Lower Gastrointestinal Bleeding Patients Research Articles

External validation of the SHA2PE score and its comparison to the Oakland score for the prediction of safe discharge in patients with lower gastrointestinal bleeding.

The growing incidence of lower gastrointestinal bleeding (LGIB) is leading to a rise in-hospital admissions even though most LGIB episodes are self-limiting. The Oakland and SHA2PE scores were designed to identify patients best suited to outpatient care. Our aim is explore the validity of the SHA2PE score and compare both of these scores in terms of predictiveness of safe discharge. Retrospective observational study of LGIB patients admitted to a tertiary hospital between June 2014 and June 2019. Safe discharge was defined as the absence of all the following: blood transfusion, haemostatic intervention, re-bleeding, in-hospital death, and re-admission due to LGIB within 28days after discharge. From 595 hospital admissions for LGIB, 398 episodes were included. Fifty-four per cent met safe discharge criteria, with these cases being younger, with a lower score in the Charlson's index and significantly higher haemoglobin concentration upon arrival. The performance of both scores was good, with an AUC for the Oakland score of 0.85 (95% CI 0.82-0.89) and of 0.797 (95% CI 0.75-0.84) for the SHA2PE score. The Oakland score performed better in terms of prediction of safe discharge, with a positive predictive value and specificity of 100% when a cut-off value of ≤ 8 points was used; however, only a minority of patients might benefit from its implementation given its low sensitivity. Almost half of the patients admitted for LGIB met criteria for safe discharge. However, the available indexes only allow for the identification of a small proportion of those patients candidates for outpatient care.

External Validation of the Oakland Score for Acute Lower Gastrointestinal Bleeding.

Introduction Acute lower gastrointestinal bleeding (LGIB) presents challenges in emergency settings, with incidence influenced by demographic shifts and anticoagulant usage. The Oakland score aids in risk stratification for safe discharge based on clinical and laboratory parameters. However, external validation remains limited. Methods This study validated the Oakland score in a French cohort of patients with acute LGIB and assessed the discriminatory value of the score using the area under the curve (AUC) and then its sensitivity and specificity. Results A retrospective examination of 343 patient records that satisfied the inclusion criteria showed a median score of 14 points and good discriminatory capacity (area under the receiver operating characteristic (AUROC) curve: 0.83). There was low sensitivity (20.9%) for safe discharge but good specificity (98.5%) when using an 8-point threshold. With a 9-point threshold, the sensitivity was increased to 36.5%, while the specificity remained at 95%. Conclusion Identifying low-risk LGIB patients is accomplished without sacrificing sensitivity by increasing the Oakland score threshold to 9 points. This modification improves patient safety and resource allocation in the emergency room and has been verified by other large series. For wider implementation, additional validation and long-term outcome evaluations are required.

Outcomes and performance of risk scores in acute lower gastrointestinal bleeding.

Treatment of acute lower gastrointestinal bleeding (LGIB) remains problematic, and clinical data is limited compared to that of upper GIB. This study aimed to describe the clinical outcomes and predictors of rebleeding and validate the performance of proposed scoring systems in patients with acute overt LGIB. Patients with LGIB who underwent colonoscopies between 2013 and 2018 were retrospectively reviewed. Overt LGIB patients who presented within 72 h after bleeding onset were included. Demographics, comorbidities, initial management, endoscopic finding, and treatment outcomes were collected. Factors associated with rebleeding were explored, and the performance of Oakland, NOBLAD, and Strate scores regarding mortality and rebleeding were validated. A total of 537 patients from 3402 (age 72 years, 63-80) were included. Of this, 53% took antithrombotic agents and 59% required red cell transfusion, with a median of 4 red cell units. The most common diagnoses were diverticular bleeding (31.3%) and colorectal polyp/cancer (28.9%). The median time to colonoscopy was 2.3 days, and 80.3% of patients did not receive any hemostatic intervention. The 30-day mortality and rebleeding were 2.6% and 18.3%, respectively. Patients with radiation proctitis, angioectasia, diverticulosis and using dual antiplatelet drugs were associated with recurrent bleeding. The risk scores showed low performance in predicting recurrent bleeding and mortality. Acute, overt LGIB was common among elders with comorbidities. The rebleeding risk was mostly linked to underlying lesions and the use of antiplatelet drugs. The performance of current risk stratification scores remains unsatisfactory and requires further development.

