Lower Gastrointestinal Bleeding Research Articles

Appendiceal bleeding caused by vascular malformation: A case report

BACKGROUND Acute lower gastrointestinal bleeding (LGIB) is a common occurrence in clinical practice. However, appendiceal bleeding is an extremely rare condition that can easily be overlooked and misdiagnosed. The preoperative detection of appendiceal bleeding often poses challenges due to the lack of related guidelines and consensus, resulting in controversial treatment approaches. CASE SUMMARY We presented a case of a 33-year-old female who complained of hematochezia that had lasted for 1 d. Colonoscopy revealed continuous bleeding in the appendiceal orifice. A laparoscopic appendectomy was performed immediately, and a pulsating blood vessel was observed in the mesangium of the appendix, accordingly, active bleeding into the appendicular lumen was considered. Pathological examination revealed numerous hyperplastic vessels in the appendiceal mucosa and dilated capillary vessels. CONCLUSION The preoperative detection of appendiceal bleeding is often challenging, colonoscopy is extremely important, bowel preparation is not routinely recommended for patients with acute LGIB or only low-dose bowel preparation is recommended. Laparoscopic appendectomy is the most appropriate treatment for appendiceal bleeding.

Colonic diverticular bleeding due to a rupture of an ileocolic artery pseudoaneurysm secondary to colonic diverticulitis.

A 53-year-old woman with a history of recurrent right lower quadrant pain presented with slightly bloody stools in April 2023. She was initially diagnosed with acute diverticulitis using an abdominal computed tomography (CT) scan and was treated conservatively. On the second day, however, she reported significant hematochezia. A subsequent contrast-enhanced CT scan revealed an extravasation in the ascending colon, which was promptly managed with colonoscopy. Despite initial hemostasis, she experienced recurrent bleeding. Another contrast-enhanced CT scan revealed a pseudoaneurysm with ongoing extravasation in the same area. Angiography confirmed a pseudoaneurysm in a branch of the ileocolic artery, which was successfully treated by embolization. She was discharged after an 18day hospital stay. This case highlights a pseudoaneurysm caused by diverticulitis.

Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review

Acute upper and lower gastrointestinal (GI) bleeding may be a potentially life-threatening event that requires prompt recognition and an early effective management, being responsible for a considerable number of hospital admissions. Methods. We perform a clinical review to summarize the recent international guidelines, helping the physician in clinical practice. Older people are a vulnerable subgroup of patients more prone to developing GI bleeding because of several comorbidities and polypharmacy, especially related to an increased use of antiplatelet and anticoagulant drugs. In addition, older patients may have higher peri-procedural risk that should be evaluated. The recent introduction of reversal strategies may help the management of GI bleeding in this subgroup of patients. In this review, we aimed to (1) summarize the epidemiology and risk factors for upper and lower GI bleeding, (2) describe treatment options with a focus on pharmacodynamics and pharmacokinetics of different proton pump inhibitors, and (3) provide an overview of the clinical management with flowcharts for risk stratification and treatment. In conclusion, GI is common in older patients and an early effective management may be helpful in the reduction of several complications.

The Role of Topical Sucralfate in Reducing Post-Hemorrhoidectomy Pain

Hemorrhoids are one of the most common perianal cases and may cause lower gastrointestinal bleeding. Most cases can be treated with medications and/or simple procedures. Surgical intervention is required in advanced stages or complicated cases. However, this procedure is often associated with postoperative pain. Topical sucralfate is known to reduce postoperative pain.

Efficacy of ferric carboxymaltose on haemoglobin response among older patients with gastrointestinal bleeding: a randomised clinical trial.

