Life-threatening Gastrointestinal Bleeding Research Articles

A Rare Cause of Lower Gastrointestinal Bleeding: Rectal Dieulafoy’s Lesion

Dieulafoy’s lesion is rare cause of life-threatening gastrointestinal bleeding. Mortality is high if not early diagnosed and treated properly. Thus, it must be excluded and treated in patients with GIB as fast as possible. These lesions are usually observed in upper gastrointestinal system and mostly in the stomach. It is very rare in rectum. Here we report a rare case of lower gastrointestinal bleeding caused by rectal Dieulafoy’s lesion.

Comparative assessment of long-term survival of patients after primary and recurrent myocardial infarction: a data from the RIMIS registry

Aim. To compare the long-term prognosis of life of patients after primary and recurrent acute myocardial infarction (MI).Material and methods. The study was based on the RIMIS registry, which included all patients after transmural MI in 2017 in one of the Moscow vascular centers. The prospective part included 191 patients who survived the acute stage of MI, of which 145 suffered a primary acute MI, 46 — a recurrent acute MI. Long-term follow-up data were collected 71 (53;75) months after discharge from the hospital. The primary endpoint was any-cause death.Results. During the follow-up period, 35 (25,2%) patients with a primary MI and 25 (64,1%) patients with a recurrent MI died (p<0,001). It was not possible to establish the fate of 13 (6,81%) patients, of which 7 (4,83%) were people with primary MI and 6 (13,04%) people with recurrent MI. The death risk was significantly higher in patients who had a recurrent MI compared to patients who had a primary MI: hazard ratio (HR)=3,52 (2,09;5,96), p<0,001). An unfavorable prognosis was determined not by the fact of a recurrent MI, but by the complications that resulted from a previous MI, primarily heart failure, as well as age, sex, smoking status, and hospitalizations for cardiovascular diseases in the year before the reference MI, history of angina and following comorbidities: a prior stroke, major bleeding (life-threatening gastrointestinal bleeding requiring complex surgical intervention). Patients who had a recurrent MI were significantly more adherent to follow-up and prescribed therapy.Conclusion. Despite the modern strategy for treating MI both in the acute stage and in the long-term period, the prognosis after recurrent MI remains unfavorable. Signs negatively affecting the prognosis were sex, age, a history of heart failure and angina pectoris, and hospitalizations for cardiovascular diseases one year prior to reference MI.

Histopathological features of idiopathic portal hypertension: A systematic review and meta-analysis.

Portal hypertension (PH) is a clinically significant entity that could present with life-threatening gastrointestinal bleeding. Cirrhosis is the most common cause of PH, with well-documented histopathology and etiology. However, in idiopathic portal hypertension (IPH), no single histopathologic finding is associated with PH. Our systematic review aims to identify and summarize the prevalence of the common histological findings of IPH. We systematically searched PubMed, Cochrane CENTRAL, Web of Science, and Scopus till 1ST March 2022 for studies describing the histopathological features of IPH. Data were extracted from eligible studies and pooled as events rate and 95% confidence interval (CI) using binary random-effects model by open meta-analyst software. We included 23 retrospective studies with a total sample size of 813 patients. The overall incidence of nodular regenerative hyperplasia was 38.6%, 59.8% for portal fibrosis, 51.3% for periportal fibrosis, 39.3% for perisinusoidal fibrosis, 89.8% for portal vein sclerosis, 42.2% for portal inflammation, 53.3% for mega-sinusoids, 39.5% for thickening of portal vein branches, 93.8% for narrowing of portal veins, 53.3% for hepatic veins/venous outflow obstruction, 51.4% for aberrant portal/periportal vessels, 42.4% for shunt vessel, 50.9% for ductular proliferation, and 16.3% for steatosis. Due to the relatively non-pathognomonic and non-specific nature of IPH, a combination of different histological features such as the portal and periportal fibrosis, portal vein sclerosis, mega-sinusoids, narrowing of portal veins, hepatic venous outflow obstruction, aberrant portal or periportal vessels, and ductular proliferation may be of value in diagnosing IPH as the incidence rate of these features was at approximately 50%.

