Gastrointestinal Bleeding Hemorrhage Research Articles

Efficacy and safety of empiric treatment with omeprazole continuous infusion in critically ill children with gastrointestinal bleeding.

Gastrointestinal bleeding (GI) is a prevalent condition among pediatric patients, with a reported incidence of 6.4%, often severe enough to require admission to the pediatric intensive care unit (PICU). There are multiple therapies utilized in the management of GI bleeding in pediatrics, among which continuous intravenous (IV) infusion of omeprazole is used off-label without standard pediatric dosing recommendations. Reviewing the current literature reveals a lack of studies assessing the efficacy, safety, and appropriate dosing regimen of continuous omeprazole infusion in children with GI bleeding. This study aimed to evaluate the efficacy and safety of continuous IV omeprazole infusion in comparison to other therapeutic modalities in children. This study is a single-center, retrospective chart review of children admitted to the PICU at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. The treatment group included pediatric patients with GI bleeding and receiving omeprazole IV continuous infusion over ≥24 h while the control group included pediatric patients with GI bleeding managed using other therapies. Primary outcomes were the efficacy of omeprazole continuous infusion in stopping GI bleeding, and PICU length of stay (LOS). Secondary outcomes included instances of rebleeding post- therapy discontinuation, transfusion requirements, and the safety of omeprazole continuous infusion. The study included 81 critically ill pediatric patients, 22 of whom received continuous infusion omeprazole while 59 received other therapies. The results indicated that patients in the control group had a significantly shorter PICU LOS (8 vs. 18.5 days, p < 0.001) and bleeding episode (4 vs. 10.5 days, p < 0.001) than those in the treatment group. However, no significant differences were observed between the two groups regarding secondary outcomes. The treatment group had a significantly lower all-cause mortality rate during hospitalization compared to the control group (16 patients [72.7%] vs. 56 patients [94.9%], respectively, p = 0.005). Empirical use of omeprazole continuous intravenous infusion in children with GI bleeding was not favorable in terms of shortening PICU LOS and duration of GI bleeding. Our study results provide evidence supporting the safety and tolerability of omeprazole continuous infusion. Additional larger studies are necessary to determine the implication of such results.

Shock Index as a Predictor of Mortality and Hospital Admission in Prehospital Gastrointestinal Bleeding: A Retrospective Cohort Study

Objective: To evaluate the Shock Index (SI) as a predictive tool for triage of gastrointestinal bleeding (GI) in the prehospital setting, assessing its correlation with mortality, admission rates, and hospital length of stay. Methods: In this retrospective cohort study, we analyzed data from the ESO Data Collaborative encompassing EMS records from the year 2022, focusing on 1525 patients with a primary GI bleeding diagnosis. The primary measure was the SI, calculated at initial contact and highest recorded prior to ED arrival. Statistical analysis included t-tests, linear regression, and ROC curves, performed using SPSS v29. Results: A significantly higher mean SI was observed in patients who died (mean SI 0.997) compared to survivors (mean SI 0.795), p < 0.001. Admission rates also correlated with higher SI values, p < 0.001. However, SI was not predictive of the hospital length of stay. ROC analysis for mortality prediction yielded an AUC of 0.656 for the initial SI and 0.739 for the highest SI. The standard SI cutoff of 0.9 predicted mortality with a sensitivity of 74.14% and specificity of 55.35% for the highest SI. Conclusion: The SI is a valuable predictive tool for mortality among prehospital patients with GI bleeding. Its application may improve the triage process, potentially influencing transport decisions and initial hospital care. Despite its predictive capability for mortality, the SI should be supplemented with other clinical assessments to make comprehensive prehospital care decisions. Further research into SI as part of a comprehensive assessment which includes end-title CO2, mentation, and heaviness of bleeding.