Usefulness of the CHAMPS score for risk stratification in lower gastrointestinal bleeding

We have recently developed a simple prediction score, the CHAMPS score, to predict in-hospital mortality in patients with upper gastrointestinal bleeding. In this study, the primary outcome of this study was the usefulness of the CHAMPS score for predicting in-hospital mortality with lower gastrointestinal bleeding (LGIB). Consecutive adult patients who were hospitalized with LGIB at two tertiary academic medical centers from 2015 to 2020 were retrospectively enrolled. The performance for predicting outcomes with CHAMPS score was assessed by a receiver operating characteristic curve analysis, and compared with four existing scores. In 387 patients enrolled in this study, 39 (10.1%) of whom died during the hospitalization. The CHAMPS score showed good performance in predicting in-hospital mortality in LGIB patients with an AUC (95% confidence interval) of 0.80 (0.73–0.87), which was significantly higher in comparison to the existing scores. The risk of in-hospital mortality as predicted by the CHAMPS score was shown: low risk (score ≤ 1), 1.8%; intermediate risk (score 2 or 3), 15.8%; and high risk (score ≥ 4), 37.1%. The CHAMPS score is useful for predicting in-hospital mortality in patients with LGIB.

Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy.

To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB). Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention. Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (<30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered. This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.

Risk Factors for Adverse Outcomes in the Elderly Inpatients with Gastrointestinal Bleeding

To explore the factors affecting the adverse prognosis of elderly inpatients with gastrointestinal bleeding (GIB). We retrospectively analyzed the clinical data of elderly patients aged 60 and over admitted with GIB to the Department of Gastroenterology, West China Hospital, Sichuan University between January 2016 and January 2021. The adverse outcome was defined as admission to the intensive care unit and/or in-hospital death during the patient's stay at the hospital. Univariate and multivariate logistic regression analyses were done to identify the risk factors associated with the adverse outcome of the elderly. A total of 885 elderly patients (median age: 72.00 years, 517 males and 368 females) with GIB were enrolled, including 436 cases of upper GIB (UGIB) and 449 cases of lower GIB (LGIB). The overall rate of adverse outcome was 13.22% (117/885), which was significantly higher in the UGIB patients than that in the LGIB patients ( P<0.001). Univariate logistic regression identified UGIB ( P<0.001), shock index>1 ( P<0.001), hemoglobin ( P<0.001), blood urea nitrogen ( P<0.001), creatinine ( P<0.001), and international normalized ratio (INR) ( P<0.001) on admission, as well as erythrocyte transfusion ( P<0.001), fresh frozen plasma (FFP) transfusion ( P<0.001), and platelet transfusion ( P<0.001) were associated with adverse outcome. Multivariate logistic analysis showed that UGIB ( P<0.001), shock index >1 on admission ( P=0.001), higher INR on admission ( P=0.015) and FFP transfusion during hospitalization ( P<0.001) were independent risk factors for adverse outcome of elderly patients with GIB. Further analysis showed that INR>1.5 on admission significantly increased the risks of adverse outcome ( P<0.001). Elderly patients with UGIB exhibited worse prognosis than those with LGIB. After adjusting for age and the location of bleeding, shock index>1, INR>1.5 on admission and FFP transfusion were considered independent risk factors for the adverse outcome of elderly inpatients with GIB.

Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding.

BackgroundLower gastrointestinal bleeding (LGIB) is a common reason for hospitalization. However, recent data suggest low-risk patients may be safely evaluated as an outpatient. Here, we compare stable LGIB patients discharged from the emergency department (ED) with those admitted, determine factors associated with discharge and 30-day outcomes, and evaluate follow-up rates amongst the discharged cohort.MethodsA retrospective study of stable LGIB patients (heart rate < 100 beats/min, systolic blood pressure > 100 mm Hg and blood on rectal exam) who presented to the ED was conducted. Factors associated with discharge and rates of outpatient follow-up were determined in the discharged cohort. Therapeutic interventions and 30-day outcomes (including re-bleeding, re-admission and mortality rates) were compared between the admitted and discharged groups.ResultsNinety-seven stable LGIB patients were reviewed, of whom 38% were discharged and characteristics associated with discharge included age (P < 0.001), lack of aspirin (P < 0.002) and anticoagulant (P < 0.004) use, higher index hemoglobin (P < 0.001) and albumin (P < 0.001), lower blood urea nitrogen (P < 0.001) and creatinine (P = 0.008), lower Oakland score (P < 0.001), lower Charlson Comorbidity Index (P < 0.001) and lack of transfusion requirements (P < 0.001). There was no statistical difference in 30-day re-bleeding, re-admission or mortality rates between admitted and discharged patients. Discharged patients had a 46% outpatient follow-up rate.ConclusionsWhile early discharge in low-risk LGIB patients appears to be safe and associated with a decrease in length of stay, further studies are needed to guide timely and appropriate outpatient evaluation.

