Gastrointestinal Angiodysplasia Research Articles

Tranexamic acid for bleeding in a child with extensive small bowel angiodysplasia

Abstract Gastrointestinal (GI) angiodysplasia is a rare cause of lower GI bleeding in the paediatric population. This disease caused intermittent per-rectal bleeding and severe anemia in 2-year-old girl with Turner's syndrome. She was initially suspected to have Meckel's diverticulum and taken to the operation room for laparoscopy. A Meckel's diverticula was not found but an extensive distribution of abnormal vessels on the surface of the small bowel was noted from close to the duodeno-jejunal junction to the terminal ileum. GI angiodysplasia was suspected but the lesion was too extensive to be resected. It was also not clear if any specific area was the source of the current bleeding. After conversion to open surgery, an enterotomy was done in the mid portion of the affected bowel and an on table enteroscopy was done. This revealed a normal mucosal lining in the visualized areas and so was not contributory. Prior to closure of the enterotomy a doughnut of bowel was taken for histopathology. This confirmed small bowel angiodysplasia. She had one minor recurrence of lower GI bleeding 4 months later but has been well since then. This case sheds light on angiodysplasia as a cause of lower GI bleeding and we discuss its diagnostic and management options.

Digoxin Treatment Reverses Angiogenic Switch during HeartMate 3 Support and is Associated with Decrease Risk for Gastrointestinal Bleeding

Gastrointestinal bleeding (GIB) in LVAD patients is most commonly caused by gastrointestinal angiodysplasia (GIAD). Non-pulsatile blood flow in LVAD patients can cause splanchnic submucosal hypoperfusion and hypoxia leading to activation of a HIF1-α /Angiopoietins (Ang) signaling cascade, that can trigger pathological angiogenesis. We have recently shown that the use of digoxin, a potent inhibitor of HIF1-α, is associated with a significant reduction in GIAD related GIB in HeartMate (HM) II and HeartWare HVAD patients. However, HM3 support is associated with less GIB then previous generation pumps. We now hypothesize that dysregulation of Ang-1 and Ang-2 levels in patients with HM3 can be restored by digoxin treatment and may contribute to decreased incidence of GIB. We have collected blood samples from 7 patients supported with HM3 before and after two weeks of digoxin therapy (0.125 mg daily). Ang-1 and Ang-2 levels were measured in patients' serum by ELISA. In single-center retrospective study, charts of all patients implanted with HM3 between June 2015 and October 2019 were reviewed with emphasis on the occurrence of GIB and digoxin therapy. Pearson's chi-squared test was used to assess the frequency of overall GIB and their association with digoxin therapy. Digoxin treatment in HM3 patients increased Ang-1 (11.5 to 30.7 ng/ml, p=0.02), and decreased Ang-2 levels (14.9 to 9.4 ng/ml, p=0.04), reversing angiogenic switch. Seven of 72 patients (10%) supported by HM3 during median observation time (236, IQR76-620) days experienced a GIB. We identified 38 patients treated and 34 not treated with digoxin (age 52.38 vs. 52.65, p=0.97). The frequency of GIB was significantly lower in the patients receiving compared to the ones not receiving digoxin (3% vs. 17% p=0.03; Fig.1), respectively. Digoxin, an inhibitor of HIF1-α signaling cascade, may contribute to a lower risk of GIB in HM3 patients by restoring angiogenic equilibrium.

Heart Failure Duration Association with Gastrointestinal Bleeding Post Left Ventricular Assist Device

