfort, or evidence of gastrointestinal bleeding was observed during the 1-week follow-up period. Open-chest visual inspection in those two animals did not show damage to the esophageal mucosa or surrounding structures. A novel esophageal device, utilizing high-flow transesophageal dry air, was able to efficiently induce hypothermia despite external heating. Therapy was well-tolerated, and no acute or chronic complications were found.

Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study.

To describe current stress ulcer prophylaxis practice in Canadian PICUs. Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. Seven PICUs in Canada. Three hundred seventy-eight children requiring mechanical ventilation. None. Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea. Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.

P1716 Aorto-left atrial fistula with left atrium dissection

Abstract We report a 71 year-old female with a history of rheumatic valvulopathy, who underwent St. Jude 23 and St. Jude 21 in mitral and aortic position replacement. The patient was admitted to the ER for pulmonary edema with haemoglobin level of 7.7 g/dL .No evidence of gastrointestinal bleeding. She was assessed to exclude intravascular hemolysis: bilirrubin 3.1mg/d,L direct bilirrubin 1.0 mg/dL, reticulocytes 207.000/mcL 6.8%, LDH 1.213, free plasmatic haemoglobin 9.6mg/dL, haptoglobin < 1 mg/dL, negative direct and indirect Coombs. Upon suspicion of hemolytic anemia in relation to prosthetic dysfunction, TEE was performed revealing stenotic mechanical aortic prosthesis with abundant pannus and normofunctional mitral prosthesis, no leakages were observed. A coronary CT scan showed severe calcification of the aortic root and mitral annulus without evidence of redundant tissue than hindered the opening of the aortic or mitral valves. Cardiac catheterization revealed normal coronary arteries, cardiac output preserved and mild passive predominance of PAP. Heart Team decided on aortic prosthesis valve replacement. On March 22, 2019 surgery was performed. There was a heavily calcified ascending aorta and aortic root with abundant pannus at the ventricular aspect of the aortic prosthesis. Former aortic prosthesis was resected and the root reconstructed with a pericardial patch. 18-mmATS mechanical aortic prosthesis was implanted. After 127minutes of cross-clamping time, the patient was admitted to the ICU. She presented a torpid course in the postoperative period after cardiac surgery and cardiogenic shock ensued. TEE was repeated, showing pseudoaneurysm of the mitral–aortic intervalvular fibrosa, left atrium dissection and severe paraprosthetic aortic leakage. Coronary CT scan revealed a large cavity, 7x4x3.5 cm, extending posteriorly and displacing cranially the right pulmonary artery and subsequently rejecting the cavity of left atrium; with final diagnosis of aorto-left atrial fistula with left atrium dissection. Emergent surgery was decided. During the procedure, mitral–aortic intervalvular fibrosa pseudoaneurysm was confirmed, perforation from the subaortic left ventricle into the left atrium was also appreciated at the junction of the aortic root pericardial patch with the dissected left atrium wall. Surgery was complicated with hemorrhagic shock and massive uncontrolled bleeding with severe coagulopathy and thrombocytopenia. The patient went into cardiac arrest and passed away in the operating room. Conclusion Aorto atrial fistulas are rare but important complications of many disease processes of the aorta and aortic valve. Classical clinical signs of continuous murmurs may not be present and echocardiography forms the cornerstone of diagnosis. AAF should be suspected in patients with poorly controlled heart failure and prior aortic surgery. Prompt surgical repair is usually helpful in relieving symptoms and decreasing mortality. Abstract P1716 Figure. Aortoatrial fistula

The diagnostic ability of SPECT/CT fusion imaging for gastrointestinal bleeding: a retrospective study