708 Examining the Management of Acute Lower GI Bleeds in Order to Improve Policies and Reflect Safe and Updated Guidance

Abstract Introduction Acute lower gastrointestinal bleeding (LGIB) tends to occur in elderly patients with complex comorbidities. At North Middlesex University Hospital (NMUH), LGIB patients are primarily managed by the surgical department. We amended local policies by integrating aspects of new guidelines published by the British Society of Gastroenterology (BSG). Method Handover documentation between November 2019 and January 2020 established patients admitted with LGIB (n = 45). Further data regarding the management of these patients was collated from clinical software and compared to standards set from BSG guidelines. Results We found NMUH to be efficient in ruling out upper GI bleeds via 24-hour OGDs and had low surgical intervention rates (0.02%). 40% of patients were transfused with an admission haemoglobin above suggested NICE thresholds, accounting for cardiovascular comorbidities. 56% of patients were discharged without a documented anticoagulation plan. Over 50% of patients did not have BSG recommended inpatient investigations. Conclusions Updated Trust guidelines aim to uphold areas that NMUH were shown to excel in, while reiterating NICE transfusion thresholds and include guidance regarding anticoagulant and antiplatelet medications. The Oakland score and shock index have been integrated into local protocols and will aid clinicians in making safe decisions in the management of LGIB patients.

End-stage renal disease and lower gastrointestinal bleeding-A propensity-matched analysis of nationwide inpatient sample.

We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients. The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients. We identified 2187954 ESRD patients, of whom 242075 has LGIB, and 1945879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P=.00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P=.00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P=.002). Advanced age (OR 1.02 CI 1.02-1.03 P=.00), anaemia (OR 1.04 CI 1.59-1.91 P=.006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P=.00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P=.00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P=.00) and sepsis (OR 1.5, CI 4.1-5.08, P=.00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8±14.9 vs 6.3±8.5, P<.01) and mean total charges (37054 $ vs 18080 $, P<.01) were also higher. In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher.

Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding.

To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA). A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability. Eighty-five patients (67.6years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n= 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85). Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA. • A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.

Mo1711 EXTERNAL VALIDATION OF THE OAKLAND SCORE IN 38,067 PATIENTS WITH ACUTE LOWER GASTROINTESTINAL BLEEDING

Most patients hospitalized with lower gastrointestinal bleeding (LGIB) require no in-hospital intervention nor experience adverse outcome. The Oakland Score (OS) was developed to identify patients with LGIB who can avoid hospitalization, using a threshold of ≤8, but requires further external validation. We assessed the operating properties of the OS amongst patients admitted to 140 hospitals in the United States. The discriminative ability of the OS to predict safe discharge, defined as the absence of transfusion, re-bleeding, hemostatic intervention, death and readmission was assessed using area under the receiver operator characteristic curves (AUROCs) with 95% confidence intervals (CI) and sensitivities were calculated for each score threshold. Overall 38,067 cases had complete data on outcomes, including 22,074 (58.0%) who met the criteria for safe discharge. The OS AUROC for safe discharge was 0.868 (95% CI 0.866 to 0.872). An OS of ≤8 applied to 3305 (8.7%) patients and had a sensitivity for safe discharge of 98.3%. Extending the threshold to ≤10 identified 6770 (17.8%) patients whilst maintaining a sensitivity of 96%. There was no difference between patients scoring ≤8 or ≤10 in terms of death (1.1% versus 1.4%, respectively, p=0.255) or in-hospital re-bleeding (4.6% versus 5.1%, p = 0.351), but more patients were re-admitted with further bleeding by 28 days (0.2% versus 0.6%, p < 0.05). The OS reliably identified LGIB patients at low risk of adverse outcomes who could safely be managed without hospital admission. The threshold to identify low risk patients could be extended to ≤10 to allow identification of a greater proportion of low risk patients.