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis.

Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies. A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH. All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark). Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06-0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01-0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01-0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20-1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy. This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients. This study has been registered on the PROSPERO database with the registration number CRD42023483764.

Definition of factor Xa inhibitor-related, life-threatening gastrointestinal bleeding and guidance on when to use reversal therapy: A Delphi panel.

To define and contextualize life-threatening gastrointestinal (GI) bleeding in the setting of factor Xa (FXa) inhibitor therapy and to derive a consensus-based, clinically oriented approach to the administration of FXa inhibitor reversal therapy. We convened an expert panel of clinicians representing specialties in emergency medicine, gastroenterology, vascular medicine, and trauma surgery. Consensus was reached among the clinician panelists using the Delphi technique, which consisted of 2 survey questionnaires followed by virtual, real-time consensus-building exercises. Hypovolemia and hemodynamic instability were considered the most important clinical signs of FXa inhibitor-related, life-threatening GI bleeds. Clinician panelists agreed that potentially life-threatening GI bleeding should be determined on the basis of hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. Last, the panel agreed that all patients with life-threatening, FXa inhibitor-associated GI bleeding should be considered for FXa inhibitor reversal therapy; the decision to reverse FXa inhibition should be individualized, weighing the risks and benefits of reversal; and when reversal is elected, therapy should be administered within 1h after initial emergency department evaluation, when possible. Consensus-based definitions of life-threatening GI bleeding and approaches to FXa inhibitor reversal centered on hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. The results from this Delphi panel may inform clinical decision-making for the treatment of patients experiencing GI bleeding associated with FXa inhibitor use in the emergency department setting.

Life-threatening "hyper-progression" on immunotherapy revealed as pseudo-progression in DNA mismatch repair deficiency: a case report.

Distinguishing pseudo-progression from true progression on immunotherapy remains a clinical challenge. Clinical tools to aid in this task are currently lacking. DNA mismatch repair (MMR) status is a known predictive marker for anti-programmed death (PD)-1 therapy, but its role in helping to address this situation is not well-defined. We report the first case, to our knowledge, of life-threatening hyper-progression which was later revealed to be pseudo-progression in a patient with a deficient MMR (dMMR) tumor. We describe a 62-year-old man with advanced dMMR gastric cancer who was being treated with pembrolizumab monotherapy. After three doses of pembrolizumab he exhibited signs and symptoms that met all applicable definitions of hyper-progression in the setting of acute life-threatening gastrointestinal hemorrhage, extensive radiographic progression of metastases, and increasing carcinoembryonic antigen (CEA). Comfort measures were considered given the appearance of hyper-progression. But partly given the patient's request, aggressive support was provided, including blood products, vasopressors, and splenic artery embolization. His condition improved, and subsequent scans revealed regression of his metastases and decreased CEA, confirming pseudo-progression. Pembrolizumab was restarted. The patient remains on pembrolizumab with minimal tumor burden more than one year later. This case demonstrates that life-threatening hyper-progression can represent pseudo-progression and suggests that MMR status could be important to consider in determining the aggressiveness of clinical management during apparent hyper-progression.

Mechanisms of action of rebamipide in the treatment of chronic erosive gastritis patients with type 1 diabetes mellitus