Gastrointestinal bleeding (GIB) is a frequent post left ventricular assist device (LVAD) co-morbidity with gastrointestinal angiodysplasia (GIAD) commonly implicated. Timing of LVAD therapy is variable, but no study has specifically analyzed duration of pre-LVAD heart failure on GI bleeding outcomes after VAD implantation. Between February 2007 and June 2019, 389 patients underwent primary LVAD implantation at our clinic. Median age at implant was 62 years (range, 18-82 years) and 306 (79%) were male. Etiology of heart failure was ischemic in 182 patients (47%) and indication for implant was destination therapy in 266 (69%). Axial flow pump was utilized in 282 (73%) and centrifugal flow in 105 (27%). Median preoperative duration of heart failure was 8.9 years. Early mortality occurred in 27/387 patients (7%). Follow-up was available in all 350 early survivors for a median of 1.8 years (920 years of patient support). There were 462 GI bleeding events in the 350 early survivors during the follow up time period. Figure 1 shows the relative hazard of GIB as time from heart failure diagnosis to LVAD implant increases and suggests a possible nonlinear trend for time from heart failure diagnosis to LVAD implant between 1000 and 6000 days and lowest relative hazard of GIB. There are wider confidence bands below 3000 days and above 6000 days so it cannot be concluded that hazard of GIB decreases in these ranges. This approached statistical significance (P=0.06) supporting a possible trend. GI bleeding events are common after LVAD implant and a longer preoperative duration of heart failure prior to LVAD implant may increase burden of this adverse event. This would be a powerful factor in considering someone for LVAD implant earlier rather than protracted heart failure management if clinically indicated.

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study.

Background Patients with chronic kidney disease (CKD) with or without hemodialysis were considered to have bleeding tendency and higher risk for gastrointestinal (GI) bleeding. Previous studies had documented that hemodialysis may increase the gastroduodenal ulcer bleeding. Few studies evaluated the relationship between CKD and lower GI bleeding. Materials and Methods. An observational cohort study design was conducted. The end-stage renal disease (ESRD) patients receiving regular hemodialysis (dialysis CKD), CKD patients without dialysis (dialysis-free CKD), and controls were selected from 1 million randomly sampled subjects in the National Health Insurance Research Database of Taiwan. These three group subjects were matched by age, sex, comorbidity, and enrollment time in a 1 : 2 : 2 ratio. The Cox proportional hazard regression models were used to identify the potential risk factors for lower gastrointestinal bleeding. Results Dialysis CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both Conclusion Hemodialysis may have higher risk of lower GI bleeding and angiodysplasia bleeding.

Aortic stenosis and anemia with an update on approaches to managing angiodysplasia in 2018.

Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.

Risk factors for bleeding from gastrointestinal angiodysplasia: acase-control study in patients with bleeding and non-bleeding angiodysplasia.

Angiodysplasia (AD) is a common source of gastrointestinal bleeding. Yet, little is known about factors forwarding bleeding in these vascular malformations. The presented study aims to determine risk factors for bleeding that occurs only in patients with symptomatic, but not with asymptomatic, AD. Case-control study in patients with AD and either a positive or a negative history of gastrointestinal bleeding in Munich, Germany. Groups were compared by clinical, laboratory, and endoscopic features. 80 patients with (58, f 31, med. age 72) or without bleeding AD (22, f 12, med. age 61) were included. Bleeding from AD was significantly associated with the total number of AD (OR 1.4 (95 % CI 1.1-1.7) p = 0.01) and closure time in PFA/collagen-epinephrine test (OR 1.0 (95 % CI 1.0-1.0) p < 0.01). The total number of AD correlated significantly with age (r = 0.36; p = 0.01). AD were mainly detected in the upper small intestine (> 30 %). Although patients with aortic stenosis suffered not significantly more frequently from bleeding from AD, they demonstrated a loss of high molecular multimers of VWF. The amount of AD is clearly correlated to the age of the patient. A higher number of ADs and inhibition of primary hemostasis increase the risk of bleeding.

583 Rebleeding After Hemoclip versus Argon Plasma Coagulation Use for Bleeding Gastrointestinal Angiodysplasias in Patients Receiving Antithrombotics: A Retrospective Multi-Center Study