Angiography versus colonoscopy in patients with severe lower gastrointestinal bleeding: a nation-wide observational study.

AimClinical guidelines for acute lower gastrointestinal bleeding (LGIB) recommend non‐endoscopic treatment when endoscopic treatment is difficult or the patient is hemodynamically unstable. The aim of this study was to investigate whether angiography should be prioritized as initial treatment for severe LGIB patients over colonoscopy.MethodsWe undertook a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database. We compared adult patients who underwent colonoscopy or angiography within 1 day of admission for severe LGIB from 2010 to 2017. The primary outcome was in‐hospital mortality. Secondary outcomes included surgery carried out within 1 day after admission and surgery carried out between 2 and 7 days of admission. Propensity score‐matched analyses were undertaken to adjust for confounders.ResultsWe identified 6,546 eligible patients. The patients were divided into the colonoscopy group (n = 5,737) and angiography group (n = 809). After one‐to‐four propensity score matching, we compared 3,220 and 805 patients who underwent colonoscopy and angiography, respectively. The angiography group was not significantly associated with reduced in‐hospital mortality compared with the colonoscopy group. In contrast, the number of patients who underwent surgery within 1 day of admission was significantly lower in the angiography group than in the colonoscopy group.ConclusionsThe present study revealed that in‐hospital mortality did not significantly differ between colonoscopy and angiography, even in severe LGIB patients. Although this study was unable to identify which subgroups should undergo angiography for primary hemostasis, angiography might be a better option than colonoscopy for initial hemostasis in more severe cases of LGIB.

P121: Derivation of a clinical decision tool for predicting adverse outcomes among emergency department patients with lower gastrointestinal bleeding

Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.

3:09 PM Abstract No. 102 Transcatheter arterial embolization for acute lower gastrointestinal hemorrhage: a 12-year experience of safety, efficacy and predictors of outcomes

To investigate the safety and efficacy of transcatheter arterial embolization (TAE) in the management of lower gastrointestinal bleeding (LGIB) and to determine the prognostic factors associated with clinical outcomes. Between December 2005 and April 2017, 919 patients were admitted to our hospital with symptoms of gastrointestinal bleeding, and the patients with positive angiographic findings for LGI were included in a retrospective study. Technical success and clinical outcomes including rates of clinical success, recurrent bleeding, major complication and in-hospital mortality for TAE were evaluated. The prognostic factors associated with clinical outcomes were analyzed. A total of 134 patients (mean age, 59.7 years; range, 14-82 years) received TAE for LGIB identified on angiography. The bleeding focus was small bowel in 74 patients (55.2%), colon in 35 (26.1%), and rectum in 25 (18.7%). Technical success was achieved in 127 patients (94.8%). The clinical success rate was 63% (80/127); there were 31 recurrent bleedings, 13 TAE-related major complications that resulted in operation or mortality and 3 deaths due to underlying disease within 1 day after TAE. The rates of recurrent bleeding, major complication and in-hospital mortality were 25%, 18.5% and 24.2%. Embolized artery number, the use of N-butyl cyanoacrylate (NBCA) and the origin of feeding artery were significant prognostic factors for recurrent bleeding. Underlying vascular disease, the embolized artery number, and the use of NBCA were significant prognostic factors for major complications. Transarterial embolization was a safe and effective treatment modality for LGIB patients, especially NBCA could be a primary choice as embolic material with a high rate of clinical success.

