Nonvariceal Gastrointestinal Bleeding Research Articles

Prediction of Adverse Events in Stable Non-Variceal Gastrointestinal Bleeding Using Machine Learning.

Clinical risk-scoring systems are important for identifying patients with upper gastrointestinal bleeding (UGIB) who are at a high risk of hemodynamic instability. We developed an algorithm that predicts adverse events in patients with initially stable non-variceal UGIB using machine learning (ML). Using prospective observational registry, 1439 out of 3363 consecutive patients were enrolled. Primary outcomes included adverse events such as mortality, hypotension, and rebleeding within 7 days. Four machine learning algorithms, namely, logistic regression with regularization (LR), random forest classifier (RF), gradient boosting classifier (GB), and voting classifier (VC), were compared with the Glasgow–Blatchford score (GBS) and Rockall scores. The RF model showed the highest accuracies and significant improvement over conventional methods for predicting mortality (area under the curve: RF 0.917 vs. GBS 0.710), but the performance of the VC model was best in hypotension (VC 0.757 vs. GBS 0.668) and rebleeding within 7 days (VC 0.733 vs. GBS 0.694). Clinically significant variables including blood urea nitrogen, albumin, hemoglobin, platelet, prothrombin time, age, and lactate were identified by the global feature importance analysis. These results suggest that ML models will be useful early predictive tools for identifying high-risk patients with initially stable non-variceal UGIB admitted at an emergency department.

Angiography and transcatheter arterial embolization for non-variceal gastrointestinal bleeding

Background and goals Acute non-variceal gastrointestinal bleeding (NVGIB) is one of the most common medical emergencies, leading to significant morbidity and mortality without proper management. This study was to analyze the causes of NVGIB and to evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) for the treatment of NVGIB. Study From November 2012 to October 2018, 158 patients with NVGIB underwent digital subtraction angiography, and TAE was performed for confirmed gastrointestinal bleeding. Patient characteristics, cause of bleeding, angiographic findings, technical and clinical success rates, complication rates, and outcomes were retrospectively analyzed. Results Bleeding was confirmed in 71.5% (113/158) of performed angiographies, and 68 patients had visible contrast extravasation on angiography, with the other 45 patients having indirect signs of bleeding. Among the 113 patients with confirmed gastrointestinal bleeding, TAE was technically successful in 111 patients (98.2%). The mean procedure time required for TAE was 116 ± 44 min (ranging from 50 to 225 min). The primary total clinical success rate of TAE was 84.7% (94/111). The primary clinical success rates of TAE for vascular abnormality, neoplastic disease, and iatrogenic condition were 84.5% (49/58), 84.1% (37/44), and 88.9% (8/9), respectively. Intestinal necrosis and perforation were found in two patients after TAE. Conclusions The causes of NVGIB are complex and the onset, location, risk, and clinical presentations are variable. NVGIB can be generally divided into three types: vascular abnormality, neoplastic disease, and iatrogenic condition. TAE is a safe, effective, and fast procedure in the management of gastrointestinal bleeding.

Classifications and scores used in digestive endoscopy

Interpretation and description of findings detected in upper-endoscopy and colonoscopy are qualitative processes which depend on the experience and skills of the endoscopist performing the procedure. This explains the high variability of endoscopic reports, hampering their interpretation, specially by general practitioners. Classifications, scores and scales give a quantitative support to these qualitative processes. The aim of this review is to describe the classifications, scores and scales most frequently reported in digestive endoscopy, specially those with the highest methodological support in terms of validation and reproducibility. These tools facilitate the description of findings related to gastroesophageal reflux, Barrett's esophagus, gastroesophageal varices, stigmas related to non-variceal gastrointestinal bleeding, advanced and incipient neoplasms, bowel preparation for colonoscopy and severity scores of inflammatory bowel diseases. In summary, these tools enable to standardize endoscopic reports, simplifying their interpretation.