INTRODUCTION: Endoclips have been used for treating bleeding gastrointestinal angiodysplasias (GIAD), but the supporting evidence in the literature has been limited. We previously presented a retrospective study that showed a significantly lower rebleeding rate with clips compared to argon plasma photocoagulation (APC); however, the sample size was small particularly the number of patients receiving antithrombotics (ATs). Aim of the current study is to compare the rebleeding rate with the use of clips versus APC in patients with bleeding GIAD receiving ATs. METHODS: We retrospectively included adults with bleeding GIAD that received either APC, clips monotherapy or in combination, at any of the Cleveland Clinic hospitals between 1/1/2009 to 11/1/2016. Only patients who resumed ATs after the intervention were included. Charts were reviewed to collect baseline and outcome characteristics. RESULTS: 178 patients were included, 92 received APC, 28 received clips monotherapy and 58 received clips combined with a second modality. At baseline, the clips group had more single GIADs, more actively bleeding lesions on index endoscopy and a tendency towards more overt bleeding. Baseline characteristics were otherwise similar [Table 1]. Median follow up duration was 18.5 months [IQR 9.9-27.3]. Rebleeding was significantly lower in the clips group (34.9% compared to 51.1% for APC, P = 0.03). The probability of remaining free of rebleeding was also higher in the clips group compared to APC (P = 0.037) [Figure 1a] but not significantly different when patients were classified into 3 groups [Figure 1b]. On a multivariate hazards regression model [Table 2], receiving clips combined with a second modality was predictive of lower rebleeding (HR 0.46 (0.25-0.84)). Other significant factors were having a smaller sized GIAD and having higher hemoglobin nadir at the initial bleed. CONCLUSION: Clips were associated with a lower probability of rebleeding in patients with GIADs receiving ATs compared to APC. After accounting for potential confounders, using clips in combination with a second modality remained significant, suggesting a role for combined intervention in patients that will resume ATs after endoscopic therapy.

Endovascular embolization management of gastrointestinal angiodysplasia: single center three-year experience

Endovascular embolization management of gastrointestinal angiodysplasia: single center three-year experience

Uso de análogos de somatostatina en las angiodisplasias gastrointestinales refractarias a otros tratamientos

La malformación vascular más común del tracto digestivo son las angiodisplasias gastrointestinales. Se caracterizan por una dilatación venocapilar con elevada fragilidad vascular, estado patológico que deriva en sangrados gastrointestinales. La prevalencia aumenta en pacientes de edad avanzada y pluripatológicos, lo que condiciona el tratamiento y pronóstico de las angiodisplasias.El objetivo es evaluar la eficacia del tratamiento de las angiodisplasias con análogos de somatostatina, siendo estos el Octreótido y el Lanreótido (fuera de ficha técnica para la indicación), en condiciones de práctica clínica habitual. Además, se tratará de relacionar la respuesta terapéutica con la localización de las lesiones, comorbilidades, reingresos, transfusiones sanguíneas y prescripción de anticoagulantes.Se llevó a cabo un estudio observacional retrospectivo con datos obtenidos de pacientes tratados en el Complejo Asistencial Universitario de León. Tras el análisis estadístico de los datos, se concluyó que no existen diferencias significativas entre los fármacos. Tampoco se encontró asociación significativa del éxito con las localizaciones de las angiodisplasias, ni con las comorbilidades coexistentes, ni con la toma de anticoagulantes. Sólo tratamientos de larga duración (&gt; 11 meses) se relacionan con indicadores objetivos de éxito, como la reducción del número de transfusiones y de reingresos.

Gastrointestinal Angiodysplasia: Report of Two Cases in Pediatrics

Intestinal angiodysplasia is a vascular abnormality where blood vessels are ectatic, tortuous with minimal muscle lining, being able to affect any segment of the gastrointestinal tract, showing single or multiple lesions at different sites, with the left hemicolon the most frequent location in children. The pathophysiological mechanism that originates it is still unknown, as is the epidemiology of this condition. The spectrum of clinical manifestations is wide, being able to debut and recur at any time in life with hemorrhage of varying intensity. Endoscopic and radiological tools are used for diagnosis. Treatment options include pharmacological, endoscopic therapies and surgical resection. In this article we describe two pediatric cases (6 months and 7 years respectively) which presented with recurrent gastrointestinal bleeding in need of transfusion therapy, in whom it was not possible to identify the origin of the disease until later, with adequate control of symptoms. After definitive treatment, which in one of them was total gastrectomy

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points.

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Mo1286 – Can Clinical Factors and Demographics Determine If Gastrointestinal Angiodysplasia Need to Undergo Therapy?

Mo1286 – Can Clinical Factors and Demographics Determine If Gastrointestinal Angiodysplasia Need to Undergo Therapy?

