Management Of Lower Gastrointestinal Bleeding Research Articles

1293 Audit of Initial Management of Lower Gastrointestinal Bleeding as per the British Society of Gastroenterology Guidelines

1293 Audit of Initial Management of Lower Gastrointestinal Bleeding as per the British Society of Gastroenterology Guidelines

Review article: Advances in the management of lower gastrointestinal bleeding.

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Hemorragia digestiva en urgencias

Gastrointestinal bleeding is defined as blood loss of an acute nature through the gastrointestinal tract. Its main classification method is according to the location of the bleeding, differentiating between upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) according to whether its origin is proximal or distal to the ligament of Treitz, respectively. Of them, UGIB is more common; it is responsible for 80% of gastrointestinal bleeding cases. Though the initial treatment measures for both types are the same, this update will focus on management of UGIB, given that in addition to being more frequent, it entails greater morbidity and mortality and hospital load. Lastly, some specific aspects regarding management of LGIB will also be covered.

A case report of systemic lupus erythematosus and intestinal tuberculosis with lower gastrointestinal bleeding: A treatment approach utilizing parenteral nutrition.

Limited literatures are available on lower gastrointestinal bleeding in systemic lupus erythematosus (SLE) combined with intestinal tuberculosis. Sharing the treatment experiences of a 26-year-old female patient diagnosed with this complex condition in this report may contribute valuable insights. The patient initially presented with abdominal pain and active gastrointestinal bleeding, leading to admission to the hospital. Over a 2-week period, she experienced persistent bleeding, with daily volumes ranging from 300 mL to 800 mL. Lower gastrointestinal bleeding was diagnosed in this patient with concurrent systemic lupus erythematosus and intestinal tuberculosis. As her symptoms rapidly progressed, food and water intake had to be completely restricted. The parenteral nutrition was implemented. The medical team effectively controlled the bleeding, leading to a notable improvement in the patient's condition. Consequently, she was able to resume oral intake and was discharged from the hospital. This case highlights the significance of using parenteral nutrition in the management of lower gastrointestinal bleeding in patients with concurrent systemic lupus erythematosus and intestinal tuberculosis. Close monitoring and collaborative efforts among healthcare professionals are crucial to achieve successful outcomes in similar cases.

Management of Lower Gastrointestinal Bleeding.

Management of Lower Gastrointestinal Bleeding.

The use of surgical intervention for lower gastrointestinal bleeding and its association with clinical outcomes and resource use

BackgroundTo assess the use of surgical intervention for lower gastrointestinal bleeding and evaluate its associated factors. MethodsThe 2016 to 2019 National Inpatient Sample was queried to identify non-elective adult (≥18 years) hospitalizations for lower gastrointestinal bleeding. The International Classification of Diseases, 10th Revision, codes were used to ascertain patient characteristics, including signs of hemodynamic instability, potential lower gastrointestinal bleed source, and transfusion of blood products, as well as endoscopic, radiologic, and surgical intervention. Multivariable regression analyses were used to elucidate factors associated with operative management of lower gastrointestinal bleeding and evaluate its associated mortality, length of stay, and hospitalization costs. ResultsOf an estimated 364,495 patients, 1.7% underwent an operation for lower gastrointestinal bleeding. Compared to those managed conservatively, patients who underwent surgical intervention more commonly had diverticular-related bleeding, signs of hypovolemia, and less frequently underwent endoscopic intervention. After the adjustment of patient and hospital characteristics, ischemic colitis (adjusted odds ratio 7.5, 95% confidence interval 1.8–30.9, ref: hemorrhoids), hemodynamic instability (adjusted odds ratio 1.7, 95% confidence interval 1.5–2.0), and angiographic embolization (adjusted odds ratio 4.9, 95% confidence interval 3.9–6.0, ref: no endoscopic/radiologic intervention) were associated with greater odds of surgical intervention. Additionally, surgical intervention portended greater odds of in-hospital mortality (adjusted odds ratio 6.2, 95% confidence interval 4.5–8.5), a longer length of stay (8.5 days, 95% confidence interval 8.0–9.0), and greater hospitalization cost ($29.1K, 95% confidence interval 26.7K-31.5K). ConclusionOperative management of lower gastrointestinal bleeding is rare and associated with significant morbidity and mortality compared to those managed conservatively. However, when surgical intervention is indicated, preoperative patient characteristics should be used to identify those at greater risk of an operation to facilitate early surgical consultation and inform expectations during the perioperative period.