BackgroundBlood loss from the gastrointestinal tract can be an acute and life-threatening event. For the treatment of gastrointestinal bleeding, it is important to accurately detect gastrointestinal bleeding and to localize the sites of bleeding. The purpose of this study was to retrospectively assess the capabilities of SPECT/CT in the diagnosis of gastrointestinal bleeding by a comparison with planar imaging alone as well as planar and SPECT.MethodsWe conducted a retrospective analysis of 20 patients (21 examinations) who underwent gastrointestinal bleeding scintigraphy in the past 7 years and in whom the bleeding site was identified by endoscopy or capsule endoscopy, or in whom no evidence of gastrointestinal bleeding was identified during the clinical course. Five patients (5 examinations) were diagnosed by planar imaging (planar group). Eight patients (9 examinations) were diagnosed by planar imaging and SPECT (planar + SPECT group). Seven patients (7 examinations) were diagnosed by planar imaging and SPECT/CT (planar + SPECT/CT group). We calculated the diagnostic ability of each method in detecting the presence of bleeding, as well as the ability of each method to identify the sites of bleeding. The sensitivity, specificity, and accuracy of the methods were compared.ResultsThe diagnostic ability of the three imaging methods in detecting the presence of gastrointestinal bleeding was as follows. Planar imaging showed 100% sensitivity (3/3), 100% specificity (2/2), and 100% accuracy (5/5). Planar + SPECT imaging showed 85.7% sensitivity (6/7), 100% specificity (2/2), and 88.9% accuracy (8/9). Planar + SPECT/CT imaging showed 100% sensitivity (6/6), 100% specificity (1/1), and 100% accuracy (7/7). The diagnostic ability of the three modalities in detecting the site of bleeding was as follows: planar, 33.3% (1/3); planar + SPECT, 71.4% (5/7); and planar + SPECT/CT, 100% (6/6).ConclusionsAll 3 imaging methods showed good accuracy in detecting the presence of gastrointestinal bleeding. The addition of SPECT or SPECT/CT made the anatomical position of the uptake clear and contributed to the localization of the site of gastrointestinal bleeding. Planar + SPECT/CT imaging therefore showed the highest diagnostic ability for detecting the site of gastrointestinal bleeding.

Acute Esophageal Necrosis Following Kidney Transplantation

Acute esophageal necrosis (Black esophagus) is a rare complication typically seen as a circumferential black appearing esophagus in the less vascularized distal region. Etiologies include hypoperfusion, infectious etiologies (e.g. CMV, Candida albicans), DKA, and toxic ingestion. Two cases have been previously reported in kidney transplant recipients involving intra-operative cardiac arrest with associated hypotension, and primary CMV infection, respectively. Our patient developed acute esophageal necrosis without an episode of hypotension, or infectious etiology. A 48 year-old Asian man with end-stage renal disease due to IgA nephropathy received a deceased donor kidney transplant. Both donor and recipient had positive cytomegalovirus (CMV) IgG antibodies prior to transplant. The patient did not experience intraoperative hypotension. He received standard induction and maintenance immunotherapy including tacrolimus target trough levels between 8 and 10 ng/ml. Post-operatively, the patient developed hiccups, postprandial chest and epigastric pain, dysphagia, and odynophagia. He was afebrile, normotensive, and had no fever or evidence of gastrointestinal bleeding. Labs revealed a stable normocytic normochromic anemia with hemoglobin of 9.8g/dL without evidence of leukocytosis, thrombocytopenia and a normal coagulation profile. At symptom onset, tacrolimus level was slightly elevated at 11.1 ng/ml, and his serum creatinine peaked at 15.4. Hemodialysis was started without symptomatic improvement. On POD 4, patient underwent esophagogastroduodenoscopy (EGD) that demonstrated evidence of diffuse blackdiscoloration, ulceration and erythema in the distal esophagus. Biopsies were consistent with necrosis and showed no evidence of CMV infection. Conservative management including NPO, TPN, and PPI for one week led to marked improvement in symptoms and EGD two weeks later revealed adequate reepithelization and no visualization of necrotic tissue (Figure 1D-F). Despite the absence of frank hypotension, infections or DKA, acute esophageal necrosis may occur in the setting of normal blood pressure and major surgery. It is difficult to determine, but tacrolimus with vasoconstrictive properties could have resulted in distal esophageal hypoperfusion and subsequent necrosis. The current case raises clinician awareness in considering the possibility of esophageal necrosis post-transplant in the setting of dysphagia, odynophagia, and elevated tacrolimus levels.1827 Figure 1. A) Normal-appearing upper esophagus on initial EGD. B) Middle esophageal tissue discoloration, erythema and friability with contact bleeding. C) Lower esophageal tissue friability, ulceration and sloughing. D) Normal-appearing upper esophagus on follow-up EGD one week afterwards. E) Normal-appearing middle esophagus. F) Erythema and evidence of re-epithelization in lower third of the esophagus.