Mo1287 – Charlson Comorbidity Index, Hemoglobin Level and Number of Gastrointestinal Angiodysplasia May Affect the Decision to Treat and Response in the Treatment for Gastrointestinal Angiodysplasia

Mo1287 – Charlson Comorbidity Index, Hemoglobin Level and Number of Gastrointestinal Angiodysplasia May Affect the Decision to Treat and Response in the Treatment for Gastrointestinal Angiodysplasia

Gastrointestinal Angiodysplasia is Part of the Vascular Pathophysiology of Advanced Heart Failure

Purpose We have previously reported a high prevalence of gastrointestinal angiodysplasia (GIAD) in advanced HF patients undergoing LVAD evaluation. We now hypothesize that GIAD develop in relation to advancing heart failure and are associated with angiogenic dysregulation. Methods After informed consent, patients being evaluated for LVAD underwent video capsule endoscopy (VCE) for assessment of GIAD. Two control groups were formed: (1) NYHA Class 1 HF patients with LVEF angiogenesis was measured in both HF groups and a subset of paired pre and post LVAD patients. Results Median age and percent female of the advanced HF (n=17), NYHA 1 (n=4), non-HF controls (n=36) were as follows: (61, 61, 56; p = .789) and (18%, 0%, and 56%; p =0.020). Prevalence of GIAD was much higher in the advanced HF group as compared to the NYHA 1 and non-HF controls: 71% vs 25% vs 33% (p=0.009). Median Ang2 levels were numerically higher in the advanced HF as compared to the NYHA 1 group (5.4 vs 3.3ng/mL; p=0.138) although this did not reach statistical significance in this small sample. In 9 subjects with paired measurements, Ang2 increased from a mean of 6.7±3.5 to 11.3±7.6ng/mL (p=0.047) after LVAD implantation. Conclusion GIADs are already present in the majority of patients undergoing LVAD implantation and appear to be part of the pathophysiology of advanced heart failure. Angiogenic dysregulation predates LVAD implantation but is augmented in the setting of continuous flow LVAD support. Enrollment in this study is ongoing and at the time of abstract presentation, we anticipate a larger sample size.

Digoxin Restores Angiogenic Equilibrium in CF- LVAD Patients

Purpose Gastrointestinal bleeding (GIB) in patients supported by Continuous-Flow Left Ventricular Assist Devices (CF-LVAD) is most commonly caused by gastrointestinal angiodysplasia (GIAD). It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients can cause splanchnic submucosal hypoperfusion and activate a Hypoxia Inducible Factor (HIF)1-alpha /Angiopoietins (Ang) signaling cascade that triggers pathological neoangiogenesis. Specifically, it has been established in CF-LVAD recipients that the increased levels of Ang-2, decreased Ang-1 and resultant increase in the ratio of Ang-2/Ang-1, presents angiogenic switch that may favor GIAD development. We have recently shown that use of digoxin, a potent inhibitor of HIF1-alpha, is associated with a significant reduction in GIAD related GIB in CF-LVAD patients. We now hypothesize that dysregulation of Ang-2 and Ang-1 levels in patients with CF-LVADs can be restored by digoxin treatment. Methods Blood samples were collected from 10 patients supported with CF-LVAD before and 2 weeks after they were started on digoxin. Ang-1 and Ang-2 was measured in patients’ serum by ELISA. Statistical difference between the groups was tested with paired t-test. Results Digoxin treatment in CF-LVAD patients decreased Ang-2 (14.1 to 8.8 ng/ml, p=0.015) and increased Ang-1 levels (11.6 to 29.8 ng/ml, p=0.002), reversing angiogenic switch (Fig.1). Conclusion Digoxin may restore angiogenic equilibrium in patients supported by CF-LVADs. The relevance of this finding for development of GIB needs to be prospectively studied.