Acute gastrointestinal bleeding (AGIB) is common in older patients but the use of iron in this context remains understudied. This study aimed to evaluate prospectively the efficacy of ferric carboxymaltose to treat anaemia in older patients after AGIB. This randomised double-blinded placebo-controlled clinical trial was conducted in 10 French centres. Eligible patients were 65years or more, had controlled upper or lower gastrointestinal bleeding and a haemoglobin level of 9-11g/dl. Patients were randomly assigned, in a 1:1 ratio, to receive either one intravenous iron injection of ferric carboxymaltose or one injection of saline solution. The primary endpoint was the difference in haemoglobin level between day 0 and day 42. Secondary endpoints were treatment-emergent adverse events, serious adverse events, rehospitalisation and improvement of quality of life (QOL) at day 180. From January 2013 to January 2017, 59 patients were included. The median age of patients was 81.9 [75.8, 87.3] years. At day 42, a significant difference in haemoglobin level increase was observed (2.49g/dl in the ferric carboxymaltose group vs. 1.56g/dl in the placebo group, P = 0.02). At day 180, QOL, measured on European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, improved by 10.5 points in the ferric carboxymaltose group and by 8.2 points in the placebo group (P = 0.56). Rates of adverse events and rehospitalisation were similar in the two groups. Intravenous iron seems safe and effective to treat anaemia in older patients after AGIB and should be considered as a standard-of-care treatment. ClinicalTrials.gov (NCT01690585).

Proportion of Colonic Diverticulosis and Its Associated Factors among Patients Underwent Colonoscopy

Aim: Diverticular disease is one of the most common gastrointestinal disorders to date, with a notable rising trend in developing countries. However, the proportion of colonic diverticulosis and its associated factors among patients who have undergone colonoscopy remains controversial. This study aimed to determine the local data on the proportion of diverticular disease in the community, its complications, the association of diverticulosis with diabetes mellitus and hypertension, as well as demographic characteristics. Material and Methods: A retrospective review of medical records was performed among patients who had undergone colonoscopy between January and December 2019. Demographic and clinical characteristics, the presence of diabetes mellitus, hypertension, and diverticular disease and its complications were examined, and the association of diverticular disease and its complications with demographic and clinical characteristics were analyzed. Results: Out of 221 patients, 12.7% (n=28) of them had diverticular diseases with a slightly predominant right-sided occurrence (42.9%, n=12). There were significant associations with age (p=0.002), ethnicity (p=0.011), and hypertension (p=0.036), but not with gender and diabetes mellitus (p=0.261, and p=0.334, respectively). There was no significant association between hypertension and recurrence of complicated diverticulitis (p=0.741), septic complications (p=0.678), and diverticular bleeding (p=0.243). Diabetes mellitus was significantly associated with diverticular bleeding complications (p=0.001) but not with septic complications (p=0.418) and recurrence of complicated diverticulitis (p=0.629). Conclusion: This study showed almost a similar percentage of diverticulosis compared to previous local studies. Age, ethnicity, and hypertension were associated with the presence of diverticulosis, and diabetes mellitus was associated with diverticular bleeding.

Gastrointestinal bleeding in elderly patients with atrial fibrillation: prespecified All Nippon Atrial Fibrillation in the Elderly (ANAFIE) Registry subgroup analysis

Gastrointestinal (GI) bleeding control is critical in elderly patients with atrial fibrillation (AF) receiving oral anticoagulants (OAC). This subgroup analysis aimed to clarify the actual state and significance of GI bleeding in elderly non-valvular AF (NVAF) patients. We evaluated the incidence and risk factors of GI bleeding during the 2-year follow-up and examined the GI bleeding impact on mortality. Of the 32,275 patients in the ANAFIE Registry, 1139 patients (3.5%) experienced GI bleeding (incidence rate, 1.92 events per 100 person-years; mean follow-up, 1.88 years); 339 upper and 760 lower GI bleeding events occurred. GI bleeding risk factors included age ≥ 85 years, body mass index ≥ 25.0 kg/m2, prior major bleeding, hyperuricaemia, heart failure, P-glycoprotein inhibitor use, GI disease, and polypharmacy (≥ 5 drugs). No significant differences in GI bleeding risk were found between direct OAC (DOAC) vs warfarin users (adjusted hazard ratios [95% confidence interval], 1.01 [0.88–1.15]). The 1-year post-GI bleeding mortality rate was numerically higher in patients with upper (19.6%) than lower GI bleeding (8.9%). In elderly Japanese NVAF patients, this large-scale study found no significant difference in GI bleeding risk between DOAC vs. warfarin users or 1-year mortality after upper or lower GI bleeding.