Etiological profile, gender difference and age group patterns of 415 patients presenting with lower gastrointestinal bleeding in the western region of Nepal

Background: Lower gastrointestinal bleeding (LGIB) is a common clinical condition associated with significant morbidity and mortality. The aims of our study were to determine the etiological profile, gender difference and age group patterns of LGIB in Nepal.Methods: A total of 415 consecutive patients presenting with LGIB from April 2011 to September 2014 underwent colonoscopy and the etiology of LGIB was determined. Each diagnosis was compared with respect to the gender and age group.Results: Among 415 LGIB patients (males 62.2%, females 37.8%), the different etiologies of LGIB were as following: hemorrhoid 35.2%, non-specific colitis 24.8%, colon polyp 18.3%, inflammatory bowel disease (IBD) 10.4%, colon cancer 6.5%, diverticulosis 1.7%, unknown 1.4%, upper gastrointestinal bleeding 1.2% and radiation colitis 0.5%. The overall LGIB was more common in male; however, colon polyps were diagnosed more commonly in female (p&lt;0.001). Among LGIB patients, the hemorrhoid was more common in the age group of 30-49 years, colon polyp in 50-69 years, colon cancer in 70-84 years, and non-specific colitis and IBD in 16-29 years (p&lt;0.001).Conclusion: Hemorrhoid and non-specific colitis were the common causes of LGIB in Nepal; colon polyp, IBD and colon cancer were the next common causes. More males presented with LGIB than females; however, colon polyp was diagnosed more in females, which needs to be explored further. When LGIB was presented after 50 years of age, the most likely causes were colon polyp and colon cancer; hence colonoscopy is recommended in all LGIB patients after 50 years.Journal of Advances in Internal Medicine 2014;3(2):52-55

Adverse Events during Bowel Preparation and Colonoscopy in Patients with Acute Lower Gastrointestinal Bleeding Compared with Elective Non-Gastrointestinal Bleeding

BackgroundThere are limited data on the safety of colonoscopy in patients with lower gastrointestinal bleeding (LGIB). We examined the various adverse events associated with colonoscopy in acute LGIB compared with non-GIB patients.MethodsEmergency hospitalized LGIB patients (n = 161) and age- and gender-matched non-GIB controls (n = 161) were selected. Primary outcomes were any adverse events during preparation and colonoscopy procedure. Secondary outcomes were five bowel preparation-related adverse events–hypotension, systolic blood pressure <100 mmHg, volume overload, vomiting, aspiration pneumonia and loss of consciousness–and four colonoscopy-related adverse events–including hypotension, perforation, cerebrocardiovascular events and sepsis.ResultsDuring bowel preparation, 16 (9%) LGIB patients experienced an adverse event. None of the LGIB patients experienced volume overload, aspiration pneumonia or loss of consciousness; however, 12 (7%) had hypotension and 4 (2%) vomited. There were no significant differences in the five bowel preparation-related adverse events between LGIB and non-GIB patients. During colonoscopy, 25 (15%) LGIB patients experienced an adverse event. None LGIB patient had perforation or sepsis; however, 23 (14%) had hypotension and 2 (1%) experienced a cerebrocardiovascular event. There was no significant difference in the four colonoscopy-related adverse events between LGIB and non-GIB patients. In addition, no significant difference in any of the nine adverse events was found among subgroups: patients aged ≥65 years, those with comorbidities, and those with antithrombotic drug use.ConclusionsAdverse events in bowel preparation and colonoscopy among acute LGIB patients were low. No significant difference was found in adverse events between LGIB and non-GIB patients. These adverse events were also low in elderly LGIB patients, as well as in those with co-morbidities and antithrombotic drug use, suggesting that colonoscopy performed during acute LGIB did not increase adverse events.

Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a Tertiary Care Hospital in India: A retro-prospective study

Abstract Introduction: Lower gastrointestinal bleeding (LGIB) is one of the leading causes for hospital admissions in gastroenterology wards all over the world. Patients usually present with hematochezia or bloody diarrhea. Colonoscopy is usually the initial diagnostic intervention followed by other more sophisticated tests. Bleeding may stop spontaneously, but evaluation is important because patients may harbor a sinister lesion like cancer. Aim of the Study: To determine the various etiologies, clinical presentations, a diagnostic test used and treatments received by LGIB patients admitted in our department. Materials and Methods: A total of 300 cases were studied which included 180 retrospective cases and 120 prospective cases. For retrospective cases, all the information was obtained by analyzing their case records while as prospective patients were managed as per a predefined protocol and details of various investigations and treatments documented. Results: Most commonly affected was elderly population (&gt;60 years), constituting 40% (120/300) of studied population. Males constituted 59% (177/300) and females 41% (123/300). The most common clinical presentation of LGIB in our patients was hematochezia (63.6%, 191/300). Growth/polyp was the most common finding on colonoscopic examination seen in 29.3% (n = 88) patients. Inflammatory lesions were seen in 77 out of 239 (25.7%) patients. Wireless capsule endoscopy was positive in 13 out of 24 patients (54%). Computed tomography (CT) enterography showed positive results in 6 out of 25 (24%) cases. Red blood cell scan was done in seven patients while as CT angiography in in four patients. Therapeutic endoscopy was successful in 115 out of 239 patients with positive colonoscopy, polypectomy was the commonest procedure performed. Medical management was carried out in 34.6% patients. Surgical treatment was offered to 21% patients. Conclusion: Colonoscopy is the initial and most common investigation used in the evaluation of GI bleed. A polyp is the most common diagnosis while as polypectomy the most common therapeutic procedure.