Promising Novel Treatment with Intravenous Bevacizumab for Refractory Gastrointestinal Bleeding from Angiodysplastic Lesions in Patients Supported with a Continuous-Flow Left Ventricular Assist Device: A Pilot Study

Purpose Vascular endothelial growth factor (VEGF) has been implicated in gastrointestinal angiodysplasias (GIADs). Bevacizumab (Avastin) is a humanized monoclonal antibody against VEGF and confers potent antiangiogenic properties. We sought to examine the safety and efficacy of intravenous bevacizumab in a small group of LVAD patients with refractory GI bleeding due to GIADs. Methods We conducted a pilot study between January, 2017 and March, 2018 at a large institution to examine the efficacy and safety of intravenous bevacizumab administration in patients supported with continuous flow LVAD who presented with refractory GIADs-related bleeding, defined as endoscopy-proven GIADs that failed both conventional medical and endoscopic therapies. We assessed response to therapy based on changes in number of GI bleeding hospitalizations, blood transfusions, and scoping procedures. Results Five LVAD patients (mean age 67 years, all male, all HeartMate II) with refractory GIADs-associated bleeding were treated with intravenous bevacizumab for a total of 8 cycles according to our institutional protocol. The median (interquartile range [IQR]) of follow up while on LVAD was 11.0 (2.6, 25.5) and 11.2 (10.2, 13.5) months pre and post bevacizumab initiation, respectively. Intravenous bevacizumab administration resulted in a remarkable decrease in the annual number of blood transfusions (45.8 [13.6, 133.8] vs. 6.0 [3.7, 12.2]), hospitalizations for GI bleeding (5.6 [3.1, 11.7] vs. 1.7 [0.40, 2.8]), and scoping interventions (10.6 [4.7, 41.7] vs. 2.3 [0, 5.1]) (Figure). All patients tolerated bevacizumab therapy without serious side effects. Conclusion Intravenous bevacizumab is an effective and safe treatment option for LVAD patients with refractory GI bleeding due to GIADs. Further studies are warranted to examine its long-term efficacy and safety in a large LVAD population.

Rotational thromboelastometry-guided perioperative management of coagulation in a patient with Heyde\u2019s syndrome undergoing transcatheter aortic valve implantation

BackgroundChanges in coagulability during the hyperacute phase within 24 h after transcatheter aortic valve implantation (TAVI) for Heyde’s syndrome, or aortic stenosis complicated by gastrointestinal angiodysplasia and acquired coagulation dysfunction, have not been clarified. We evaluated perioperative changes in coagulability using rotational thromboelastometry (ROTEM).Case presentationA female patient with Heyde’s syndrome in her 80s underwent TAVI. ROTEM showed coagulation dysfunction before and at 6 h after surgery. Improvements in coagulation function started at 12 h after surgery. Based on ROTEM findings, oral administration of antiplatelet agents was started on the day after surgery. No hemorrhagic complications were observed in the postoperative phase.ConclusionsEvaluation of coagulation function using ROTEM was useful for monitoring perioperative hemostasis and coagulation in this patient.

Long-term results with lanreotide in patients with recurrent gastrointestinal angiodysplasias bleeding or obscure gastrointestinal bleeding. Benefits in efficacy and procedures consumption

Background: Gastrointestinal angiodysplasias (GIAD) bleeding and obscure gastrointestinal bleeding (OGIB) are increasing health problems. Somatostatin analogues have been proposed as rescue therapy, but data for lanreotide are scarce.Objective: To determine the efficacy, safety and resource saving of long-acting lanreotide for GIAD and OGIB.Methods: Retrospective study including adults with GIAD bleeding or OGIB and lanreotide treatment for at least 6 consecutive months. Demographics, comorbidities and treatments were collected. Anaemia and health resource consumption were analysed and compared between the year before and three years after starting lanreotide. Complete response was defined as a lack of new blood transfusion or endovenous iron dose need.Results: Twenty-seven patients (mean age 76.8 years) were included, 63% taking anticoagulants/antiplatelets. The bleeding was attributable to angiodysplasia in 85.2%, of whom half had multi-site lesions. Lanreotide was administered for a median of 27.1 months. During follow-up of up to 3 years (mean 32.5 months), 18.5% of patients achieved complete response and around 60% a 50% reduction of health resource consumption. Haemoglobin values improved (p = .007), while admission time, blood/iron infusions, and the number of endoscopies decreased significantly (p<.05) at least up to the second year. There were no relevant side effects during the follow-up period.Conclusion: Long-term treatment with lanreotide significantly improves anaemia and decreases health resource consumption in patients with recurrent GIAD bleeding or OGIB.