Tu1512 ASSESSING THE UTILIZATION AND EFFICACY OF HEMOSTATIC POWDER IN TREATING NON-VARICEAL GASTROINTESTINAL HEMORRHAGES

In 2018, the FDA approved hemostatic powder as a therapeutic instrument to treat non-variceal gastrointestinal bleeding. Since this treatment modality has now been in use for approximately 12 months in the US we evaluated several aspects of its application, such as pattern of utilization, efficacy, trends in hemostasis techniques and patient outcomes. To assess the last 12 months of hemostatic powder utilization, and determine its efficacy of treating non-variceal gastrointestinal hemorrhages as compared to the current hemostatic modalities used in endoscopic procedures at a tertiary medical center. In a retrospective review of our endoscopic procedural database we identified 251 cases of suspected upper gastro-intestinal bleeding (UGIB) between 11/2018 and 11/2019. Cases with confirmed malignancies and those with low risk lesions that did not require endoscopic intervention were excluded. We collected data on immediate cessation of bleeding, as well as re-bleed rates at 24 hours and 7 days after procedure. Etiology was also noted, with Forrest classifications being attributed to peptic ulcers. We identified 74 patients with UGIB requiring endotherapy. Of those cases, hemostatic powder was applied in 23 (31%); in 17 (73%) as an upfront intervention prior to other therapies or as a single modality, and 6 (27%) in combination following other hemostatic interventions (epinephrine injection, hemostatic clips, thermal probe, and over-the-scope clips). Cases in which hemostatic powder was used had a 95.6% success rate of immediate hemostasis. This was not significantly different then in those when hemostatic powder was not used (95% success rate; N.S). There was a significant decrease in 7 day rebleed rates in the hemostatic powder group (26 vs 33%; p<0.05). Peptic ulcers accounted for 52.7% of the UGIB cases seen with intervention. Within that group, hemostatic powder application carried an immediate success rate of 90.9%, and a within 7-day rebleed rate of 18.1%; whereas UGIB cases without hemostatic powder intervention carried rates of 96.4% and 28.5% respectively (p<0.05). Our study shows that hemostatic powder is being used in close to 1/3 of high risk GI bleeding cases. Although in cases when hemostatic powder was used the immediate hemostasis was not different than in other cases, we did demonstrate a lower rebleed rate in benign non-variceal upper GI bleeds.

Alcohol and risk of non-traumatic bleeding events requiring hospital care in the general population: A prospective cohort study.

Alcohol has a direct effect on blood coagulation and fibrinolysis. We studied how alcohol is related to common bleeding events (e.g., nose bleeding), as well as life-threatening bleeding events (e.g., hemorrhagic stroke) that required hospital care in the general population. We used data from The Copenhagen City Heart Study, 1991 to 1994 and 2001 to 2003. Baseline information on alcohol consumption and potential confounders was obtained by questionnaires, and participants were followed for incident bleeding events with nationwide registers until 2013. Among the 10,259 included participants, we observed 366 nose or other respiratory organ bleeding events, 149 hemorrhagic stroke events, 470 gastrointestinal bleeding events, 266 unspecified bleeding events, and 1088 any-bleeding events (composite endpoint) during follow-up. Compared to drinkers of 1-6 drinks per week, those drinking ≥35 drinks per week had a higher risk of hemorrhagic stroke [hazard ratio, 2.27 (1.14-4.55)] and non-variceal gastrointestinal bleeding [hazard ratio 2.04 (1.37-3.05)], whereas non-drinkers and drinkers of 7-13, 14-20, 21-27, and 28-34 drinks per week had not. Alcohol consumption was not associated with risk of nose or other respiratory organ bleeding or unspecified bleeding. For non-drinkers and drinkers of 7-13, 14-20, 21-27, 28-34, and 35 or more drinks per week, hazard ratios for the composite endpoint of any bleeding were 1.17 (95% CI: 0.99-1.37), 0.97 (95% CI: 0.81-1.15), 1.00 (95% CI: 0.80-1.26), 0.93 (95% CI: 0.69-1.25), 1.39 (95% CI: 1.00-1.94), and 1.83 (95% CI: 1.39-2.41) compared to drinkers of 1-6 drinks per week. In conclusion, drinking 35 or more drinks per week may be associated with a higher risk of hemorrhagic stroke and non-variceal gastrointestinal bleeding in the general population.