Introduction. Type 1 diabetes mellitus (DM-1) and its complications pose a serious medical and social problem. Erosive changes in the gastric mucosa are among the most common lesions of the digestive system in diabetes mellitus, and can lead to life-threatening gastrointestinal bleeding and early disability of patients.Aim. Substantiation of the effectiveness of rebamipid course treatment based on an assessment of the functional state and antioxidant activity of the supraepithelial gastric mucosa in chronic erosive gastritis in patients with DM-1.Materials and methods. A comprehensive examination of 12 DM-1 patients with erosive gastritis and 11 healthy individuals was carried out, including FGDS with biopsy of the antrum mucosa and stomach body, exclusion of Helicobacter pylori infection, determination of the biochemical composition of structural glycoproteins of mucus and the concentration of degraded glycoproteins, evaluation of the antiradical activity of the supraepithelial mucous layer of the stomach.Results and discussion. In chronic erosive gastritis in patients with DM-1, a significant predominance of degraded monosaccharides in the supraepithelial mucous layer of the stomach was revealed (6 times higher than in healthy individuals), a decrease in the concentration of polymerized glycoproteins in gastric mucus (21% vs. 80%) and a significant increase in the antiradical activity of mucus. Course treatment of chronic erosive gastritis in patients with type 1 diabetes with rebamipid at a dose of 100 mg 3 times a day for 3 weeks contributes to the normalization of the indicators of glycoproteins of native mucus, antiradical activity of the mucosa and complete epithelization of the erosions of the antrum of the stomach.Conclusions. The use of rebamipid in the treatment of chronic erosive gastritis in patients with type 1 diabetes contributes to reducing the degradation of polymerized glycoproteins of native mucus, normalizing the antiradical activity of the mucosa and complete epithelization of erosions of the antrum of the stomach.

A rare case of jejunal diverticula with bone causing sub-acute intestinal obstruction

Jejunal diverticula is a rare condition, usually remains asymptomatic though sometimes presents as vague abdominal pain and in the rare case may present as a life-threatening gastrointestinal (GI) bleed. In this case, the patient presented with features of subacute intestinal obstruction and contrast enhanced computed tomography (CECT) abdomen suggested intraluminal obstruction due to impacted bone in the small bowel. The patient underwent exploratory laparotomy, there were jejunal diverticula with bone as a foreign body, and a was ileal stricture causing an obstruction. Jejunal diverticula with bone as a foreign body is a rare case, requiring high suspicion index and relevant investigations for reaching a diagnosis.

S2581 Colonic Dieulafoy’s Lesions: An Elusive Source of Gastrointestinal Bleeding

Introduction: Dieulafoy’s lesions (DL) are abnormally dilated submucosal vessels, protruding out of minute erosions in the gastrointestinal (GI) mucosa. They are responsible for less than 2% of acute GI bleeding and are relatively rare to find in the colon. While recent advances in endoscopy allow for better detection of DL, subtle intermittently bleeding lesions may easily be overlooked. Thus, DL can be challenging to diagnose, and its true incidence remains unknown. In this series, we present three cases of GI bleeding due to colonic DL. Case Description/Methods: Case 1: A 42-year-old woman with renal disease on hemodialysis presented with one month of generalized weakness, melena, and a three-point hemoglobin drop from baseline. During esophagogastroduodenoscopy, she developed acute onset hematochezia and hemorrhagic shock. A small focus of active extravasation at the hepatic flexure was identified on CT angiography but subsequent angiography performed by interventional radiology was negative for active extravasation. On colonoscopy, an actively bleeding DL in the hepatic flexure was identified. Two hemostatic clips (HC) were successfully placed with no further bleeding. Case 2: A 66-year-old man with congestive heart failure, admitted with cardiogenic shock developed intermittent episodes of hematochezia requiring packed red blood cells (pRBC). On colonoscopy, he was found to have an actively bleeding DL at the cecum. Despite four HC and hemostatic spray, his bleeding persisted, and he underwent successful embolization, guided by clip location. Case 3: A 90-year-old man with coronary artery disease presented with two weeks of melena and a four-point hemoglobin drop from baseline. He was transfused three units of pRBC and on colonoscopy, an actively bleeding DL was found at the hepatic flexure. Three HC were placed with cessation of bleeding. Discussion: Colonic DL, although rare, can cause life-threatening GI hemorrhage. Patients may be asymptomatic or present with melena, hematochezia, or bright red blood per rectum. At present, endoscopy is the preferred diagnostic modality for DL followed by angiography. The endoscopic management of colonic DL primarily involves epinephrine injection, clipping, and/or laser coagulation to achieve hemostasis. Interventional radiology or surgical intervention may be required in severe or refractory cases. It is imperative to maintain a high index of suspicion for colonic DL to arrive at an accurate diagnosis and initiate prompt treatment (Figure 1).Figure 1.: (A) Case 1 Colonic DL in the hepatic flexure (B) Case 1 post-clipping (C) Case 2: Colonic DL in the caecum (D) Case 2 post clipping (E) Case 3 Colonic DL in the hepatic flexure (F) Case 3 post clipping.