EP-370 Contemporary clinical management strategies in lower gastrointestinal bleeding: A single-centre retrospective observational study

Abstract Aim Significant heterogeneity exists in the recommendations for the diagnosis and management of acute lower gastrointestinal bleeding (LGIB). This study aims to demonstrate the contemporary management strategies adopted by a busy tertiary hospital. Methods We conducted a single-centre retrospective review of adults presenting to our institution with LGIB between January and March 2021. Demographic data, observations, laboratory results, endoscopy and radiology reports, operation notes and discharge summaries were collected for each patient via a retrospectively maintained registry. Results 23 patients were included. Mean age was 66.6 years with a mean initial haemoglobin of 10.9 g/dL (Range 4.1–15.5g/dL). 17% of patients were in circulatory shock on presentation. 70% of patients presented with haematochezia. 47.8% of patients were on either an anticoagulant or anti-platelet agent at presentation. The transfusion index in this cohort was 30%. 26.1% of patients had a re-bleed during their admission. The diagnostic yield of cross-sectional imaging amongst 11 patients was 27.3% with no correlation with haemodynamic status or active bleeding. 47.8% of patients underwent endoscopy and 27% of patients who underwent an endoscopic procedure required endoscopic haemostasis. Flexible sigmoidoscopy was the commonest endoscopic modality (55%), followed by gastroscopy (27%) and colonoscopy (18%). No patients required surgical or radiological intervention. No cause of bleeding was identified in 26% of patients. Conclusion This study confirms the variation in diagnosis and management of LGIB. Despite access to onsite interventional radiology, endoscopy remained the predominant diagnostic and therapeutic modality. Routine cross-sectional imaging may not be justified given its suboptimal diagnostic yield.

TH6.4 Clinical Audit on the Assessment and Management of Lower Gastrointestinal Bleeding: A Single Centre Experience

Abstract Aim To audit our local practice in the management of patients with lower gastrointestinal bleeding (LGIB) against the 2018 British Society of Gastroenterology (BSG) acute LGIB guideline Method Patients aged ≥18 years presenting with LGIB at our local trust between January 2020 – May 2020 were included. Data were collected via electronic documentation to identify the following: shock index (SI), whether patients with high-risk Oakland score (>8) were admitted and inpatient investigations received including CT angiogram (CTA), OGD and colonoscopy. Data were analysed according to two patient groups: unstable bleed (SI <1) and stable major bleed (SI>1 with Oakland score >8). Results Conclusion There are potential barriers to implementation of the BSG LGIB guideline, such as reduced awareness of the BSG recommendations, resource availability and economic implications.

Hypered laparoscopic and endoscopic management of lower gastrointestinal bleeding from metastatic Jejunal and ileal choriocarcinoma of unknown primary.

IntroductionChoriocarcinoma is form of malignant neoplasm that arise from trophoblastic cells that occurs mostly in ovaries and testes and it can metastasis to lungs, liver or to gastrointestinal tract.Presentation of caseThis is 37 years old female presented as a case of lower gi bleeding and was diagnosed to have metastatic jejunal and ilium choriocarcinoma of unknown primary and underwent ileocecal resection first then followed up with small bowel resection around 60 cm from duodenojejunal junction with primary anastomosis. The patient was found to have liver and brain metastasis and received chemotherapy with full response.DiscussionChoriocarcinoma is the most aggressive form of gestational trophoblastic disease that metastasizes through the lymphatic and hematogenous routes, and when its metastasis to the small bowel it's considered the worst prognosis with high mortality rate. Treatment consists of surgery and combined chemotherapy which is what our patient responded with.ConclusionMetastatic choriocarcinoma with unknown primary can be treated surgically with chemotherapy.