A153 INCIDENCE OF DEEP VEIN THROMBOSIS (DVT) &amp; PROPHYLAXIS PRACTICES IN DECOMPENSATED CIRRHOSIS INPATIENTS

Abstract Background The coagulation cascade is disturbed in cirrhosis. Patients are at risk for bleeding and coagulation through an imbalance of pro and anticoagulant factors. Aims We evaluated the incidence of DVTs and prevalence of DVT prophylaxis in hospitalized patients with decompensated cirrhosis. Methods A retrospective study of decompensated cirrhotic patients admitted to a tertiary care hospital. We evaluated the incidence of DVTs and use of DVT prophylaxis in this cohort. We also evaluated differences in patient characteristics in those who received DVT prophylaxis and between patients who did or did not develop DVTs. Results This study consisted of 520 cirrhotic patients, of which 258 patients (49.6%) received DVT prophylaxis. Of the remaining 262 patients who did not receive DVT prophylaxis, 199 (75.9%) had a documented contraindication to prophylaxis (bleeding, thrombocytopenia, both, or other). Compared to patients without DVT prophylaxis, patients who received prophylaxis were older (61.2 ± 11.2 vs 56.6 ± 10.9, p= 0.00001), had less varices (16.2% vs. 46%, p=0.0048), had more severe liver disease (MELD-Na 21 ± 6.5 vs 19.7 ± 7.3, p = 0.032), and fewer incidents of variceal (3.4% vs. 35.1%, p &amp;lt;0.001) and non-variceal (5.4% vs. 17.1%, p &amp;lt;0.001) gastrointestinal bleeding. DVT prophylaxed patients also had higher mean platelet values (149 ± 89 vs 112 ± 84, p &amp;lt;0.001), but similar baseline INRs (1.6 ± 0.4 vs 1.7 ± 0.8, p= 0.16), and were more likely to be admitted for non-bleeding complications of liver disease, including incidence of hepatic encephalopathy (37.9% vs 25.1%, p = 0.002) and spontaneous bacterial peritonitis (12.1% vs 6.5%, p=0.029). The incidence of radiographically identified DVT events in cirrhotic patients receiving DVT prophylaxis and those not receiving DVT prophylaxis was similar at 1.1 and 0.7%, respectively (OR 1.52, 95% CI 0.254 to 9.1, p = 0.65). There was no difference in liver disease severity between those with DVTs to those who did not develop DVTs, including similar MELD-Na, INR, platelets and hemoglobin values. Compared to patients without DVTs, those who developed DVTs had a higher bilirubin (95.8 ± 78.0 vs. 64.1 ± 24, p = 0.202) and INR (2.1 ± 0.7 vs. 1.6 ± 0.6, p = 0.07), as well as lower platelets (81.8 ± 23.3 vs. 131.4 ± 88.9). These groups had comparatively similar MELD-Na, albumin, creatinine, and hemoglobin levels. Conclusions DVT prevalence in this cohort of decompensated liver disease patients was overall low. DVT prophylaxis rates were moderate overall, however taking into account perceived contraindications such as thrombocytopenia or bleeding, patients appeared to be appropriately prophylaxed when indicated. Further study is required to identify which cirrhotic patients are at highest risk for DVTs and the safety of prophylaxis among patients with deranged lab values such as low platelets and elevated INR. Funding Agencies None

Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis.

Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.

Clinical outcomes of non-variceal upper gastrointestinal bleeding and its relation to aspirin and anticoagulants.

BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a life-threatening emergency that requires an urgent management. Antiplatelet (e.g., aspirin) and anticoagulant drugs are widely chronically used in various cardiac and coronary artery diseases. These drugs increase the risk of NVUGIB as they may cause ulceration of the upper gastrointestinal (GI) mucosa directly or may cause bleeding or rebleeding. The management of NVUGIB is complicated as the risk between GI bleeding episodes and cardiovascular attacks needs to be well managed.&#x0D; AIM: The aim of this study is to determine the impact of antiplatelets (aspirin) and anticoagulants use on the morbidity, mortality, and clinical outcomes in patients presented with non-variceal GI bleeding.&#x0D; PATIENTS AND METHODS: A total of 105 patients presented with melena and/or hematemesis and diagnosed by upper GI endoscopy were enrolled in a prospective cohort study. Patients were sub-grouped according to their use of antiplatelets, anticoagulants, or none (controls). Patients were excluded if they had portal hypertension or nonsteroidal anti-inflammatory drugs (NSAIDs) use and divided into five groups: Group I – patients who had not taken anticoagulants and antiplatelet; Group II – patients on heparin, warfarin, and LMWH only; Group III – patients on aspirin only; Group IV – patients on clopidogrel and ticlopidine with or without aspirin; and Group V – patients on combined anticoagulants and antiplatelet. All patients were subjected to clinical, laboratory (complete blood count, liver function tests, renal function tests, prothrombin time, and partial thromboplastin time), and endoscopic investigations. Clinical details were reported including admission, blood transfusion, rebleeding, and mortality.&#x0D; RESULTS: Full medical history revealed that 43 patients were diabetic, 45 patients were cardiac, and 67 patients were hypertensive. Regarding the history of analgesic drug intake, 38 patients used NSAIDs and 29 of them used non-selective NSAIDs and 8 patients used selective NSAIDs. There were non-significant differences among the studied groups with NVUGIB regarding sex, hematemesis only presentation, melena only presentation, liver function tests, and endoscopic findings. On the other hand, there were statistically significant differences between the studied groups with NVGIB regarding increasing age, NSAIDs use whatever selective or non-selective, decrease level of HB, WBCs, serum albumin, bleeding profile, kidney function tests, clinical presentation in the form of hematemesis and melena, need for blood transfusion, history of associated diseases, especially being cardiac patients, rebleeding after 6 and 12 months, and mortality.&#x0D; CONCLUSION: Aspirin intake may be associated with less favorable clinical outcomes in patients with NVUGIB, while combined anticoagulants and antiplatelets seem to be associated with the worse outcomes.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives.

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review.

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.

Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis

BackgroundConventional endoscopic treatments can’t control bleeding in as many as 20% of patients with non-variceal gastrointestinal (GI) bleeding. Recent studies have shown that over-the-scope-clip (OTSC) system allowed for effective hemostasis for refractory GI bleeding lesions. So we aimed to conduct a systematic review to evaluate the effectiveness and safety of the OTSC system for management of acute non-variceal upper GI bleeding.MethodA comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2007 to May 2019. The literature was selected independently by two reviewers according to the inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0.ResultsA total of 16 studies including 769 patients with 778 GI bleeding lesions were identified. Pooled technical success was achieved in 761 lesions [95.7%; 95% confidence interval (CI), 93.5–97.2%], and the pooled clinical success was achieved in 666 lesions (84.2, 95% CI, 77.4–89.2%). The incidence of re-bleeding was reported in 81 patients and the post-procedure mortality was 10.9% (n = 84). Only 2 (0.3%) patients occurred complications after OTSC system procedure.ConclusionsOur study demonstrated that the OTSC system was a technically feasible modality and highly efficacious in achieving hemostasis in acute non-variceal upper gastrointestinal bleeding.