Influence of COVID-19 on Patients with Esophageal Varices under Prophylactic Endoscopic Band Ligation Therapy

Background and Objectives: Endoscopic band ligation (EBL) plays a critical role in patients with clinically significant portal hypertension, as variceal eradication (VE) is essential to prevent further variceal upper gastrointestinal bleeding (GI). The emergence of COVID-19 has led to a dramatic reduction in endoscopic activity. Our study aimed to evaluate the effect of COVID-19 on VE, GI, and 6-month mortality of patients treated with prophylactic EBL therapy. In addition, our goal was to identify the risk factors for our proposed outcomes. Methods: A single-center retrospective cohort study included patients with esophageal varices treated with prophylactic EBL therapy between 2017 and 2021. To demonstrate the impact of COVID-19 on two independent groups on prophylactic EBL therapy with 1 year of follow-up, March 2019 was selected as the cut-off date. Clinical, laboratory, and endoscopic data were recovered from electronic reports. Results: Ninety-seven patients underwent 398 prophylactic EBL sessions, 75 men (77.3%) with mean age 59 ± 12 years. Most achieved VE (60.8%), 14.4% had GI bleeding post-therapy, and 15.5% died at 6 months. The rate of variceal obliteration was significantly lower in the pandemic group (40.9% vs. 77.4% in the pre-pandemic group, p = 0.001). Mean number of EBL sessions and pandemic group were independently associated with incomplete VE, while MELD-Na, portal vein thrombosis and failed VE were identified as risk factors associated with mortality at 6 months. Conclusions: Almost 60% of patients in the pandemic group failed to eradicate esophageal varices. Failure to achieve this result conferred a higher risk of GI bleeding and death at 6 months, the latter also significantly associated with the MELD-Na score and portal vein thrombosis. Our study is among the first to demonstrate the impact of COVID-19 in patients receiving prophylactic EBL therapy.

Daily Aspirin Reduced the Incidence of Hepatocellular Carcinoma and Overall Mortality in Patients with Cirrhosis.

Cirrhosis is the primary risk factor for hepatocellular carcinoma (HCC) and gastrointestinal bleeding (GI). We aimed to assess the efficacy and safety of daily aspirin on HCC occurrence, overall survival, and GI bleeding in cirrhotic patients. A total of 35,898 eligible cases were enrolled for analyses from an initial 40,603 cirrhotic patients without tumor history. Patients continuously treated with aspirin for at least 84 days were in the therapy group, whereas those without treatment were controls. A 1:2 propensity score matching by age, sex, comorbidities, drugs, and significant clinical laboratory tests with covariate assessment was used. Multivariable regression analyses revealed that daily aspirin use was independently associated with a reduced risk of HCC (three-year HR 0.57; 95% CI 0.37-0.87; p = 0.0091; five-year HR 0.63, 95% CI 0.45-0.88; p = 0.0072) inversely correlated with the treatment duration [3-12 months: HR 0.88 (95% CI 0.58-1.34); 12-36 months: HR 0.56 (0.31-0.99); and ≥ 36 months: HR 0.37 (0.18-0.76)]. Overall mortality rates were significantly lower among aspirin users compared with untreated controls [three-year HR 0.43 (0.33-0.57); five-year HR 0.51 (0.42-0.63)]. Consistent results were obtained when the laboratory data were included in the propensity score for matching. Long-term aspirin use significantly reduced the incidence of HCC and overall mortality without increasing gastrointestinal bleeding in cirrhotic patients.

Prevalence of gastrointestinal bleeding and frequency of selected predictors of mortality on the medical emergency ward at Mulago hospital.

There was no data on the prevalence of Gastrointestinal bleeding (GI) among patients admitted on the emergency ward at Mulago hospital. This was partly because the medical records were not adequately completed as designed. To estimate the prevalence of gastrointestinal bleeding and the frequency of selected predictors of mortality on the emergency ward. This was a chart review incorporating quality improvement methods in the process of data collection. The health care team was educated on documentation of gastrointestinal bleeding while being assessed weekly for knowledge and practice of completion of the Casualty Assessment form (CAF) from which a documented diagnosis of GI bleeding and selected predictors of mortality were looked for. Of the 1881 CAF assessed, 278 had a documented diagnosis of GI bleeding, resulting in a prevalence of 6.8%. Of the patients with GI bleeding, 14.1% had age greater than 60 years, 24.0% had a systolic blood pressure less than 100mmHg and 44.5% had a heart rate greater than 100 beats per minute. The prevalence of GI bleeding on the medical emergency ward of Mulago hospital is high. This calls for strategies for resuscitative management of this life-threatening medical emergency. Among the selected predictors of mortality, tachycardia was most frequent followed by hypotension. These should always be assessed in a patient with GI bleeding and resuscitative measures with blood transfusion and intravenous fluids undertaken to correct them.