S2674 Sometimes You Have to “Dig a Little Deeper:” A Case of a Dieulafoy Lesion Leading to a Life-Threatening Gastrointestinal Bleed in a 30-Year-Old Male

S2674 Sometimes You Have to “Dig a Little Deeper:” A Case of a Dieulafoy Lesion Leading to a Life-Threatening Gastrointestinal Bleed in a 30-Year-Old Male

Life-threatening gastrointestinal bleeding caused by jejunal heterotopic gastric mucosa in an adult dog: a rare case report

BackgroundHeterotopic gastric mucosa has been scarcely reported in the veterinary literature. Its presence can be asymptomatic or associated with various clinical signs ranging from apathy, vomiting, to abdominal pain. This report illustrates the presence of heterotopic gastric mucosa in the jejunum of an adult dog. It is the first to describe severe anemia, requiring acute blood transfusion, following intestinal hemorrhage caused by heterotopic gastric mucosa.Case presentationA twelve-year-old, intact male Maltese dog was presented with a history of apathy, vomiting and anemia. The dog was on a strict diet for recurrent diarrhea, food intolerance and skin allergy. Clinical examination revealed severe anemic mucous membranes and painful abdominal palpation. Blood examination confirmed severe regenerative anemia. Ultrasonography showed an intestinal neoplasm, gall bladder sludge and non-homogeneous liver parenchyma. Three-view thoracic radiographs failed to show any metastatic lesions or enlarged lymph nodes. After initial stabilization and blood transfusion, a midline exploratory laparotomy was performed. Three different masses were found in the jejunum. Resection and anastomosis of approximately 40 cm of jejunum was performed, followed by liver and lymph node biopsy and placement of an esophagostomy tube. Two days after surgery the dog started to clinically improve and was discharged from the hospital on the sixth day after surgery. Histopathology revealed the intestinal masses to be heterotopic gastric mucosa associated with intramural cystic distensions, multifocal ulceration and bleeding into the intestinal lumen. Two years after surgery, the dog did not have a recurrence of anemia or gastrointestinal signs.ConclusionsThis case demonstrates that heterotopic gastric mucosa can be considered one of the differential diagnoses in case of severe anemia due to gastrointestinal hemorrhage and suspected intestinal tumors. Although in most described cases in literature the finding seems to be incidental on necropsy, our report shows that heterotopic gastric mucosa can be the etiology of life-threatening signs. In addition, because no recurrent diarrhea episodes occurred after surgical resection of the ectopic tissue, it is likely that the heterotopic gastric mucosa was the cause of the food intolerance signs in this dog.

Gastrointestinal bleeding as a life-threatening complication of liver abnormality in a Turner syndrome patient

Background: Turner syndrome is a rare condition with high morbidity and mortality rates, it leads to multiple organ damage when left untreated. Meanwhile, liver involvement in this condition ranges from asymptomatic to severe such as cirrhosis with massive gastrointestinal bleeding. This study presents a case of gastrointestinal bleeding due to cirrhosis in Turner syndrome where the patient showed third-grade esophageal varices as a sign of portal hypertension. Case Presentation: A 26-years old female came to the Emergency Department of Dr. Soetomo General Hospital in Surabaya with massive gastrointestinal bleeding. The patient was a Turner syndrome, diagnosed ten years ago. The patient was negative for hepatitis B surface antigen (HbsAg) and anti-hepatitis C virus (anti-HCV). The gastric lavage was performed to reduce active bleeding with blood transfusion. The upper gastrointestinal endoscopy indicated portal hypertension with third-grade esophageal varices, fibro scan indicated cirrhosis hepatic and abdominal CT-scan showed early cirrhosis and splenomegaly supporting the presence of portal hypertension. Since the patient refused to endoscopic varices ligation, hematemesis repeated three times after the first visit resulting death of the patient. Conclusion: This is a Turner syndrome patient who experienced life-threatening gastrointestinal bleeding as complication of liver abnormality. This case highlights that liver cirrhosis should be evaluated in individuals with Turner syndrome to prevent such complications.