Assessing guideline adherence in patients with non-variceal upper gastrointestinal bleeding receiving antiplatelet and anticoagulant therapy

Background & aims: Non-variceal upper gastrointestinal bleeding (NVUGIB) occurs frequently and is associated with a significant morbidity and mortality, especially in patients receiving antiplatelet or anticoagulant therapy (APT and ACT, respectively). We aimed to evaluate adherence to guideline recommendations published by European Society of Gastrointestinal Endoscopy (ESGE).Methods: Retrospective analysis of patients with NVUGIB und prior exposition to APT or ACT at a single university hospital between 01 January 2016 and 31 December 2017.Results: 270 patients were identified (70.4% male, median age 72 years). 6/17 (35.3%) patients receiving APT for primary cardiovascular prophylaxis, 39/71 (54.9%) and 35 (49.3%) patients receiving APT for secondary cardiovascular prophylaxis (using strict and liberal definition, respectively) and 13/25 (52%) patients receiving dual antiplatelet therapy (DAPT) were not managed according to current recommendations. Management of ACT for secondary thromboembolic prophylaxis did not follow guideline recommendations in 59/93 (63.4%) and 34/93 (36.6%) patients (using strict and liberal definition, respectively). 23.7% of patients with NVUGIB were exposed to combined APT and ACT for whom no guideline recommendations exist. Mortality for any reason was twice as high in patients who were not managed according to guideline recommendations (18.8% vs. 8% using strict definition, 20.5% vs. 10.2% using liberal definition), which did not remain significant after adjusting for comorbidities, whereas cardiovascular events were observed at similar rates.Conclusion: A significant number of patients with NVUGIB receiving APT or ACT is not managed according to current ESGE guideline recommendations. Strategies to implement these guidelines into daily practice need to be developed.

1878 Migration of Over-the-Scope Clip (OTSC) Resulting in Intestinal Obstruction

INTRODUCTION: Iatrogenic perforations are a known and feared complication of diagnostic and therapeutic colonoscopy. Over-the-scope clips (OTSCs) have recently been utilized for management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®) clip for an iatrogenic post-polypectomy perforation with subsequent intestinal obstruction occurring as a result of migration of the clip. CASE DESCRIPTION/METHODS: A 40-year-old male with familial adenomatous polyposis and total proctocolectomy, ileoanal anastomosis and a J pouch had an ileoscopy performed for polyp surveillance. A 3 cm flat polyp was removed with Eleview® injection lift technique. A hole like defect was noted in the postpolypectomy site that developed into an obvious small 2-3 mm perforation. To repair the defect, a one 14/6 mm type gc over-the-scope clip (Ovesco®) and a 12/6 mm type gc over-the-scope clip (Ovesco®) was successfully placed. Four months later the patient presented to the emergency department with severe anal pain. He felt a hard metallic object in the anal canal. He denied any fevers, chills, nausea, vomiting, or abdominal pain. Rectal tenderness was found on digital rectal examination. A CT abdomen and pelvis showed an object of metallic density at the anal verge with nonobstructive bowel gas pattern. Colonoscopy revealed two over-the-scope clips approximately 2 cm from the anal verge embedded in the mucosa (Figure 1) which were removed. The patient did well post procedure and was discharged home the next day. DISCUSSION: The Ovesco® clip (Ovesco, Tübingen, Germany) is a novel endoscopic method to achieve mechanical compression of gastrointestinal tissue with current indications including closure of fistulas, iatrogenic perforations, hemostasis and non-variceal gastrointestinal bleeding. Iatrogenic perforations during colonoscopy have an incidence ranging from 0.1% to 0.3% of cases. These complications carry a high mortality rate and in the past warranted surgical intervention. However, with the advances in therapeutic endoscopy many perforations can be managed effectively with endoclips, OTSCs and/or endosuturing. These new techniques do come with device-specific risks. Fischer et al. reported the first case of OTSC-induced bowel obstruction. Here we present another case of bowel obstruction as a result of OTSC placement for a perforation, treated with surgical intervention. All gastroenterologists should be aware of clinical scenarios in which the Ovesco clip can be used.