Causes and Management of Lower Gastro-Intestinal Bleeding

Gastrointestinal (GI) bleeding from the colon is a communal reason for hospitalization and is being more frequent in older patients. Gastrointestinal bleeding is known as any bleeding that takes place in the GIT from mouth to anus. Lower GI bleeding is defined as bleeding distal to the ligament of Treitz. Lower GI bleed is typically presented as hematochezia which is the passing of bright red blood clots or burgundy stools through the rectum. The causes of lower GI bleeding are changing over the past several decades from diverticulosis (which is the protrusion of the colon wall at the site of penetrating vessels), infectious colitis, ischemic colitis, angiodysplasia, inflammatory bowel disease, colon cancer, hemorrhoids, anal fissures, rectal varices, dieulafoy lesion, radiation-induced damage following cancer treatment to post-surgical. Management of lower GI bleeding is done through assessing the severity of symptoms and the condition of the overall case.

322 Clinical Factors Predictive of Both Successful and Unsuccessful Arterial Embolization in The Management of Lower Gastrointestinal Bleeding

Abstract Aim To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at Digital Subtraction Angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB. Method A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis. Results 123 DSAs were evaluated. Technical success was 81% (64/78) with clinical success 78%. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis time from CT to DSA was significant with a higher success probability within 120 minutes with different factors being salient depending on degree of delay. Clinical success was only associated with APTT (<27.5s). Technical failure from a negative DSA following a positive CTMA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis. Conclusions A triaging approach to utilising emergency DSA may be helpful. If prolonged delay between a positive CT and DSA is anticipated, with haemodynamic stability and a near normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120mins. Clinical success may be more likely if APTT is within normal range.

Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis

Background and study aims There is limited evidence on the effectiveness of hemostatic powders in the management of lower gastrointestinal bleeding (LGIB). We aimed to provide a pooled estimate of their effectiveness and safety based on the current literature. Patients and methods Literature review was based on computerized bibliographic search of the main databases through to December 2020. Immediate hemostasis, rebleeding rate, adverse events, and mortality were the outcomes of the analysis. Pooled effects were calculated using a random-effects model. Results A total of 9 studies with 194 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95 % of patients (95 % confidence interval [CI] 91.6 %–98.5 %), with no difference based on treatment strategy or bleeding etiology. Pooled 7- and 30-day rebleeding rates were 10.9 % (95 %CI 4.2 %–17.6 %) and 14.3 % (95 %CI 7.3 %–21.2 %), respectively. Need for embolization and surgery were 1.7 % (95 %CI 0 %–3.5 %) and 2.4 % (95 %CI 0.3 %–4.6 %), respectively. Overall, two patients (1.9 %, 95 %CI 0 %–3.8 %) experienced mild abdominal pain after powder application, and three bleeding-related deaths (2.3 %, 95 %CI 0.2 %–4.3 %) were registered in the included studies. Conclusion Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.

Efficacy of hemostatic powders in lower gastrointestinal bleeding: Clinical series and literature review

BackgroundThere is limited evidence on the efficacy of hemostatic powders in the management of lower gastrointestinal bleeding. Aimsto revise our series of patients with lower gastrointestinal bleeding treated with hemostatic powders and to provide a pooled estimate of their efficacy based on the current literature. MethodsSixty-five patients underwent topical endoscopic application of hemostatic powder between 2016 and 2020. The primary endpoint was treatment success, with 7- and 30-day rebleeding rate, adverse events and mortality as secondary outcomes. Literature review was based on computerized bibliographic search on the main databases through December 2020. Pooled effects were calculated using a random-effects model. ResultsOverall, the powder was applied as monotherapy in 37 patients (56.9%), as combination therapy in 15 patients (23.4%), and as rescue therapy in 13 cases (19.9%). Hemostasis was achieved in 100% of patients. Rebleeding rate at 7- and 30-day was 7.7% and 9.2%, respectively. A total of 10 studies with 259 patients were included in the meta-analysis. Immediate hemostasis was achieved in 96.3% (93.4%-99.2%) patients, whereas pooled 7- and 30-day rebleeding rates were 9.6% (4.5%-14.6%) and 12.9% (7.2%-18.5%), respectively. ConclusionNovel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.

Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding.