Coats plus syndrome: a rare cause of severe gastrointestinal tract bleeding in children \u2013 a case report

BackgroundCoats plus syndrome, cerebroretinal microangiopathy with calcifications and cysts, is a rare disease with autosomal recessive pattern occurring due to a mutation in CTC1, encoding conserved telomere maintenance component 1, gene. Besides retinal involvement, abnormalities in brain and osteopenia, serious life-threatening bleeding in gastrointestinal tract and portal hypertension can be observed.Case presentationA 6-year-old girl with Coats plus syndrome presented to the pediatric emergency department with vomiting blood and blood in stool. An upper and lower gastrointestinal endoscopy revealed esophageal varices and vascular telangiectasia in the pyloric antrum, duodenum, and colon. She received palliative care and the bleeding was stopped after receiving intravenous octreotide. She then was followed in the pediatric gastroenterology, neurology, and ophthalmology clinics. She was later hospitalized and admitted to the intensive care unit as she continued to have intermittent gastrointestinal system bleeding. She eventually died due to severe gastrointestinal system bleeding.ConclusionsCoats plus syndrome can lead to life-threatening gastrointestinal bleeding and portal hypertension. As Coats plus syndrome is quite rare, there is little published data on this syndrome. This report presents a case of Coats plus syndrome as a rare cause of gastrointestinal bleeding and portal hypertension.

S2325 Life-Threatening Gastrointestinal Hemorrhage as a Complication of a Cholecystogastric Fistula

S2325 Life-Threatening Gastrointestinal Hemorrhage as a Complication of a Cholecystogastric Fistula

Physicians\u2019 decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015

BackgroundPhysicians’ decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians’ decision.MethodsA postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians’ background factors and attitudes on their decision were assessed.ResultsThe response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family’s benefit on the decision-making decreased, whereas the influence of the patient’s benefit and ethical values as well as the patient’s or physician’s legal protection increased from 1999 to 2015.ConclusionsPhysicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.

"Endoshield": A Physical Protective Box for Pediatric Endoscopy during the COVID-19 Pandemic.

Background/Aims:The coronavirus disease (COVID)-19 pandemic presents challenges for gastrointestinal endoscopy. Although the virus is transmitted through contact and droplets, aerosol-generating procedures produce aerosols that can spread through airborne routes. Several gastrointestinal societies have released statements to protect patients and health care providers (HCPs). This study describes a barrier box that may be used as an adjunctive device in addition to personal protective equipment during endoscopies. Methods:A transparent acrylic box called “Endoshield” was created to place over patient’s head and shoulders and was tested for its ease of use for the endoscopist and suitability for patient size and position. Results:Twelve children (66.67%, male) with a median age of 9 years (range, 2–11 years) underwent emergency or urgent endoscopy between April and June 2020 during the COVID-19 outbreak. The most common presenting symptom was life-threatening gastrointestinal bleeding (8/12, 66.67%), while the rest had urgent symptoms (4/12, 33.33%). The “Endoshield” was suitable for all patient positions (left lateral position: 9/12, 75% and supine position: 3/12, 25%). The patients and HCPs were followed up for their symptoms on day 14, and none of them had any symptoms of concern. Conclusions:The “Endoshield” is affordable, reusable, and suitable for both positions.

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization.