Treatment of Small Bowel Angiodysplasia Using a Novel Radiofrequency Ablation Device

Introduction: Gastrointestinal angiodysplasia (GIAD) is the most common cause of small bowel bleeding. Argon plasma coagulation (APC) has been the preferred modality for the treatment of GIAD, though there are limitations to this method. The angulated small bowel can often hinder the passage of the APC catheter, impairing repeated re-insertion through the enteroscope. Additionally, targeting of lesions can be difficult with APC, resulting in incomplete ablation. There is also potential for significant intestinal insufflation during prolonged procedures, as argon gas flow is set at a rate of 0.5 to 2 liters/minute. Ideally, an instrument capable of repetitive use, covering more mucosal area per treatment with low risk of damage to healthy mucosa and improved ablation is desirable. Here we present a case series of 8 patients treated with a novel through-the-scope small bowel radiofrequency ablation (SB RFA) catheter that has many of these advantages over APC. Methods: This was an open label pilot study involving 8 patients with small bowel bleed from GIAD. Informed consent was obtained for the procedure. A novel SB RFA catheter (Medtronic, Minneapolis, MN) with a shaft diameter of 2.5 mm and length of 240 cm; at settings 10 J/cm2 was used to treat small bowel GIAD with an enteroscope with a double or single balloon overtube system (FUJIFILM Medical Systems, Wayne NJ, EN-450BI5, and TS-13140, or Olympus America, Center Valley, PA Olympus SIF Q180, and ST-SB1, respectively). Results: Hemostasis was achieved in all 8 cases. There were no procedural complications, and each lesion only needed 1 treatment. There was wide variation in the number of lesions treated in each procedure, ranging from 1 to 78. The performance characteristics of the SB RFA catheter were excellent, and the RFA catheter was felt to have better targeting and bleeding control than APC. Conclusion: This early pilot study demonstrates the safety and feasibility of a novel SB RFA catheter as a viable treatment modality for small bowel GIAD. Its advantages include a more durable shaft that can tolerate multiple re-insertions and the ability to rotate the catheter, which allows for direct targeting of the lesion. Additional studies are needed to compare this to conventional APC catheters, as well as establish long term durability of treatment.765_A Figure 1. Insertion of RFA catheter through enteroscope765_B Figure 2. Successful ablation of GIAD using RFA catheter

Digoxin Is Associated With a Decreased Incidence of Angiodysplasia-Related Gastrointestinal Bleeding in Patients With Continuous-Flow Left Ventricular Assist Devices.

Gastrointestinal bleeding (GIB) is one of the principal adverse events affecting patients with continuous-flow left ventricular assist devices (CF-LVADs). Despite the early recognition that GIB is commonly because of gastrointestinal angiodysplasia (GIAD), the exact pathophysiology of this process remains elusive. It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients may activate the angiogenesis signaling cascade via the HIF (hypoxia-inducible factor)-1α/angiopoietin-2 pathway leading to formation of GIADs. Digoxin is a potent inhibitor of HIF-1α synthesis, and we hypothesized that its use reduces the incidence of GIAD and GIB in patients with CF-LVAD. Charts of all adult patients implanted with CF-LVAD between February 2006 and February 2017 were reviewed with particular emphasis on occurrence and cause of GIB. Fifty-four of 199 patients (27%) experienced a GIB. Overall frequency of GIB was lower in the 64 patients receiving digoxin compared with the 135 patients not receiving digoxin (16% versus 33%, P=0.01). Multivariable-adjusted Cox regression analysis confirmed that digoxin use was independently associated with a reduced risk for overall GIB (hazard ratio, 0.49; 95% CI, 0.24-0.98; P=0.045). GIBs were then categorized as non-GIAD, GIAD, or likely GIAD. Although the incidence of non-GIAD was similar in both groups (11% versus 7%, P=0.41), the frequency of GIAD/likely GIAD bleeding was significantly reduced in the digoxin group (5% versus 25%, P=0.0003). Multivariable-adjusted analysis confirmed that digoxin use was independently associated with a reduced risk for GIAD/likely GIAD bleeding (hazard ratio, 0.18; 95% CI, 0.06-0.6; P=0.005). However, digoxin use was not associated with reduced risk for non-GIAD GIB (hazard ratio, 1.54; 95% CI, 0.58-4.08; P=0.39). Use of digoxin was associated with a significant reduction in GIAD-related GIB in patients with CF-LVAD.