Abstract Background and study aims Current guidelines conditionally recommend performing early colonoscopy (EC) (< 24 hours) in patients admitted with acute lower gastrointestinal bleeding (LGIB). It remains unclear whether this practice is implemented widely. Therefore, we used the Nationwide Inpatient Sample to investigate trends for timing of colonoscopy in patients admitted with acute LGIB. We also assessed trend of hospitalization and mortality in patients with LGIB. Patients and methods Adult patients with LGIB admitted from 2005 to 2014 were examined. ICD-9-CM codes were used to extract LGIB discharges. Trends were assessed using Cochrane-Armitage test. Factors associated with mortality, cost of hospitalization, and length of stay (LOS) were assessed by multivariable mixed-effects and exact-matched logistic, linear regression, and accelerated-failure time models, respectively. Results A total of 814,647 patients with LGIB were included. The most common etiology of LGIB was diverticular bleeding (49 %) and 45 % of patients underwent EC. Over the study period, there was no change in the trend of colonoscopy timing. Although admission with LGIB increased over the study period, the mortality rate decreased for patients undergoing colonoscopy. Independent predictors of mortality were age, surgery (colostomy/colectomy) during admission, intensive care unit admission, acute kidney injury, and blood transfusion requirement. Timing of colonoscopy was not associated with mortality benefit. However, cost of hospitalization was $ 1,946 lower and LOS was 1.6 days shorter with EC. Conclusion Trends in colonoscopy timing in management of LGIB have not changed over the years. EC is associated with lower LOS and cost of hospitalization but it does not appear to improve inpatient mortality.

888 Challenges in The Management of Lower Gastrointestinal Bleeding in General Surgery: Developing Consistent Practice and Application of BSG Guidelines

Abstract Introduction Lower gastrointestinal bleeding (LGIB) accounts for 3% of all surgical referrals in the UK, with an in-hospital mortality of 3.4%. The BSG 2019 guidelines recommend risk stratification as per Oakland scoring, inpatient lower GI endoscopy for admissions and CT-angiography for unstable patients. This study evaluates the delivery of these outcomes in a district hospital setting. Method Retrospective audit assessing all acute LGI bleed admissions from 01-07-2019 to 28-02-2020 at Russells Hall Hospital. Shock Index (SI) and Oakland score used to stratify patients into unstable, stable-major and stable-minor LGIB. Compliance with BSG standards was assessed by review of investigations and emergent patient management. Results 143 patients (Median age = 70years) evaluated, with 64 admissions having no formal risk stratification (OAKLAND-score) documented. Only 12 admissions underwent inpatient LGI endoscopy with sigmoid diverticulosis the most common pathology (39.3%). CT-angiogram was the initial investigation for 75% of patients admitted with unstable LGIB. Conclusions OAKLAND-scoring is a sensitive tool to stratify LGIB patients based on clinical parameters. Application of BSG-2019 guidelines and developing consistency in management is challenged by the lack of routine access to LGI endoscopy and tools to manage bleeding endoscopically.

A Predictive Model for the Diagnostic and Therapeutic Yield of Colonoscopy Performed for Lower Gastrointestinal Bleeding.

Although colonoscopy is routinely performed for the management of lower gastrointestinal bleeding (LGIB), the quality of evidence supporting its use is poor and its yield for active bleeding or malignancy is low in practice. We conducted a retrospective analysis of all adult patients who underwent colonoscopies for LGIB at our hospital system between January 1, 2015, and December 31, 2019. A statistical model was built on a cohort of 5195 cases using multiple logistic regressions to predict the detection of various colonoscopy findings and the use of different colonoscopy maneuvers. The model was converted into a risk scoring system, named the TYPICAL Index, and was validated against a separate cohort of 914 cases. Active bleeding was only seen in 3.8% of colonoscopies performed for LGIB and endoscopic hemostasis was applied in 43.7% of actively bleeding lesions. Malignant-appearing lesions were detected in 2.5% of LGIB procedures and all cases of proximal colonic mass were identified in subjects age above 60. The TYPICAL Index, derived from age, gender, hemoglobin, creatinine, international normalized ratio, and prior colonoscopy for LGIB has a concordance statistic of 0.71 and a negative predictive value of 93.8% for potential bleeding sources requiring hemostasis, malignant-appearing lesions, or active bleeding on colonoscopy when applied using a threshold of 6. Active bleeding and malignancies are rarely encountered and endoscopic hemostasis is seldom required during colonoscopy performed for LGIB. We developed and validated a risk scoring system to identify cases of low predicted diagnostic and therapeutic yield and to guide clinical decision-making.