Gastroinstestinal Bleeding in Pediatrics

Gastrointestinal bleeding (GI) may occurs in infants and children. Most etiologies of GI bleeding are mild and self-limited, but may advance into life-threatening condition if not treated properly. Upper GI bleeding and lower GI bleeding can be classified based on bleeding sites that is above or below Treitz ligament. Causes of GI bleeding in infants and children varies according to their age and bleeding sites. Some conditions may be misunderstood as GI bleed such as consumption of certain red coloured food. Diagnosis of gastrointestinal bleeding in children includes complete history taking, thorough physical examination, laboratory examination, radiological examination, and other supportive modality such as endoscopy. Early diagnosis and proper therapy can improve outcomes and prevent severe conditions.

CLINICAL CHARACTERISTICS AND CAUSES OF GASTROINTESTINAL BLEEDING IN&amp;NBSP;CHILDREN

Abstract: Background: Gastrointestinal bleeding (GI) is a complication of many diseases, caused by injury at the gastrointestinal tract or outside the gastrointestinal tract, causing bleeding from mild to severe severity, which can even cause shock and death. The causes of gastrointestinal bleeding vary by age. Objectives: To describe the clinical, subclinical and common causes of non-infectious gastrointestinal bleeding in children. Subjects and methods: Patients from 2 months to 15 years old admitted to Pediatrics Department I, Pediatric Center, Hue Central Hospital from February 2020 to February 2021 with a diagnosis of gastrointestinal bleeding. The study was carried out by cross-sectional descriptive research method. Results: The study included 116 patients, 7 children in the group of 2 months - &lt; 1 year old (6.0%), 36 children in the group 1 - &lt; 6 years old (31%), 36 children in the group 6 - &lt; 11 years old (31.1%) and 37 children in the group of 11-15 years old (31.9%). The mean age was 7.6 ± 4.6. Peptic ulcer disease is the most common cause of GI bleeding, accounting for 37%; 12.9% cases unknown cause. Most of the patients had mild and moderate GI bleeding, about 60.3% and 23.3%; severe bleeding 8.6% and very severe 7.8%. The most common cause of GI bleeding in the group of 2 months - &lt; 1 year old is Mallory-Weiss syndrome and milk protein allergy (22.2%), in the group of 1-5 years old is anal fissure (41.6%) and in children over 6 years old is peptic ulcer disease. Conclusion: The most common causes of gastrointestinal bleeding depend on the age and have different clinical features depending on the cause. Key words: gastrointestinal bleeding in children, melena, hematemesis, hematochezia.

587 The Safety and Efficacy of Thalidomide for the Treatment of Gastrointestinal Bleeding Refractory to Endoscopic Intervention: A Meta-Analysis

INTRODUCTION: Thalidomide's role in patients with gastrointestinal bleeding (GI) secondary to angiodysplasia, cirrhosis, Crohn's disease, portal hypertensive gastropathy, hereditary hemorrhagic telangiectasia and left ventricular assist device which are refractory to endoscopic interventions has not been extensively studied. We conducted a meta-analysis to evaluate the safety and efficacy of thalidomide in the current body of literature. METHODS: A systematic search of Medline was performed from 2000-present. Studies enrolling adults reporting on the use of thalidomide for the treatment of refractory GI bleeding were included. The primary endpoint was the response rate, defined by reduction in frequency or resolution of GI bleed among patients treated with thalidomide. A meta-analysis of proportions was carried out to calculate pooled response rates (with calculation of 95% confidence intervals (CI)). A logistic normal random effects model was employed to account for inter-study heterogeneity and for effect sizes close to 0 and 1. Descriptive statistics were employed to outline the characteristics of included studies. RESULTS: Screening of 182 studies yielded 8 studies, enrolling 171 patients, of whom 99 were females. The most common cause for refractory GI bleed was angiodysplasia followed by left ventricular assist devices. [Figure 1] All patients had GI bleeds refractory to endoscopic therapy and most of the patient population was transfusion dependent. Patients underwent treatment with thalidomide for a median of 4 months, with doses ranging from 50-300 mg daily. The pooled response rate to thalidomide therapy was 77% (95% CI 70-83%). The pooled adverse event rate was 61% (95% CI 42-77%). [Figure 2] Thalidomide was discontinued in 8% (95% CI 1-35%) of the patients due to adverse events. The most common adverse event was peripheral neuropathy, accounting for 12% (95% CI 4-31%) of the adverse events, followed by fatigue, which accounted for 8% (95% CI 1-61%) of adverse events. [Figure 3] No treatment associated mortality was reported. CONCLUSION: Thalidomide for GI bleeding refractory to endoscopic intervention is a potentially efficacious medical therapy which can be considered before any surgical intervention is planned. Most adverse events are mild and self-limiting, though close monitoring for development of neuropathy is advised. Randomized controlled trials to validate the safety and efficacy of thalidomide for the treatment of refractory GI bleeding are warranted.