624 Clinical Outcomes and Endoscopist's Perception of the Use of Hemospray for Gastrointestinal Bleeding: Outcomes From a U.S. Academic Tertiary Care Medical Center

INTRODUCTION: Endoscopic management of gastrointestinal bleeding (GIB) has evolved with current standard treatment modalities including epinephrine injection, hemostatic clips, and thermal therapies. A growing body of evidence has demonstrated clinical efficacy of Hemospray in GIB. Recently, the FDA approved Hemospray for treatment of non-variceal GIB in the USA. METHODS: Consecutive patients treated with Hemospray for management of GIB between 10/2018 and 1/2019 were included in this prospective case series. IRB approval was obtained. Patient demographics, clinical parameters, outcomes, and endoscopist's perceptions on the ease of use of Hemospray were collected. Hemospray was used by an attending as monotherapy, dual therapy with other standard endoscopic techniques, or as a rescue therapy. RESULTS: Hemospray was used during 12 cases for GIB. Immediate hemostasis was achieved in 10/12 (83.3%) cases with an average time to hemostasis of 3 minutes and an average of 6.8 sprays used per endoscopy. The mean Blatchford score was 13.7 and the mean Rockall score was 6.3. Hemospray failed in one case of failed band ligation and in one case as rescue therapy for a Forest Class 1a duodenal ulcer. Hemospray was used as a primary modality in 3/12 cases, adjunctive therapy in 3/12 cases, and as rescue therapy in 6/12 cases. Etiologies of GIB included Forest 1a ulcers (n = 3), Forest 1b ulcers (n = 3), MW tear (n = 2), GAVE (n = 1), APC induced rectal ulcer (n = 1), post polypectomy bleed (n = 1) and esophageal variceal bleed (n = 1). No adverse events occurred. Interventional radiology was utilized in 5/12 cases. The 3 day and 7 day rebleeding rates were 0% (0/12) and 25% (3/12) respectively. All-cause mortality was 8% (1/12) at both 7 and 30 days. Hemospray was technically easier to use compared to clips (6/12), epinephrine (4/12), and thermal modalities (5/12) according to the attending endoscopists (Table 1). Difficulties reported during administration of Hemospray included a clogged catheter (n = 2) which required use of a second catheter. CONCLUSION: Hemospray is effective in achieving immediate hemostasis in non-variceal GIB with no adverse events in our cohort. Low 3 and 7 day rebleeding rates were below the predicted rebleeding rates. Overall, a majority of attending endoscopists reported that Hemospray was similar or easier to use than conventional methods of hemostasis. Our study is limited by our small patient cohort, but represents real US experience with this recently FDA approved GIB treatment modality.

2542 Emerging Use of Hemospray in Lower Gastrointestinal Bleeding: Primary Mucosal Melanoma of the Jejunum

INTRODUCTION: Small bowel (SB) primary melanomas (PM) are extremely rare; around 30 cases are reported to date. Diagnosis is challenging due to difficult endoscopic access and dealing with its complications such as bleeding is even more difficult. We describe in this report a case of jejunal primary melanoma presenting with lower gastrointestinal (GI) bleeding controlled with Hemospray. CASE DESCRIPTION/METHODS: A 70-year-old man with coronary artery disease on aspirin presented with symptomatic anemia. He endorsed recurrent melena associated with weight loss. Vital signs were stable. Physical exam remarkable for melena on rectal exam. Computed tomography scan of the abdomen revealed a jejunal mass. The patient underwent a push enteroscopy, which showed a large ulcerated necrotic mass in the mid-jejunum that was actively bleeding. The entire mass was oozing from multiple foci with a large surface area. It was invading the jejunal wall with larger vessels exposed. Hemospray was used to achieve hemostasis. Pathology revealed malignant melanoma; a thorough skin and eye exam was negative for PM. The patient denied any history of excision of pigmented skin lesions. The final diagnosis was primary melanoma of the jejunum. DISCUSSION: Malignant melanomas are mostly cutaneous. Only 3-4% originate in mucosal membranes as primaries. The diagnosis is challenging due to nonspecific manifestations and difficult pathologic access. Radiological studies are the first diagnostic approach. Balloon enteroscopy allows histopathological diagnosis and management of complications such as bleeding. In our case, the jejunal tumor was ulcerated with an extensive surface area and multiple foci of actively bleeding vessels. Due to the abundant lymphovascular supply of the intestinal mucosa, SB melanoma is a highly vascularized tumor. Hemospray was the preferred initial modality in this particular scenario and was successfully used for hemostasis. It is an inorganic powder that provides hemostasis by acting as mechanical tamponade and increasing the local concentration of clotting factors. It is easy to use with an excellent safety profile, does not require precise targeting, and is efficacious in large surfaces. Mucosal tissues do not absorb it; thus, it has no risk of systemic toxicity. It is FDA approved for hemostasis of non-variceal GI bleeding. It is contraindicated in varices and fistulas. It was also used in cancer-related bleeding with promising results. It can be applied repeatedly as a bridge to other definitive modalities.