Endoscopic Management of Lower Gastrointestinal Hemorrhage

Lower gastrointestinal bleeding (LGIB) is a common gastrointestinal emergency. Colonoscopy is the initial diagnostic and therapeutic procedure for most patients with LGIB. The optimal timing of colonoscopy is uncertain, but earlier examinations are associated with higher diagnostic yield. In patients with severe bleeding, colonoscopy should be performed within 24 hours of presentation after an adequate orally administered colon preparation. Additional washing during colonoscopy and careful inspection should be performed to identify high-risk stigmata. Endoscopic therapy should be attempted if high-risk bleeding stigmata are identified. The endoscopic treatment modality depends on the bleeding source, location, operator expertise, and the need for ongoing anticoagulation or antiplatelet therapy. This review 5 tables, 5 figures, and 50 references. Keywords: argon plasma coagulation, clipping, colonoscopy, diverticular bleeding, endoscopic band ligation, endoscopic hemostasis, postpolypectomy bleeding, stigmata of recent hemorrhage, vascular ectasias

Endoscopic Management of Lower Gastrointestinal Hemorrhage

Lower gastrointestinal bleeding (LGIB) is a common gastrointestinal emergency. Colonoscopy is the initial diagnostic and therapeutic procedure for most patients with LGIB. The optimal timing of colonoscopy is uncertain, but earlier examinations are associated with higher diagnostic yield. In patients with severe bleeding, colonoscopy should be performed within 24 hours of presentation after an adequate orally administered colon preparation. Additional washing during colonoscopy and careful inspection should be performed to identify high-risk stigmata. Endoscopic therapy should be attempted if high-risk bleeding stigmata are identified. The endoscopic treatment modality depends on the bleeding source, location, operator expertise, and the need for ongoing anticoagulation or antiplatelet therapy. This review 5 tables, 5 figures, and 50 references. Keywords: argon plasma coagulation, clipping, colonoscopy, diverticular bleeding, endoscopic band ligation, endoscopic hemostasis, postpolypectomy bleeding, stigmata of recent hemorrhage, vascular ectasias

591 Trend Analysis of Lower Gastrointestinal Bleeding 2002-2017: A Population-Based Study

INTRODUCTION: Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database. METHODS: Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016. RESULTS: Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies. CONCLUSION: The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.

Early Versus Standard Colonoscopy: A Randomized Controlled Trial in Patients With Acute Lower Gastrointestinal Bleeding: Results of the BLEED Study.

The aim of our study was to examine differences in length of hospital stay (LOHS) between patients with lower gastrointestinal bleeding who received either an early colonoscopy (within 24 h of presentation) or a standard colonoscopy (within 1 to 3 d). Diagnostic management of lower gastrointestinal bleeding has been extensively debated in recent literature, especially whether colonoscopy within 24 hours of presentation is feasible and safe. In this single center, nonblinded, randomized controlled trial, patients presenting at the emergency department with acute hematochezia were eligible if they required hospital admission. A total of 132 patients were included. Primary outcome was LOHS. Secondary outcomes included yield of colonoscopy, blood transfusion requirements, recurrent bleedings, complications, interventions related to complications, and 30-day mortality. The follow-up period was 1 month. In total, 63 patients were randomized for <24 hours colonoscopy and 69 for standard colonoscopy. In the intention to treat analysis, LOHS was significantly lower in patients that underwent an early colonoscopy, compared with the standard group: median 2.0 days (inter quartile range, 2.0 to 4.0) versus median 3.0 days (inter quartile range, 2.0 to 4.0) (P=0.009). Recurrent bleedings and hospital readmissions were significantly more frequent in the <24-hour group: 13% versus 3% (P=0.04) and 11% versus 2% (P=0.02), respectively. No difference was observed regarding the number of patients diagnosed with a confirmed or presumptive bleeding source. In both groups, blood transfusion rate was similar and 30-day mortality was 0. Early colonoscopy reduces LOHS, but also results in lower clinical efficacy compared with standard colonoscopy.