Acute mercury poisoning complicated by gastrointestinal bleeding

Mercury poisoning is a rare but potentially serious condition that can result from environmental exposure to elemental mercury. We present a case of a 22-year-young male who presented to the emergency department (ED) with symptoms of mercury poisoning after his family members brought home a vial of elemental mercury. The patient experienced nausea, anxiety, abdominal pain, diarrhea, and fever. Despite normal initial laboratory tests and imaging studies, a presumptive diagnosis of mercury poisoning was made based on the patient's history of exposure and clinical presentation. Although his hospital stay was complicated by passage of blood in stool, possibly lower GI bleed, but treatment with N-acetylcysteine (NAC) was initiated empirically, leading to resolution of symptoms and a favorable outcome. This case highlights the importance of considering mercury poisoning in patients with appropriate exposure history and the effectiveness of NAC in the treatment of acute mercury poisoning. Public education on the hazards of mercury and the importance of prompt recognition and treatment are essential in preventing severe complications associated with mercury exposure.

Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review

BackgroundLower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention.MethodsA retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data.ResultsOn logistic regression analysis, A hemoglobin drop of > 20 g/L was the only variable that predicted endoscopic intervention (p = 0.030). Tachycardia, hypotension, or presence of anticoagulation were not significantly associated with endoscopic intervention (p > 0.05).ConclusionsA hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.

Synchronous early rectal adenocarcinoma and neuroendocrine tumour: A treatment strategy

IntroductionSynchronous colorectal adenocarcinoma with neuroendocrine tumour (NET) are a unique combination of tumours. These may be incidental lesions, usually a histopathological diagnosis rather than a clinical diagnosis from symptoms, examination or even gross appearances.AimThis paper aims to highlight our management strategy on manging a middle-aged woman with synchronous rectal adenocarcinoma and NET.Case studyA 53-year-old woman presented with lower gastrointestinal bleeding with constitutional symptoms. Clinical examination and colonoscopy revealed a classical rectal adenocarcinoma, confirmed via biopsy. However, the final histopathology reports of the resected tumour revealed an early rectal adenocarcinoma with synchronous NET.Results and discussionWe review the relevant literature and a discussion regarding guidelines available for diagnosis, follow-up and surveillance of this rare case.ConclusionsThere are no current guidelines for surveillance colonoscopy after detecting gastrointestinal NET, particularly synchronous tumours. NET may be another colorectal cancer risk factor with similar mutations and common genetic markers. Clinicians should consider doing a colonoscopy when or if their patients are diagnosed with any gastrointestinal NET. Detection of any NET warrants a thorough evaluation of the whole colon for colorectal cancer and close surveillance so that timely management can be achieved.

Advances in endoscopic management of colonic diverticular bleeding.

This review is focused on diagnostic and management strategies for colonic diverticular bleeding (CDB). It aims to present the current state of the field, highlighting the available techniques, and emphasizing findings that influence the choice of therapy. Recent guidelines recommend nonurgent colonoscopy (>24 h) for CDB. However, factors such as a shock index ≥1, which may warrant an urgent colonoscopy, remain under investigation.The standard approach to detecting the source of CDB requires a water-jet scope equipped with a cap. Innovative diagnostic techniques, such as the long-cap and tapered-cap, have proven effective in identifying stigmata of recent hemorrhage (SRH). Furthermore, the water or gel immersion methods may aid in managing massive hemorrhage by improving the visualization and stabilization of the bleeding site for subsequent intervention. Innovations in endoscopic hemostasis have significantly improved the management of CDB. New therapeutic methods such as endoscopic band ligation and direct clipping have substantially diminished the incidence of recurrent bleeding. Recent reports also have demonstrated the efficacy of cutting-edge techniques such as over-the-scope clips, which have significantly improved outcomes in complex cases that have historically necessitated surgical intervention. Currently available endoscopic diagnostic and hemostatic methods for CDB have evolved with improved outcomes. Further research is necessary to refine the criteria for urgent colonoscopy and to confirm the effectiveness of new endoscopic hemostasis techniques.