Use of PC‐NSAIDs to treat 2nd degree burn injury in rodent models

BackgroundThere is a need for drug treatment for 2nd degree burn injury that can be applied quickly to both relieve pain and promote healing. Currently used drugs for chronic pain have substantial side‐effects which limit their usefulness. These include opioids and their addictive potential, gabapentin and its sedation, and coxibs with their risk of cardiovascular failure. Nonsteroidal anti‐inflammatory drugs (NSAIDs) are potent analgesics and provide relief from burn pain, but their use is limited due to side effects related to gastrointestinal (GI) bleeding insusceptible patients.Objective/AimThe goal of this project is to develop rodent model systems to evaluate the analgesic efficacy and side‐effects of a novel treatment for 2nd degree burn injury to alleviate pain and promote healing using a new class of NSAIDs that are complexed with the soy phosphatidylcholine (PC) that can be administered as a sterile topical alone, parenterally or in combination.MethodsEmploying two established methods, for the induction of 2nd degree burn injury in rats to either the dorsal skin or the hindlimb we investigated the effects of the PC‐NSAIDs, Ibuprofen‐PC and Indomethacin‐PC vs the unmodified NSAIDs administered (either subcutaneously (sc) or topically to the affected skin) daily over a 10‐day study at a dose of 20 mg/kg and 2mg/kg respectively. We then assessed pain sensation behaviorally, the depth of skin injury by light and fluorescent microscopy and tissue inflammation biochemically and by non‐invasive IVIS imaging.Results & ConclusionBoth Indomethacin‐PC and Ibuprofen‐PC when sc administered provided moderate hyperalgesia at 3‐ and 5‐days post‐burn injury, which was similar to the unmodified NSAIDs and in some cases more efficacious as analgesic/anti‐inflammatory agents. Topical administration of our test PC‐NSAIDs provided more variable responses using the two rodent model systems, with the most consistent analgesic/anti‐inflammatory effect being recorded with Indomethacin‐PC. Morphological analysis revealed that the depth of skin injury was reduced in rats treated with the PC‐NSAIDs with no evidence of GI bleeding. Supported by a USARMC grant, W81XWH‐14‐2‐0016.Support or Funding InformationSupported by a USARMC grant, W81XWH‐14‐2‐0016.

A Rare Presentation of an Aortoenteric Fistula After Aortic Aneurysm Repair

Aortoenteric fistula is a well described complication of endovascular repair of abdominal aortic aneurysms (AAA). Aortoenteric fistula formation is rare but potentially life-threatening and has been reported in 0.6%-2% of cases. Multiple causes of aortoenteric fistulas have been described including endograft infection, kinking of endograft within the aorta, or simple erosion of the foreign material. Although acute gastrointestinal bleeding is the most common presentation, chronic gastrointestinal bleeding and asymptomatic presentation have been described. Given its close proximity to the descending aorta, the third portion of the duodenum is the most common location for aortoenteric fistulas. We report an unusual case of an asymptomatic aortoenteric fistula to the duodenal bulb. An 80 year old female with history of chronic obstructive pulmonary disease, hypertension and peripheral vascular disease initially presented with intermittent abdominal pain and hematemesis. CT scan showed an infrarenal 6.5 cm AAA compressing the adjacent duodenum with evidence of air within the thrombus suggesting presence of an aortoenteric fistula to third portion of the duodenum. Patient underwent emergent placement of aortouniiliac endograft stent for repair of AAA by interventional radiology. She was maintained on total parenteral nutrition post procedure. Two months after AAA repair, an upper endoscopy was performed prior to the initiation of oral feeding and showed a 3 cm ulcer with graft material in the duodenal bulb. Patient was asymptomatic at this time with no evidence of gastrointestinal bleeding. There was no evidence of graft infection or migration. Although an unusual location, we believe the patient had developed a second aortoenteric fistula to the duodenal bulb. In recent years, endovascular aneurysm repair is the procedure of choice for repair of infrarenal aortic aneurysms. There have been multiple rare complications associated with this procedure, aortoenteric fistulas being one of the most described. Most patients present with acute gastrointestinal bleeding with fistulas affecting the third portion of the duodenum necessitating endovascular or surgical repair. There are no reported cases of asymptomatic fistulization to the duodenal bulb. Gastroenterologists should be aware of this unusual presentation.Figure 1