P4780Effectiveness and safety of non-vitamin k antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease

Abstract Background Patients with atrial fibrillation (AF) often have concomitant valvular heart disease (VHD), especially in Asia. There are limited data on non-vitamin K antagonist oral anticoagulants (NOAC) impact on outcomes for stroke prevention and bleeding for these patients in real world clinical practice. Purpose To investigate the effectiveness and safety of NOACs compared with warfarin in patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHD. Methods We identified oral anticoagulants naive patients with AF and EHRA type 2 VHD from the Korean National Health Insurance Service database between 2014 and 2016 (n=2,671 taking warfarin; n=3,058 taking NOAC). Six clinical outcomes including ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GI), major bleeding, all-cause death, and their composite outcome and fatal clinical events (any events that led to death within 30-day of its occurrence) were evaluated. Inverse probability of treatment weighting (IPTW) method was used to balance covariates between the two groups. Results After weighted using 5% trimmed IPTW method (n=2371 taking warfarin; n=2792 taking NOAC), the mean age was 71.2 years, male was 57% and CHA2DS2-VASc score was 3.9. During a mean 1.4-year follow-up, weighted incidence rate of ischemic stroke, ICH, GI bleeding, and all-cause death were lower in the NOAC group than in the warfarin group. Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.53–0.96), GI bleeding (HR 0.50, 95% CI 0.35–0.72) and major bleeding (HR 0.61, 95% CI 0.45–0.80). Although NOAC and warfarin groups showed similar incidence rate of ICH, NOAC group was associated with a significantly lower risk of fatal ICH compared to warfarin group (HR 0.28, 95% CI 0.07–0.83). Overall, NOACs were associated with a lower risk of the composite outcome (HR 0.68, 95% CI 0.58–0.80). For an exploratory analysis, patients with EHRA type 1 VHD (n=366 taking warfarin; n=345 taking NOAC) was evaluated. In multivariable Cox regression analysis, NOAC group showed a comparable risk of ischemic stroke, ICH, all-cause death and composite outcome. Clinical outcome in AF patients with VHD Conclusion In this nationwide Asian AF population with EHRA type 2 VHD, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin.

TCTAP A-039 Gastrointestinal Bleeding Events with or Without Proton Pump Inhibitors Among Patients Post Primary Percutaneous Coronary Intervention

Gastrointestinal bleeding (GI) is a known complication after primary coronary intervention while on dual antiplatelet therapy (DAPT). About 0.7%-3% of patients with acute coronary syndrome (ACS) may develop acute GI bleeding after PCI. However, in studies involving the Asian population, the risk of

Pulmonary Artery Pulsatile Index (PAPi) Score May Predict Risk of Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device

Purpose Gastrointestinal bleeding (GIB) is one of the most common complications following left ventricular assist device (LVAD) implantation. Correlation of right heart failure and GIB after LVAD has previously been demonstrated, however no predictive scores have been developed to identify those at risk. The purpose of this this study was to determine if pulmonary artery pulsatility index (PAPi) is a predictor of GIB post LVAD implantation. Methods We retrospectively reviewed electronic medical records of LVAD patients in our institution from 2015 to 2018. All patients with a clinically significant GIB were selected for analysis and compared to a random cohort of matched patients without GIB. A clinically significant GIB was defined as a drop in Hemoglobin >2 g/dL, clinical signs or symptoms of GIB and/or need for transfusion of packed red blood cells. PAPi score was calculated using pre-operative hemodynamics and comparisons between the two groups were completed using a Pearson correlation coefficient. Results A total of 110 LVAD patients were included, 53 were identified to have clinically significant GIB bleeding and were compared to 57 controls. The GIB cohort was found to be more likely to have a PAPi Conclusion PAPi has been shown to be a powerful predictor of right ventricular failure following LVAD implantation. Our study demonstrates that PAPi may also predict other clinically significant outcomes, specifically GIB.