Non-variceal gastrointestinal bleed in children: surgical experience with emphasis on management challenges.

This exclusively surgical series on pediatric non-variceal gastrointestinal bleed (NVGIB) defines three levels of bleed site and describes etiology, bleed severity, diagnostic algorithm, and surgical management for each bleed site. Management challenges are detailed. Patients aged ≤ 18years treated surgically for NVGIB were analysed. Bleed site (n = 87) was classified as: upper gastrointestinal bleed (UGIB; n = 11); small bowel bleed (SBB: n = 52); and lower GIB (n = 24). Four etiology-based groups were identified: lesions with ectopic gastric mucosa (EGM; n = 33), tumours (n = 23), ulcers (n = 21), and vascular pathology (n = 8). Bleed severity spectrum was: acute severe bleed (n = 12); subacute overt bleed (n = 59); and occult GIB (n = 16). Preoperative diagnosis was obtained in all UGIB and LGIB lesions. Eighty-two percent of surgical SB lesions were diagnosed preoperatively on Tc99m pertechnetate scan, computed tomography enterography-angiography, and capsule endoscopy; remaining 18% were diagnosed at laparotomy with intra-operative enteroscopy (IOE). Surgical management was tailored to bleed site, severity, and etiology. Indications of IOE and approach to management challenges are detailed. The commonest site-specific bleed etiologies were duodenal ulcers for UGIB, EGM lesions for SBB, and tumours for LGIB. SBB presented diagnostic challenge. Diagnostic algorithm was tailored to bleed site, age-specific etiology, bleed severity, and associated abdominal/systemic symptoms. Management challenges were acute severe bleed, occult GIB, SBB, obscure GIB, and rare etiologies. IOE has a useful role in SBB management.

Validation of prognostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding

Background. The Rockall, Glasgow-Blatchford, and AIMS65 are useful and validated scoring systems for predicting the outcomes of patients with nonvariceal gastrointestinal bleeding. However, there are no validated evidence for using them to predict outcomes on variceal bleeding. The aim of this study was to evaluate and compare the prognostic accuracy of different nonvariceal bleeding scores with other liver-specific scoring systems in cirrhotic patients. Material and methods. A retrospective multicenter study that included 160 cirrhotic patients with acute variceal bleeding. The AUROC’s to predict in-hospital mortality, and rebleeding, were analyzed for each scoring system.Results. Overall in-hospital mortality occurred in 13% and in-hospital rebleeding in 12% of patients. The systems with the best AUROC value for predicting mortality were MELD (0.828; 95% CI 0.748-0.909), and AIMS65 (0.817; 95% CI 0.724-0.909). The best score systems for predicting rebleeding were Glasgow-Blatchford (0.756; 95% CI 0.640-0.827), and Rockall (0.691; 95% CI 0.580-0.802).Conclusions. In addition to liver-specific scores, the AIMS65 score is accurate for predicting in-hospital mortality in cirrhotic patients with acute variceal bleeding. Other scoring systems might be useful for predicting significant clinical outcomes in these patients.