Correction: Pan-intestinal capsule endoscopy as first-line procedure in patients with suspected mid or lower gastrointestinal bleeding.

Correction: Pan-intestinal capsule endoscopy as first-line procedure in patients with suspected mid or lower gastrointestinal bleeding.

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.

Endoscopic Hemostasis Using Bipolar Coagulation of Small Colonic Diverticular Bleeding With a Microcaliber Tip Cap Under Direct Visualization.

Endoscopic Hemostasis Using Bipolar Coagulation of Small Colonic Diverticular Bleeding With a Microcaliber Tip Cap Under Direct Visualization.

Transcatheter Arterial Embolisation of NSAID- Induced Diverticular Haemorrhage: A Case Report

Transcatheter Arterial Embolisation of NSAID- Induced Diverticular Haemorrhage: A Case Report

Direct clipping using a half-opened reopenable clip and long hood for colonic diverticular bleeding.

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Current status and clinical outcome of endoscopic hemostatic powder in gastrointestinal bleeding: a retrospective multicenter study.

Few multicenter studies have investigated the efficacy of hemostatic powders in gastrointestinal (GI) bleeding. We aimed to investigate the clinical outcomes of hemostatic powder therapy and the independent factors affecting rebleeding rates. We retrospectively recruited patients who underwent a new hemostatic adhesive powder (UI-EWD; Next-Biomedical) treatment for upper and lower GI bleeding between January 1, 2020 and March 1, 2023. We collected patients' medical records and bleeding lesions. The primary outcomes were clinical and technical success rates, and the secondary outcomes were early, delayed, and refractory bleeding, mortality, and factors affecting early rebleeding rates. This study enrolled 135 patients (age: 67.7±13.6 years, male: 74.1%) from five hospitals. Indications for UI-EWD were peptic ulcers (51.1%), post-procedure-related bleeding (23.0%), and tumor bleeding (19.3%). The clinical and technical success rates were both 97%. The early, delayed, and refractory rebleeding rates were 19.3%, 11.1%, and 12.8%, respectively. Initially elevated blood urea nitrogen (BUN) levels (p=0.014) and Forrest classification IA or IB compared with IIA or IIB (p=0.036) were factors affecting early rebleeding. UI-EWD showed high clinical and technical success rates; however, rebleeding after UI-EWD therapy in patients with initially high BUN levels and active bleeding, according to the Forrest classification, should be considered.

Inappropriate use of proton pump inhibitors in hospitalized patients with lower gastrointestinal bleeding

ABSTRACT Objectives Use of proton pump inhibitors (PPIs) is a mainstay in treating upper gastrointestinal bleeding (UGIB). However, the beneficial effects of PPIs are not anticipated to extend beyond the duodenum and may actually contribute to the risk of lower gastrointestinal bleeding (LGIB). However, in practice, PPIs are often used for inpatients with LGIB where no benefit exists. Methods A retrospective chart review was performed on inpatients during a 2-year period at an urban academic teaching hospital. Inpatients with consults to the gastroenterology (GI) service with confirmed or highly suspected LGIB were included. Outcomes regarding PPI use and the GI consulting service recommendations in these 225 patients were evaluated. Results About 37.8% of patients were started on a PPI during their inpatient course. Of those, 46% patients started on a PPI had no indication for PPI and 85% had no recommendation by the GI consultants to start a PPI. Of the 85 patients started on PPI, the GI consultants recommended stopping it in two (2.3%) patients. Lastly, 20 patients (9%) were discharged on PPI without an indication for PPI. Conclusion To our knowledge, this is the first study that looked at the inappropriate utilization of PPIs in patients admitted for LGIBs utilizing GI consultant recommendations. Given the large proportion of patients started on PPI without a clinical indication and continued at discharge and the paucity of GI recommendations to discontinue inappropriate use, we found that clinical care may be improved with formal GI recommendations regarding use of PPI.