Background: Multivisceral transplantation entails the en-bloc transplantation of stomach, duodenum, pancreas, liver and bowel following resection of the native organs. Diffuse portomesenteric thrombosis, defined as the complete occlusion of the portal system, can lead to life-threatening gastrointestinal bleeding, malnutrition and can be associated with liver and intestinal failure. Multivisceral transplantation is the only procedure that offers a definitive solution by completely replacing the portal system. However, this procedure is technically challenging in this setting. The aim of this study is to describe our experience, highlight the challenges and propose technical solutions.Materials and Methods: We performed a retrospective analysis of our cohort undergoing multivisceral transplantation for diffuse portomesenteric thrombosis at our institution from 2000 to 2020. Donor and recipient demographics and surgical strategies were reviewed in detail and posttransplant complications and survival were analyzed.Results: Five patients underwent MVTx. Median age was 47 years (23–62). All had diffuse portomesenteric thrombosis with life-threatening variceal bleeding. Major blood loss during exenteration was avoided by combining two techniques: embolization of the native organs followed by a novel, staged extraction. This prevented major perioperative blood loss [median intra-operative transfusion of 3 packed red blood cell units (0–5)]. Median CIT was 330 min (316–416). There was no perioperative death. One patient died due to invasive aspergillosis. Four others are alive and well with a median follow-up of 4.1 years (0.3–5.9).Conclusions: Multivisceral transplantation should be considered in patients with diffuse portomesenteric thrombosis that cannot be treated by any other means. We propose a standardized surgical approach to limit the operative risk and improve the outcome.

Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines.

Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.

Australian and New Zealand Registry of Anticoagulation in the Obese: Prescribing Patterns, Drug Levels and Patient Outcomes

Background: There is limited data to guide prescribing of all available anticoagulants in obese patients, in particular those weighing &amp;gt; 150kg or with a BMI &amp;gt; 40kg/m2. We aimed to examine anticoagulant prescribing patterns in obese patients in Australia and New Zealand including choice of agent and dosing, determine whether patients with obesity achieve appropriate direct oral anticoagulant (DOAC) levels and evaluate the efficacy and safety of anticoagulation in obese patients. Methods: Patients with a BMI &amp;gt; 35kg/m2 or weight &amp;gt; 120kg receiving anticoagulant therapy are prospectively identified at 7 sites in Australia and New Zealand. Demographic data, indication for anticoagulation and choice of anticoagulant are collected at baseline. At follow-up visits, drug specific levels, dose adjustments and clinical progress (symptoms, imaging, recurrent thrombosis and adverse events) are recorded. Results: 155 patients have been recruited across seven sites (recruitment ongoing). The median age of patients was 53 (range 22-85) and 49% of patients were male. 77 (50%) of patients were anticoagulated for pulmonary embolus (PE) while 40% were anticoagulated for deep vein thrombosis (DVT) without PE. Initial anticoagulant prescribed was apixaban in 37 patients, dabigatran in 4 patients, rivaroxaban in 57 patients, low molecular weight heparin (LMWH) in 29 patients and warfarin in 28 patients (Table 1). A subset of patients initially received LMWH for 5-14 days prior to transition to a DOAC (rivaroxaban in 7, dabigatran in 6). There was cross-over between agents during the study period. Table 2 demonstrates median peak and trough DOAC levels. All peak apixaban levels and 25 of 37 (68%) peak rivaroxaban levels were within the therapeutic ranges published by the International Council for Standardization in Haematology (Gosselin, Thromb Haemost. 2018). Assessment of appropriate trough levels was limited by the limit of detection at different laboratories. 27 patients receiving enoxaparin had at least one peak Anti-Xa level (target peak 0.5-1.2U/ml). The median enoxaparin dose to achieve therapeutic peak Anti-Xa was 0.9mg/kg (range 0.52-1.3). 15 patients weighing &amp;gt; 150kg had a recorded peak Anti-Xa, 10 of these patients were prescribed a capped dose of 150mg BD (weight range 155-290kg) and nine had a therapeutic Anti-Xa and one had a supratherapeutic Anti-Xa measurement. One patient had a PE on apixaban 5mg twice daily (in the setting of suspected non-compliance), one patient had a new confirmed PE after 4 days of non-compliance with rivaroxaban 20mg daily and another patient had a confirmed recurrence on therapeutic warfarin. 1 patient had a PE when warfarin was withheld for emergency surgery. An equivocal recurrence occurred on enoxaparin with a supratherapeutic Anti-Xa (1.76 U.ml) and 1 DVT occurred on dabigatran for a cardiac indication (no drug level available). One patient had recurrent superficial thrombophlebitis on rivaroxaban 20mg daily (peak 301ng/L and trough &amp;lt;30ng/L). There was one episode of life-threatening gastrointestinal bleeding on dabigatran. Conclusion: There is limited data to guide prescribing of all anticoagulants in obese patients, in particular in patients weighing &amp;gt; 150kg or BMI &amp;gt; 40kg/m2. There is increasing use of DOACs in Australia and New Zealand in patients with obesity given the ease of administration and lack of monitoring required. Despite the recommendation to perform DOAC levels in this group of patients, interpretation of levels is difficult due to a lack of well validated therapeutic ranges with clinical correlation. Further data regarding the clinical utility of DOAC levels, appropriate dosing strategy for enoxaparin, and clinical outcomes in this population is required. Our registry provides data regarding drug levels in this population, prescribing characteristics and clinical outcome data. Disclosures No relevant conflicts of interest to declare.