64-Year-Old Woman With Diarrhea and Increased Abdominal Girth

64-year-old woman presented to our institution for evaluation of diarrhea and increasing abdominal girth. She had a 1-month history of postprandial diarrhea unrelated to the type of foods she consumed. Her stool was watery, with no evidence of gastrointestinal bleeding. Concurrently, she also noted increasing abdominal girth requiring new pants with a larger waist size. She had no abdominal pain, nausea/vomiting, flushing, light-headedness, or constitutional symptoms. Her medical history was notable for a previous stroke with a mild residual right hand tremor. She was a lifetime nonsmoker, had no history of illicit drug use, and drank alcohol rarely. She had no history of recent travel, infectious exposures, new medications, or herbal supplement intake. Her blood pressure was 136/83 mm Hg, and herheart rate was 98beats/min.Heroxygensaturation was 95% while she breathed room air, and her respiratory rate was 18 breaths/min. Her temperature was 36.9C. Her mental status was normal. Her abdomen was soft, nontender, and mildly distended with hyperactive bowel sounds. Shifting dullness with a fluid wave was present. 1. Which one of the following is the most appropriate diagnostic approach to evaluate the patient’s abdominal symptoms? a. Paracentesis b. Colonoscopy c. Clostridium difficile toxicology screen or polymerase chain reaction d. Serology testing for transglutaminase antibody e. Abdominal radiography

The Charlson Comorbidity Index Can Be Used to Identify Patients Who Are No Longer Appropriate for Surveillance Colonoscopy

Purpose: The Charlson Comorbidity Index (CCI) is primarily used to predict survival among dialysis patients by assigning numerical weights to certain major medical problems and the patient's age. We sought to determine if the CCI can also be used to identify patients who, by virtue of significant comorbidity or advanced age, should no longer undergo surveillance colonoscopy. Methods: We performed a retrospective chart review of 1,554 patients who underwent a surveillance colonoscopy at the Manhattan Veterans Affairs Hospital from 2004-2011. Patients were included if they had a colonoscopy for a “history of colonic polyps,” “follow-up of colonic polyps,” or “established colonic polyps.” Patients were excluded if they had evidence of gastrointestinal bleeding, history of colorectal cancer, familial polyposis syndrome, or inflammatory bowel disease. We utilized the CCI to compare patients who died within five years of their surveillance colonoscopy with patients who lived longer than five years after their surveillance colonoscopy. The age at last colonoscopy, gender, race, number of medical conditions, albumin, and CCI level were recorded for each patient. An algorithm that factors in CCI and albumin levels was used to calculate one and two year survival probabilities for each patient. Only medical conditions that fell under CCI criteria were counted. The two groups were compared using a Student's two-tailed t-test. Results: Sixty patients died within five years of their last surveillance colonoscopy and were compared with our control group. The average time to death after colonoscopy was 31.8 months. None of the deaths were due to colorectal cancer. All patients were male. When comparing patients who died within five years to patients who were alive beyond that point, there were significant differences in CCI (5.53 and 4.25, respectively; p=0.005), one year survival probability (0.82 and 0.90, respectively; p=0.003), two year survival probability (0.67 and 0.79, respectively; p=0.001), and number of medical conditions (1.70 and 1.08, respectively; p=0.025). There was no significant difference in age among the two groups (75.12 for dead and 72.28 for alive; p=0.13). Conclusion: Patients who died within five years of colonoscopy had a significantly higher CCI and lower one- and two-year survival probabilities compared to those who are alive at least five years after their colonoscopy. Though there are clear recommendations for ages at which to discontinue screening colonoscopy, similar guidelines for stopping surveillance colonoscopy are currently lacking. CCI could be used to help determine which patients would no longer benefit from continued surveillance colonoscopy by evaluating their mortality risk.

AB0446 Gastrointestinal bleeding in adult patients with henoch-schönlein purpura

BackgroundAdult Henoch-Schönlein purpura (HSP) has a significantly higher frequency of gastrointestinal (GI) bleeding, compared with childhood HSP. However, the clinical characteristics of GI bleedings in adult HSP are still largely...