Lower Gastrointestinal Bleed in Children: Safety, Utility, and Yield of Colonoscopy: an Experience from a Large Tertiary Referral Endoscopy Center

Abstract Objective: There is paucity of data on lower gastrointestinal bleed (LGIB) in the pediatric population. We aimed to retrospectively review the endoscopy findings in patients younger than 18 years, presenting with lower gastrointestinal (GI) bleed and undergoing colonoscopy. Materials and Methods: Retrospective review of the endoscopy database at the department of gastroenterology at a tertiary care center from Western India was conducted between June 2017 until December 2021. Patients ≤18 years with LGIB, who underwent colonoscopy within 7 days of onset of bleed, were included in the study. Demographic details, endoscopic findings, and complications were noted. Results: In all, 55 patients were included in study (65% males; median age: 13 years [range: 1–18 years]). The most common endoscopic findings were polyps in 26 (47.2%) patients, colitis in 15 (27.2%) patients, solitary rectal ulcer syndrome (SRUS) in 6 (11.3%) patients, and hemorrhoids in 3 (5.4%) patients. Five (9%) patients had normal colonoscopy in whom the cause remained unidentified on further evaluation. However, no repeat episode was documented on a follow-up of 30 days. The most common location of a polyp was the rectum (64%). Two patients had multiple polyps (2 each). All the patients underwent a successful polypectomy. Pathology reported juvenile polyps in 25 biopsies. Four were diagnosed as inflammatory bowel disease (IBD), while 11 had acute infective colitis. Patients with infectious colitis as compared to IBD had higher incidence of fever (55 vs. 0%) and lesser incidence of previous similar events (22 vs. 66%). Those with polyps were younger than those without polyps (9.1 vs. 14.3 years; p = 0.000). Polyps were significantly more common in boys (84%; 22/26; p = 0.014) than in girls. No complications occurred in this cohort of patients. Conclusions: Polyps are the most common cause of LGIB in patients ≤18 years, followed by colitis. Polyps were more common in younger males.

External Validation of the Oakland Score for Predicting Safe Discharge in Patients Presenting With Lower Gastrointestinal Bleeding at the William Harvey Hospital in the United Kingdom.

Introduction Lower gastrointestinal bleeds (LGIB) are defined by having a bleeding point in the gastrointestinal tract beyond the ligament of Treitz. The most common causes include diverticular bleeds, tumours, and colitis. There are noNational Institute for Health and Care Excellence (NICE) guidelines regarding safe discharge of patients with LGIB. The aim of this study was to investigate the effectiveness and safety of the Oakland score, as suggested by the British Society of Gastroenterology (BSG) guidelines, in patients presenting with LGIB at William Harvey Hospital. Methods Patients with LGIB who presented to Accident & Emergency or inpatient referral from January to December 2023 were included in this retrospective study. Data was extracted from patients' Sunrise documentation. The Oakland score for each patient was calculated. Those with a score of ≤8 were deemed safe for discharge; those with a higher score were deemed unsuitable. Patients' admission, discharges, and adverse outcomes, such as representation, blood transfusion, or further intervention, were investigated. Patients with no adverse outcomes were deemed to have had a safe discharge. The area under the receiver-operating characteristic curve (AUROC) for the Oakland score and adverse outcome (and therefore safe discharge) were calculated. Results A total of 123 patients were included. These led to a total of 144 LGIB presentations to the hospital. Twenty-nine patients had an Oakland score of ≤8; 21 (72.4%)cases were initiallydischarged with four representations (19.0%) and eight (27.6%) were admitted although none of these suffered from any adverse outcomes. For those who scored ≤8, 25 (86.2%) were therefore deemed to have had a safe discharge. A total of 115 had a score >8; 43 (37.4%) were initiallydischarged, 72 (62.6%) admitted and 41 (35.7%) experienced at least one adverse outcome including 16 (13.9%) representations, 21 (18.3%) blood transfusions, three (2.6%) surgical interventions and one (0.9%) endoscopic haemostasis. Out of the 115 cases which scored >8, 74 (64.3%) were deemed to have had a safe discharge. The AUROC for safe discharge was 0.84. Conclusion The Oakland score seems to be a safe and reliable tool for identifying LGIB patients who could be safely discharged home without hospital intervention. However, further research is required to assess whether a score of >8 could be used as many patients with a higher score did not experience adverse outcomes.