Ten New Cases of Hermansky-Pudlak Syndrome in the Iberian Peninsula: Identification of Novel Genetic Variants in HPS3, HPS4, HPS6 and DTNBP1 Associated with Significant Clinical Complications

IntroductionHermansky-Pudlak syndrome (HPS) is an inherited platelet disorder characterized by bleeding diathesis, oculocutaneous albinism (OCA) and, sometimes, serious clinical complicationssuch as immunodeficiency, granulomatous colitis, and/or pulmonary fibrosis. Heterogeneous clinical symptoms and a large number of possible genetic culprits (10 HPS genes, >120 exons) complicate an unequivocal diagnosis of HPS. This study aimed to assess the clinical and platelet phenotype in ten patients with suspected HPS, and to identify the underlying genetic defects.MethodsTen patients from six families (F1 and F3 were Spanish, F2 was Turkish and F4, F5 and F6 were Portuguese) presenting with OCA (confirmed by skin biopsy) and bleeding diathesiswere included. Bleeding was evaluated by ISTH-BAT score. Phenotyping included, in patients with fresh blood samples available, platelet aggregation and ATP release, flow cytometry (FC), 14C-serotonin uptake and whole-mount electron microscopy (EM). Patients DNA was analyzed using two different targeted panels by high throughput sequencing (HTS). Sequence variants classification was performed according to ACMP recommendations.ResultsPatient characteristics are summarized in table 1. In F1, that had no history of consanguinity, there were two affected sisters. Patients 1 (P1) had several episodes of gastrointestinal bleeding (GI), which was attributed to granulomatous colitis. F2 is a consanguineous Turkish family, were P3 had severe rectal bleeding, requiring colectomy combined with ileostomy surgery. Pathological examination of the colon was reported as non-granulomatous colitis. Her older sister (P4) had exhibited dyspnea and shortness according to diffuse bilateral pulmonary fibrosis (BPF) diagnosis. In F3, P5 had been referred with acute GI bleeding secondary to angiodysplasia. In the non-consanguineous F4, HPS was first confirmed in P6, who showed blonde hair, nystagmus and low visual acuity; his older sister was diagnosed with HPS later, at the age of 56 years old (P7), because her OCA was masked using dark brown hair-coloring products. In P8, born from a non-consanguineous family (F5), HPS was suspected early in life, four months of age, upon recognition of OCA, nystagmus, deep visual deficiency and exotropia with compensatory torticollis. Lastly, in the consanguineous Portuguese family (F6), the two affected children (P9 and P10) had also showed a horizontal and torsional nystagmus and reduced visual activity. P10 also suffered from epilepsy and mild development delay. In phenotyping studies, the Spanish patients (P1, P2, P5) showed impaired platelet aggregation to mild agonists and reduced platelet dense granules by FC and EM. No platelet studies could be performed in F2. In Portuguese patients (F4, F5 and F6), the ATP release studies demonstrated a dense granule deficiency (Table 1). Molecular diagnosis was achieved, as a first-line approach, by means of HTS gene panels that revealed: a) F1 (P1 & P2) a homozygous deletion c.2054delC (p.P685L fs17*) in exon 13 of the HPS4, which had been previously reported in one Asian patient who showed BPF; b) F2 (P3 & P4): anovel missense homozygousvariant c.272T>C (p.L91P) in exon 4 of the HPS4. Remarkably, the phenotype of the two Turkish sisters was different, with one having had severe GI bleeding requiring colectomy, and the other had developed BPF. C) F3 (P5): a novel heterozygous variant c.2464C>T (p.R822*) in exon 13 of the HPS3 was detected; d) F4 (P6 & P7) and F5 (P8): here a nonsense variant c.307C>T (p.Q103*) was identified in exon 5 of the DTNBP1, which was previously reported in a Portuguese patient. E) F6 (P9 & P10): these patients carried a novel five base pair duplication in the single exon of HPS6, c.60_64dup (p.L22R fs*33).ConclusionsThis study reports 10 new HPS patients, which demonstrates the heterogeneous nature of this syndrome and the complex phenotype-genotype correlations. The novel HTStechnology has facilitated the molecular diagnosis of HPS in these patients. Among the underlying molecular pathology, we identified a novel p.L91P variant in HPS4 that is associated with a severe clinical phenotype.FundingGerencia Regional de Salud (GRS 1647/A/17), Fundación Séneca (19873/GERM/15), Instituto de Salud Carlos III (ISCIII, PI17/01966, PI17/01311,CB15/00055), Grupo de trabajo SETH and Instituto de Investigación Biomédica de Salamanca (IBSAL, IBY17/00006). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