A meta-analysis of salicylates for type 2 diabetes mellitus

The aim of this study was to assess the effects and safety of salicylates on type 2 diabetes mellitus (T2DM). We searched six databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CBM, CNKI and VIP) for all randomized controlled trials (RCTs) and self-control studies which investigated the effects of salicylates on T2DM. We included 34 RCTs and 17 self-control studies involving 13 464 patients with T2DM. It was demonstrated that salicylates had obvious effects on several parameters for patients with T2DM. (1) Any dose of salicylates could significantly reduce HbA1c level [mean difference (MD) -0.39%; 95% CI -0.47 to -0.32] in RCTs, but only high doses of salicylates (≥3000 mg/day) could effectively reduce fasting plasma glucose (FPG) level [standardized mean difference (SMD) -1.05; 95% CI -1.47 to -0.62] for patients with T2DM in both RCTs and self-control studies. Furthermore, high doses of salicylates could also increase plasma fasting insulin level (MD 12.20 mU/L; 95% CI 3.33 to 21.07); (2) In both RCTs and self-control studies, high doses of salicylates could significantly reduce plasma triglycerides concentration. The results for RCTs were MD -0.44 mmol/L, 95% CI -0.71 to -0.18, and those for self-control studies were 227±29 mg/dL (pre-treatment) and 117±8 mg/dL (post-treatment) (P=0.009); (3) All trials which reported cardiovascular events were RCTs using low doses (<1000 mg/day) of salicylates, and it was revealed that aspirin could significantly reduce the risk of myocardial infarction (OR 0.73; 95% CI 0.57 to 0.92); (4) Two RCTs and two self-control studies with ≥3000 mg/day salicylates reported adverse effects, and the overall effects were mild, and tinnitus occurred most frequently. No evidence of gastrointestinal bleeding was found in all these studies. In conclusion, from our systematic review, the anti-diabetic effect of salicylates is in a dose-dependent manner. High doses of salicylates may have beneficial effects on reducing FPG, HbA1c level and increasing fasting insulin concentration, and may also have some positive effects on lipidemia and inflammation-associated parameters for patients with T2DM, without serious adverse effects.

A Case of Angiographic Embolization of Aortoenteric Fistula Caused by Endovascular Stent Grafting for an Abdominal Aortic Aneurysm

Aortoenteric fistula (AEF) developed after treatment for an abdominal aortic aneurysm (AAA) is a rare but usually fatal complication. We report a rare case of AEF bleeding after endovascular stent grafting for AAA which was managed angiographically. An 81-year-old man presented with hematochezia and acute abdominal pain for 1 day ago. Four years ago, an aortic stent was implanted in the infrarenal aorta for AAA. Endoscopies were performed to evaluate the hematochezia. Evidence of gastrointestinal bleeding was observed, but a clear bleeding point was not detected on upper endoscopy and colonoscopy. Contrast-enhanced computed tomography performed subsequently showed that the bleeding point was located in the fourth portion of the duodenum as an AEF caused by an inflammatory process in the stent-graft. Intra-arterial angiography showed a massive contrast leakage into the bowel via a small fistula from around the aortic stent graft site. Embolization was successfully performed by injecting a mixture of glue and lipiodol into the AEF tract. The patient was discharged with no evidence of gastrointestinal bleeding after the embolization.

Is Prophylactic Intravenous Administration of a Proton Pump Inhibitor Necessary for Perioperative Management of Cardiac Surgery?

Mortality from gastrointestinal (GI) hemorrhage caused by antiplatelet or anticoagulant therapy (or both) is quite high after cardiac surgery. We previously reported that proton pump inhibitor (PPI) therapy is indispensable in preventing postoperative GI complications. PPIs are usually administered intravenously immediately after surgery and subsequently by oral formulations. We conducted a prospective study to evaluate whether intravenous PPI followed by oral administration is more efficient as prophylaxis than oral-only administration. We enrolled 40 patients scheduled to undergo coronary artery bypass grafting with cardiopulmonary bypass and randomly assigned them to receive oral PPIs alone (group 1) or intravenous PPI followed by oral administration (group 2). Postoperative upper GI endoscopy evaluations showed no evidence of GI bleeding. Only gastritis, esophagitis, and hiatal hernia were observed at similar incidences in the groups. Mean hospital stays were also similar, but the cost of PPI treatment was significantly lower in group 1. No additional benefits of intravenous PPIs over oral formulations were demonstrated. Oral PPIs alone were effective and economical as prophylaxis against GI complications. Intravenous PPIs might be unnecessary in selected patients after cardiac surgery.