Pharmaco-induced vasospasm therapy for acute lower gastrointestinal bleeding: A preliminary report

PurposeTo report a novel technique and preliminary clinical outcomes in managing lower gastrointestinal bleeding (LGIB). Materials and methodsEighteen LGIB patients (11 men and 7 women, mean age: 66.2 years) were treated with artificially induced vasospasm therapy by semi-selective catheterization technique. Epinephrine bolus injection was used to initiate the vascular spasm, and followed by a small dose vasopressin infusion (3–5 units/h) for 3h. The technical success, clinical success, recurrent bleeding and major complications of this study were evaluated and reported. ResultsSixteen bleeders were in the superior mesenteric artery and 2 in the inferior mesenteric artery. All patients achieved successful immediate hemostasis. Early recurrent bleeding (<30 days) was found in 4 patients with local and new-foci re-bleeding in 2 (11.1%) each. Repeated vasospasm therapy was given to 3 patients, with clinical success in 2. Technical success for the 21 bleeding episodes was 100%. Lesion-based and patient-based primary and overall clinical successes were achieved in 89.4% (17/19) and 77.7% (14/18), and 94.7% (18/19) and 88.8% (16/18), respectively. None of our patients had complications of bowel ischemia or other major procedure-related complications. The one year survival of our patients was 72.2±10.6%. ConclusionsPharmaco-induced vasospasm therapy seems to be a safe and effective method to treat LGIB from our small patient-cohort study. Further evaluation with large series study is warranted. Considering the advanced age and complex medical problems of these patients, this treatment may be considered as an alternative approach for interventional radiologists in management of LGIB.

Watch and wait: Conservative management of lower gastrointestinal bleeding

BackgroundAlthough indications for surgery in lower gastrointestinal bleeding (LGIB) are widely described, practice varies. This study was designed to assess outcomes of patients allowed to exceed traditional triggers for surgery because of LGIB. MethodsThis is a retrospective review of patients at an urban tertiary hospital over a 3-y period that had LGIB necessitating 99mTc-labeled red blood cell scintigraphy. Traditional indications for operative treatment of LGIB were defined as transfusion of >6U of packed red blood cells, hemodynamic instability, bleeding lasting >72h, and rebleeding after cessation of bleeding for >24h. ResultsOne hundred ninety-four LGIB patients had scintigraphy during the period of study with 180 meeting inclusion criteria. Fifty-six (31%) patients had at least one operative indication, and 32 (60%) were managed nonoperatively without a mortality. There were two (8.3%) mortalities in those who had operative management, one of which was because of exsanguination. Eighteen (32%) patients who met operative criteria were unlocalized. ConclusionsPatients with LGIB can be safely managed nonoperatively, even when the bleed is unlocalized and traditional indications for surgery are met. Exsanguinations because of LGIB treated nonoperatively are rare except in patients deemed not to be surgical candidates.

Interventional management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) arises from a number of sources and is a significant cause of hospitalization and mortality in elderly patients. Whereas most episodes of acute LGIB resolve spontaneously with conservative management, an important subset of patients requires further diagnostic workup and therapeutic intervention. Endovascular techniques such as microcatheter embolization are now recognized as safe, effective methods for controlling LGIB that is refractory to endoscopic intervention. In addition, multidetector CT has shown the ability to identify areas of active bleeding in a non-invasive fashion, enabling more focused intervention. Given the relative strengths and weaknesses of various diagnostic and treatment modalities, a close working relationship between interventional radiologists, gastroenterologists and diagnostic radiologists is necessary for the optimal management of LGIB patients.