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

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

Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device

Modern left ventricular assist devices (LVAD) require anti-coagulation (AC) with warfarin and anti-platelet therapy to prevent thromboembolic complications in patients. Gastrointestinal bleeding (GI) is a significant adverse event in these patients and treatment typically requires reduction or elimination of AC or anti-platelet therapy. It is not known whether alterations in AC to treat GI bleeding influence subsequent risk of thromboembolic (TE) events during LVAD support. Between July 2003 and September 2011, 389 patients (308 male) underwent implantation of a continuous-flow LVAD at the University of Michigan Health System and the Mayo Clinic. Median age at implant was 60 years (range 18 to 79 years). Outcomes were analyzed for the association of GI bleeding events and subsequent TE events, defined as stroke, transient ischemic attack, hemolysis or suspected or confirmed pump thrombosis. Median survival was 10 months (maximum 7.2 years, total 439 patient-years). TE events occurring within the first 30 days were not counted. Overall survival and freedom from an outcome event were assessed using the Kaplan-Meier method. Associations between GI bleeding and subsequent TE events and survival impact were analyzed as time-dependent covariates. One hundred ninety-nine GI bleeding episodes occurred in 116 of 389 patients (30%) for an event rate of 0.45 GI bleed/patient-year of support. One hundred thirty-eight TE events occurred in 97 of 389 patients (25%) for an event rate of 0.31 TE event/patient-year of support. Median time from LVAD implant to first GI bleed was 5 months (range 1 to 116 months) and to first TE event was 6 months (range 1 to 29 months). For patients who had a TE event after GI bleed, the median interval was 5 months (range 0.5 to 25 months). TE events were 7.4-fold more likely in patients who had a prior GI bleed (range 4.9- to 11.1-fold) (p < 0.001); however, neither the presence of GI bleeding (0.7 to 1.2) nor a TE event (0.8 to 2.0) portended a lower overall survival. Patients who had GI bleeding were at significantly higher risk for a subsequent TE event. Although the exact cause of this relationship is unknown, it suggests that a reduction in anti-coagulation and anti-platelet management to treat GI bleeds may contribute to this risk.

Adams–Oliver syndrome and portal hypertension: Fortuitous association or common mechanism?

Adams-Oliver syndrome (AOS) is a rare condition defined by combination of cutis aplasia and transverse limb abnormalities. Some authors have described a possible association between this syndrome and portal hypertension (PH) due to hepatoportal sclerosis (HPS). We present a boy with AOS who developed a progressive splenomegaly and hypersplenism at the age of 2 months, and was admitted for acute gastrointestinal bleeding (GI) at the age of 9 months. Subsequently, we documented an extrahepatic portal vein obstruction and esophageal varices. After several episodes of cataclysmic upper GI bleeding a mesentero-portal shunt (MPS) was performed at 10 months. The shunt thrombosed, and after three failed attempts of thrombectomy, it was removed. One month later a splenorenal shunt was performed, and this closed spontaneously by 3 years. The patient suffered from ischemic stroke after placing the first shunt, and has spastic diplegia, left frontal lobe epilepsy, hyperactivity and attention deficit disorder, and severe psychomotor delay. At 11 years and he presented with chronic liver failure and hyperammonemia and coagulopathy. We hypothesize that there may be an early embryonic vascular abnormality (vascular disruption) that may explain these vascular phenomena.