Diagnostic yield of Capsule Endoscopy in the Setting of Iron Deficiency Anemia without Evidence of Gastrointestinal Bleeding

The diagnostic yield of capsule endoscopy (CE) in the setting of iron deficiency anemia (IDA) without evidence of occult⁄overt bleeding has been questioned. Often, these patients have nongastrointestinal causes of iron deficiency but undergo CE to exclude a potential small bowel source. To assess the diagnostic yield of CE, the characteristics predicting positive results, the presumed etiology of IDA in negative⁄normal CE and patient management after CE. A retrospective review of 934 patients who underwent CE between December 2001 and February 2010 was conducted. All patients had undergone previous negative endoscopic examinations before CE. Patients with IDA but no evidence of overt⁄occult bleeding were separated into three categories based on CE findings: group A - positive; group B - negative⁄normal; and group C - incomplete⁄indeterminate. A total of 101 capsules in 97 patients were evaluated. Group A had 25 subjects with positive findings on CE, 18 of whom were managed supportively. Group B consisted of 69 subjects with negative⁄normal CE, 60 of whom were treated supportively. Group C consisted of three subjects with incomplete CE results. In patients with IDA without evidence of gastrointestinal bleeding, CE had a low diagnostic yield (25.7%), which increased to 45.5% after adjusting for low dietary iron intake and menorrhagia. However, CE did not alter management in most patients regardless of findings, and many of the lesions requiring intervention were within reach of standard endoscopes. No predictor of positive results was found. In this patient population, careful history taking and thorough endoscopy could improve CE utilization, although its value is still relatively limited.

Case 1: Recurrent iron-deficiency anemia in a teenager

A 16-year-old girl was referred by her paediatrician for evaluation of persistent microcytic anemia. Two years previously, she presented to her local hospital complaining of fatigue and weakness. At that point, her hemoglobin level was 46 g/L, with a low mean corpuscular volume and decreased iron and ferritin levels. She had no evidence of gastrointestinal bleeding and was otherwise healthy. Furthermore, she reported a regular menstruation cycle without increase in blood loss. She received a blood transfusion and was started on iron supplements, to which she had a good response as her hemoglobin level rose up to 129 g/L. Her clinical symptoms also resolved and iron supplementation was discontinued one year later. However, on follow-up, her hemoglobin level dropped to 85 g/L. Again, her iron stores were considerably low. A hemoglobin electrophoresis was normal. She still had no history of overt bleeding, but one of three fecal occult blood tests was positive. She was then evaluated in our centre. The physical examination was unremarkable apart from a small hemangioma of the tongue. Both upper endoscopy and colonoscopy showed no source of bleeding. A small bowel follow-through was normal. Further investigations revealed the diagnosis.

Investigating Iron Deficiency Anemia without Clinical Evidence of Gastrointestinal Blood Loss