Randomised clinical trial: intravenous vs oral iron for the treatment of anaemia after acute gastrointestinal bleeding.

SummaryBackgroundAcute gastrointestinal bleeding is prevalent condition and iron deficiency anaemia is a common comorbidity, yet anaemia treatment guidelines for affected patients are lacking.AimTo compare efficacy and safety of intravenous ferric carboxymaltose (FCM) and oral ferrous sulphate (FeSulf) in patients with anaemia secondary to non‐variceal gastrointestinal bleedingMethodsA prospective 42‐day study randomised 61 patients with haemoglobin <10 g/dL upon discharge (Day 0) to receive FCM (n = 29; Day 0: 1000 mg, Day 7: 500 or 1000 mg; per label) or FeSulf (n = 32; 325 mg/12 hours for 6 weeks). Outcome measures were assessed on Days 0 (baseline), 7, 21 and 42. The primary outcome was complete response (haemoglobin ≥12 g/dL [women], ≥13 g/dL [men]) after 6 weeks.ResultsA higher proportion of complete response was observed in the FCM vs the FeSulf group at Days 21 (85.7% vs 45.2%; P = 0.001) and 42 (100% vs 61.3%; P < 0.001). Additionally, the percentage of patients with partial response (haemoglobin increment ≥2 g/dL from baseline) was significantly higher in the FCM vs the FeSulf group (Day 21:100% vs 67.7%; P = 0.001, Day 42:100% vs 74.2%; P = 0.003). At Day 42, normalisation of transferrin saturation to 25% or greater was observed in 76.9% of FCM vs 24.1% of FeSulf‐treated patients (P < 0.001). No patient in the FCM group reported any adverse event vs 10 patients in the FeSulf group.ConclusionFCM provided greater and faster Hb increase and iron repletion, and was better tolerated than FeSulf in patients with iron deficiency anaemia secondary to non‐variceal acute gastrointestinal bleeding.

Comparison Between Argon Plasma Coagulation And Endoscopic Band Ligation InTreatment Of Gastric Antral Vascular Ectasia In Egyptian Cirrhotic Patients

Background and study aim: The Gastric antral vascular ectasia (GAVE) is one of the causes of upper gastrointestinal bleeding and accounts nearly four percent of all non-variceal upper gastrointestinal hemorrhage. Although Argon Plasma Coagulation is the standard treatment of GAVE, EBL may be used in the treatment of GAVE. This study was done to evaluate the therapeutic effect of APC in comparison to EBL for the treatment of bleeding GAVE in cirrhotic patients. Patients and Methods: Our study was conducted on 36 adult cirrhotic patients with bleeding from GAVE. Patients were divided into 2 groups: 18 patients in each group. Group I was subjected to APC and group II was subjected to EBL. All patients were followed endoscopically after the first endoscopic intervention for 6 months as well as their hemoglobin level had been evaluated monthly during that period. Results: There was a statistically non-significant difference between both treatment groups as regards cessation of bleeding, increase in hemoglobin levels, reduction of transfusion requirements, decreasing of hospital admissions or decreasing of endoscopic recurrence of GAVE during the follow-up period (6 months), but EBL group has a better result than APC group. The application of the EBL technique has significantly increased in the band related complications as hypertrophied polyps and post band ulcerations, which are decreased in the following sessions, in comparison to the APC technique, which had no complications-related. Conclusion: EBL and APC are effective methods in the treatment of bleeding GAVE in cirrhotic patients.

Su1537 – Non-Variceal Upper Gastrointestinal Bleeding in Patients with Liver Cirrhosis: Clinical Features, Endoscopic Findings and Mortality

Su1537 – Non-Variceal Upper Gastrointestinal Bleeding in Patients with Liver Cirrhosis: Clinical Features, Endoscopic Findings and Mortality