S2143 Hepatic Artery Pseudoaneurysm Due to Aortic Dissection: An Unusual Cause of Portal Hypertension and Bile Duct Compression

INTRODUCTION: Hepatic artery pseudoaneurysm is rarely seen as a result of aortic dissection. Life-threatening gastrointestinal bleeding requiring urgent therapeutic intervention can occur as a complication of pseudoaneurysm formation. CASE DESCRIPTION/METHODS: A 66 year-old male with a history of a type A aortic dissection which was repaired four years prior to presentation was evaluated in the the emergency department for multiple episodes of melena. He was previously treated at another institution for a biliary stricture with a metal stent. On physical exam, he was hemodynamically stable and had scleral icterus. Initial labs revealed hemoglobin 8.7 gm/dl, platelets 240 K/CUMM, aspartate aminotransferase 192 U/L, alanine aminotransferase 161 U/L, alkaline phosphatase 380 U/L, total bilirubin 21 mg/dl, and INR 1.6. ERCP revealed a patent stent in the common bile duct and no evidence of hemobilia. Subsequent esophagogastroduodenoscopy revealed three columns of large, non-bleeding esophageal varices with stigmata of recent bleeding. Endoscopic band ligation was performed. After completion of the procedure, abdominal aortic angiography revealed interval enlargement of a fusiform aneurysm of a false lumen of the common hepatic artery as well as resultant central compression of the adjacent portal venous system and intrahepatic bile ducts. The patient then had an episode of hypotension and tachycardia and required transfusion of four units of red blood cells. Interventional radiology emergently performed catheter-directed embolization of the common and right hepatic artery pseudoaneurysms, and the patient did not experience any further episodes of gastrointestinal bleeding. DISCUSSION: Our evaluation of this clinical case revealed two interesting points. In retrospect, the biliary stricture was the result of direct compression of the bile duct by the pseudoaneurysm, which may not have been appreciated by the endoscopist performing the initial procedure. Second, the etiology of this patient's portal hypertension was also a direct result of compression of the portal vein by the aneurysm. On his initial presentation, we did not make these associations, but further cross-sectional imaging led us to the correct answer. The patient benefited from early involvement of vascular interventional radiology, who were able to provide a therapeutic intervention via catheter-directed coil embolization. In cases where interventional radiology is unable to intervene, surgical management with vascular surgery may be necessary.Figure 1.: Aneurysmal dilation of the false lumen of the common hepatic artery (1.9 cm in diameter) causing extrinsic compression of the adjacent biliary tract and portal venous system.