Iron deficiency anemia is a common indication for referral to gastroenterologists. The referral triage process includes complete blood count including mean corpuscular volume, iron status by serum ferritin, iron and transferrin saturation and celiac serology. An often posed question is whether to investigate patients with iron deficiency without anemia – these patients, if older than 50 years of age, are at a higher risk of gastrointestinal malignancy compared with subjects with normal iron status and, therefore, should be investigated for gastrointestinal blood loss (1). All patients should undergo a detailed medical history and examination to exclude dietary insufficiency and menorrhagia. An ultrasound scan of the abdomen and pelvis may be useful to rule out a gynecological cause or a renal carcinoma. Patients with iron deficiency anemia and no overt or occult evidence of gastrointestinal bleeding are generally investigated by upper and lower gastrointestinal endoscopy. Patients with a hemoglobin concentration <100 g/L should be investigated urgently. It is reasonable to perform both upper endoscopy and colonoscopy – an effective strategy in those older than 50 years of age of age might be to perform colonoscopy with ileoscopy first and, if negative, perform upper endoscopy or limited push enteroscopy. Symptoms are a poor guide to the diagnostic yield of either procedure. Small intestinal biopsies should be taken irrespective of celiac serology. Patients with iron deficiency anemia with no overt or occult evidence of gastrointestinal bleeding and negative upper endoscopy and colonoscopy present a diagnostic challenge. The available options include proceeding to small intestinal investigations, iron supplementation and proceeding to small intestinal investigations if anemia persists despite adequate iron supplementation, discontinuation of any potentially incriminating drugs, such as nonsteroidal anti-inflammatory drugs, despite negative investigations or simply wait and see with hemoglobin monitoring if the anemia is mild or hemoglobin is normal with iron deficiency. Wireless capsule endoscopy is commonly used in these patients as a first-line small intestinal investigation. The study published in the current issue of the Canadian Journal of Gastroenterology by Tong et al (2) (pages 687–690), demonstrated that patients investigated with negative endoscopies for iron deficiency anemia without evidence of bleeding were generally managed with supportive therapy irrespective of positive or negative findings at wireless capsule endoscopy. Many of the positive findings at wireless capsule endoscopy were within the reach of conventional endoscopies. Therefore, while obscure upper gastrointestinal bleeding is the most common indication for referral for wireless capsule endoscopy, a meaningful clinical decision change as a result of the findings is uncommon. Therefore, better selection criteria for referral to wireless capsule endoscopy are required (3). Otherwise, the impact of wireless capsule endoscopy in patients with iron deficiency anemia with no overt or occult bleeding and negative upper and lower gastrointestinal tract endoscopy is likely to be very limited. The extent to which these challenging patients are investigated depends on comorbidities, the severity of anemia, whether the anemia is symptomatic, whether alternative routes of blood loss have been excluded and the rapidity with which anemia recurs after iron supplementation (4). The role of cross-sectional imaging, such as computed tomography (CT) or magnetic resonance-enterography, CT-angiography or double-balloon enteroscopy, in this specific patient group is uncertain. These investigations are generally performed in patients with definite clinical evidence of gastrointestinal blood loss. A practical approach in these patients may be to institute supportive treatment with iron supplementation after negative upper and lower gastrointestinal tract endoscopies. If hemoglobin levels are restored and maintained on long-term iron supplementation, a watch-and-wait policy may be best. If hemoglobin levels cannot be normalized or drop while on iron supplementation, repeat upper and lower endoscopies may be performed before wireless capsule endoscopy. Double-balloon enteroscopy may be performed for confirming significant abnormalities detected at wireless capsule enteroscopy and to perform therapeutic interventions such as for vascular lesions (Figure 1). Small intestinal tumours or Crohn disease may require CT or magnetic resonance-enterography. Figure 1) A pragmatic algorithm for investigating iron deficiency anemia with no evidence of overt or occult gastrointestinal bleeding

Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients on Dual Antiplatelet Therapy With Aspirin and Clopidogrel

The benefits of dual antiplatelet therapy are counterbalanced by the increased incidence of gastrointestinal (GI) complications. The aim of this study was to determine the frequency of GI bleeding, identify the predictors associated with the increased bleeding, and determine the short-term and long-term outcomes. This was an observational, case-control cohort study carried out at the Albert Einstein Medical Center. It included all patients who had a drug-eluting stent implanted between May 2003 and April 2007. A total of 1852 patients were identified; of these 50 patients were readmitted for a GI bleed. A control group of 202 patients who did not have any evidence of GI bleeding were compared with the original group. All data were expressed as mean±SD. The baseline clinical characteristics between the 2 groups were compared using the t test and the Fisher exact test. Multivariate analysis was used to determine the predictors of GI bleeding. The rate of GI bleeding was 2.7%. The mean age in the group with GI bleeding was 70.9±12.2 years, whereas in the group without GI bleeding it was 66.5±12.8 years (P<0.05). The majority of the patients presented with melena (40%). Gastritis and gastric ulcers were the most common findings seen in 49% of the patients on endoscopy. On multivariate logistic regression analysis, a history of GI bleeding was the most important independent predictor of future GI bleeding (P<0.001), whereas the use of statins was found to be protective (95% confidence interval, 0.13-0.48; P<0.001) against future GI bleeding. The 30-day mortality rate in the GI bleeding and control groups was 3.7% and 0%, respectively (P<0.01), whereas in the corresponding 1 year the mortality rate was 18.9% and 0%, respectively (P<0.001). The rate of GI bleeding in patients on dual antiplatelet therapy is low. Earlier history of GI bleeding is the most significant multivariate predictor of future GI bleeding whereas statins seemed to be protective. Patients with GI bleeding have increased short-term and long-term mortality; thereby a history of earlier GI bleeding needs to be assessed carefully before starting dual antiplatelet therapy. This may play a vital role in the selection of therapeutic strategies in these patients.