Report of a Case of Heyde's Syndrome Diagnosed by Abnormal Closure Times Despite Normal Von Willebrand's Activity

AbstractAbstract 1403In 1958, EC Heyde described a syndrome of iron deficiency anemia due to gastrointestinal bleeding (GI) in a patient with calcific aortic stenosis. In 1992, Warkentin et al. hypothesized a bleeding diathesis due to a link between Heyde's Syndrome and acquired Von Willebrand Syndrome. This bleeding syndrome has now been shown to result from the loss of the largest multimers of von Willebrand Factor (VWF) and is therefore classified as acquired Type 2A Von Willebrand Syndrome. Hypotheses suggest that the high shear stresses that are obtained in tortuous angiodysplastic lesions work with this deficiency of VWF, to produce gastrointestinal bleeding that is notoriously difficult to elucidate on endoscopy. It has been shown repeatedly that replacement of a stenotic aortic valve results in cessation of bleeding. Here we present a case of Heyde's Syndrome diagnosed with abnormal Closure Times and normal VWF Ristocetin cofactor activity. In this case, a 79-year-old man with known aortic stenosis and several episodes of GI bleeding was cured of a life threatening hemorrhage after the replacement of his stenotic aortic valve. At the time of his first notable gastrointestinal bleed, a tagged RBC scan showed a source of hemorrhage in the small bowel. Subsequently, two video capsule endoscopies showed jejunal angiodysplasia. After recurrent bleeding episodes, this patient presented with a life-threatening GI hemorrhage, which, in the context of aortic stenosis, raised the suspicion for Heyde's Syndrome. At this time, he presented with hematochezia requiring massive transfusions, and admission to the Intensive Care Unit. A tagged RBC scan showed active bleeding in a location that matched previous scans. The following tests were within normal limits: Factor VIII (1.53), VWF Ag (1.26), VWF:Rco activity (1.11), and the ratio of VWF Ag/VWF:Rco (0.88). However, the Dade Behring PFA-100 platelet function analyzer demonstrated that Closure Times with collagen/adenosine (> 300 sec) and with collagen/epinephrine (> 300 sec) were prolonged. In the clinical context consistent with Heyde's Syndrome, the patient's native aortic valve was replaced with a 21mm Carpentier-Edwards Magna Ease Bovine valve. As is classic for this syndrome, the valve replacement was curative. Since the surgery, the patient has not required further transfusions or interventions for gastrointestinal hemorrhage. In this case, our observations are consistent with previous reports by Warkentin et al. and Vincentellli et al. What is unique about our current report is that we measured both Ristocetin cofactor activity and Closure Times, two commonly available assays in most coagulation laboratories. Ristocetin cofactor activity is the current gold standard for measuring platelet function activity but may miss activities under high shear stress. The Closure Time, on the other hand, is able to detect defects in platelet aggregation under such conditions and may be the only manner by which such abnormalities in VWF function are detected. Therefore, we conclude that Closure Times should be used to screen for acquired Von Willebrand's Syndrome in Heyde's Syndrome. Disclosures:No relevant conflicts of interest to declare.

Embolization for gastrointestinal hemorrhages

Retrospective evaluation of interventional embolization therapy in the treatment of gastrointestinal hemorrhage over a long-term observation period from 1989 to 1997. Included in the study were 35 patients (age range 18-89 years) with gastrointestinal bleeding (GI) referred for radiological intervention either primarily or following unsuccessful endoscopy or surgery. Sources of GI bleeding included gastric and duodenal ulcers (n = 7), diverticula (n = 3), erosion of the intestinal wall secondary to malignancy (n = 6), vascular malformations (n = 4), and hemorrhoids (n = 2), as well as from postoperative (n = 6), posttraumatic (n = 2), postinflammatory (n = 4) or unknown (n = 1) causes. Ethibloc (12 cases) or metal coils (14 cases) were predominantly used as embolisates. In addition, combinations of tissue adhesive and gelfoam particles and of coils and Ethibloc were used (six cases). Finally, polyvinyl alcohol particles, a coated stent, and an arterial wire dissection were utilized in one case each. Bleeding was stopped completely in 29 of 35 cases (83%). In one case (3%) the source of bleeding was recognized but the corresponding vessel could not be catheterized. In five other cases (14%) there was partial success with reduced, though still persistent, bleeding. The rate of complications was 14%, including four instances of intestinal ischemia with fatal outcome in the first years, and, later, one partial infarction of the spleen without serious consequences. Gastrointestinal hemorrhage can be controlled in a high percentage of patients, including the seriously ill and those who had previously undergone surgery, with the use of minimally invasive interventional techniques. The availability of minicoils instead of fluid embolization agents has reduced the risk of serious complications.