Incidence and possible risk factors for clinical upper gastrointestinal events in patients taking selective cyclooxygenase-2 inhibitors: A prospective, observational, cohort study in Taiwan

Background: Use of selective cyclooxygenase (COX)-2 inhibitors is associated with a better gastrointestinal (GI) safety profile than use of other NSAIDs. However, the risk factors for clinical upper GI events (symptomatic ulcers and ulcer complications) in COX-2 inhibitor users have been rarely evaluated in the past. Objective: The aim of this study was to assess the annual incidence of and identify the risk factors for clinical upper GI events in chronic COX-2 inhibitor (celecoxib and etoricoxib) users. Methods: A prospective, hospital-based, observational cohort study was conducted in patients taking COX-2 inhibitors (celecoxib or etoricoxib) without comorbidity. COX-2 inhibitor prescription was conducted according to the guidelines issued by the Taiwan National Health Insurance and was identified by the computerized prescribing system of the Taipei Veterans General Hospital, Taipei, Taiwan. Patients with cardiovascular disease, pulmonary, hepatic or renal insufficiency, or malignancy were excluded. Patients received regular follow-up once a month. Between visits, patients were asked to report to the outpatient clinic if they had persistent ulcer or GI symptoms (dyspepsia, vomiting, nausea, heartburn, or acid regurgitation) not relieved by antacids for 1 week, or to the emergency department if they had evidence of GI bleeding or ulcer complications (melena, hematemesis, hematochezia, or sudden onset of severe epigastric pain). Endoscopy was performed to document any gastroduodenal ulcers with or without ulcer complications. The primary end point was the annual incidence and the significant risk factors for clinical upper GI events (symptomatic ulcers and ulcer complications). Results: A total of 1158 COX-2 inhibitor users were identified; 96 refused to participate and 129 were excluded. The mean (SD) age of the remaining 933 COX-2 inhibitor users was 69 (15) years with 528 women (56.6%) and 405 men (43.4%). Mean time of follow-up was 12.4 months. The annual incidence of clinical upper GI events in these patients taking COX-2 inhibitors was 4.6% (44 events/959 patient-years), with symptomatic ulcers in 3.6% and ulcer complications in 1.0%. Multivariate logistic regression analysis found that a history of peptic ulcer disease (PUD) (odds ratio [OR = 4.61; 95% CI, 1.86–11.40; P = 0.001), concomitant use of steroids (OR = 2.99; 95% CI, 1.39–6.46; P = 0.005), aspirin (OR = 13.47; 95% CI, 5.89–30.82; P < 0.001), and other NSAIDs (OR = 60.49; 95% CI, 11.93–306.64; P < 0.001) were significant independent risk factors for clinical upper GI events in these patients taking COX-2 in-hibitors. Age >60 years was not found to be a risk factor. Conclusions: The annual incidence of clinical upper GI events was 4.6% in these Taiwanese patients without comorbidity taking COX-2 inhibitors. A history of PUD and concomitant use of steroids, aspirin, or other NSAIDs, were found to be significant risk factors for clinical upper GI events in these patients.

Helicobacter pyloriInfection

A 29-year-old man presents with intermittent epigastric discomfort, without weight loss or evidence of gastrointestinal bleeding. He reports no use of aspirin or nonsteroidal antiinflammatory drugs. A serologic test for Helicobacter pylori is positive, and he receives a 10-day course of omeprazole, amoxicillin, and clarithromycin. Six weeks later, he returns with the same symptoms. How should his case be further evaluated and managed?