Nonbleeding Visible Vessel Research Articles

Systematic review and meta-analysis of endoscopic versus medical management of peptic ulcers with adherent clots.

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non-bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs)comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random-effects meta-analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8years and a mean follow up of 20days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR]=0.40, 95% confidence interval [CI] 0.16-0.95, 268 participants). However, there was no difference in mortality (RR=0.90, 95% CI 0.23-3.59, 52 participants) or need for ulcer surgery (RR=0.48, 95% CI 0.10-2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery.

Epinephrine injection monotherapy shows similar hemostatic efficacy to epinephrine injection combined therapy in high-risk patients (Forrest Ib) with bleeding ulcers.

Whether combination therapy has higher hemostatic efficacy than epinephrine injection monotherapy in different Forrest classifications is not clear. This study aimed to compare hemostatic efficacy between epinephrine injection monotherapy (MT) and combination therapy (CT) based on different Forrest classifications. We retrospectively analyzed peptic ulcer bleeding (PUB) patients who underwent endoscopic epinephrine injections or epinephrine injections combined with a second therapy between March 2014 and June 2022 in our center, and the patients were divided into MT group or CT group. Subsequently, a propensity score matching analysis (PSM) was performed and rebleeding rates were calculated according to Forrest classifications via a stratified analysis. Overall, 605 patients who met the inclusion criteria were included, and after PSM, 173 patients in each of the CT and MT groups were included. For PUB patients with nonbleeding visible vessels (FIIa), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 8.8%, 17.5%, 19.3%, and 19.3% in the MT group, respectively, and rates were 0%, 4.1%, 5.5%, and 5.5% in the CT group, respectively, with significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.015, P = 0.011, P = 0.014, and P = 0.014, respectively). However, for PUB patients with oozing bleeding (FIb), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 14.9%, 16.2%, 17.6%, and 17.6% in the MT group, respectively, and rates were 13.2%, 14.7%, 14.7%, and 16.2% in the CT group, respectively, with no significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.78, P = 0.804, P = 0.644 and P = 0.825). Combined therapy has higher hemostatic efficacy than epinephrine injection monotherapy for PUB patients with visible blood vessel (FIIa) ulcers. However, epinephrine injection monotherapy is equally as effective as combined therapy for PUB patients with oozing blood (FIb) ulcers.

S3543 An Unusual Complication of Peptic Ulcer Disease

Introduction: In patients with severe peptic ulcer disease (PUD), perforation is a serious complication, often presenting with acute abdominal pain. Perforation occurs in approximately 5% of patients with PUD over their lifetime. Although fistulas have been reported as a potential complication of postoperative perforated peptic ulcer disease, we present a unique case of antral-abscess fistula complicated by duodenal adenocarcinoma. Case Description/Methods: A 57-year-old female presented to the hospital with a chief complaint of epigastric pain. The patient had a history of perforated gastric ulcer status post graham patch repair. Computed Tomography (CT) of abdomen revealed remote gastric perforation with chronic fistulous connection between the gastric antrum and an abscess along the superior margin of the gastric antrum, underneath the left liver. Upper GI endoscopy revealed diffuse mildly erythematous mucosa without bleeding in the stomach as well as non-bleeding large cratered chronic appearing duodenal ulcer with a clean ulcer base (Forrest Class III) in the duodenal bulb involving more than 90% of the duodenal circumference, causing narrowing at the duodenal sweep and 2nd portion of duodenum. There were multiple ulcer/mucosal changes spots of bluish/reddish concerning for non-bleeding visible vessel and fistula given the severity of the ulcer/mucosal changes. Subsequent duodenal ulcer biopsy revealed necrotic tissue with infiltrating cells which were significant for adenocarcinoma of the duodenum (Figure). Discussion: To our knowledge, this is the first report demonstrating antral stomach-abscess fistula with concomitant evidence of duodenal adenocarcinoma after perforated peptic ulcer disease. With this report, we not only aim to shed light on this unique complication but also to spark the scientific community to further investigate potential associations of duodenal adenocarcinoma including peptic ulcer disease.Figure 1.: Endoscopy of duodenum demonstrating ulcerations concerning for non-visible bleeding vessels and fistula.

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding.

Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding. To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding. We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials. We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding. At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane. We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis. There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.

Nontraumatic tube method for detecting a vessel responsible for colonic diverticular hemorrhage.

Colonic diverticular hemorrhage has been reported as the most common cause of lower gastrointestinal bleeding [1] [2] [3]. In colorectal diverticular hemorrhage, active bleeding, nonbleeding visible vessels, and adherent clot (indicating active bleeding or nonbleeding visible vessels when removed) are defined as stigmata of recent hemorrhage (SRH) [4].

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.

Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding.

BACKGROUNDColonoscopy within 24 h of hospital admission for colonic diverticular bleeding (CDB) is recommended. However, little is known about rates of rebleeding within 30 d. We posited that a group of patients who underwent contrast-enhanced computed tomography (CT) within 4 h of the last hematochezia and colonoscopy within 24 h would experience fewer incidences of rebleeding.AIMTo evaluate the outcomes of early colonoscopy for CDB among different groups of patients.METHODSData from 182 patients with CDB who underwent contrast-enhanced CT and colonoscopy between January 2011 and December 2018 at the study site were retrospectively reviewed. Patients were divided into groups based on the timing of the CT imaging, within or at 4 h were defined as urgent CTs (n = 100) and those performed after 4 h were defined as elective CTs (n = 82). Main outcomes included rebleeding within 30 d and the identification of stigmata of recent hemorrhage (SRH) (i.e., active bleeding, non-bleeding visible vessels, or adherent clots).RESULTSIn total, 182 patients (126 men and 56 women) with median ages of 68.6 (range, 37-92) and 73.7 (range, 48-93) years, respectively, underwent CT imaging and colonoscopy within 24 h of the last hematochezia. Patients for whom CT was performed within 4 h of the last hematochezia were included in the urgent CT group (n = 100) and patients for whom CT was performed after 4 h were included in the elective CT group (n = 82). SRH were identified in 35.0% (35/100) of the urgent CT cases and 7.3% (6/82) of the elective CT cases (P < 0.01). Among all patients with extravasation-positive images on CT, SRH was identified in 31 out of 47 patients (66.0%) in the urgent CT group and 4 out of 20 patients (20.0%) in the elective CT group (P < 0.01). Furthermore, rates of rebleeding within 30 d were significantly improved in the urgent CT and extravasation-positive cases (P < 0.05). Results from the evaluation of early colonoscopy did not show a difference in the ability to detect SRH identification or rebleeding rates. Only cases by urgent CT reduced risk of rebleeding due to the evidence of active bleeding on the image.CONCLUSIONTo improve rates of rebleeding, colonoscopy is recommended within 24 h in patients with extravasation-positive CT images within 4 h of the last hema-tochezia. Otherwise, elective colonoscopy can be performed.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

497 WHAT TREATMENT TO USE FOR SEVERE NON-VARICEAL UGI HEMORRHAGE: STANDARD ENDOSCOPIC HEMOSTASIS, DOPPLER GUIDED HEMOSTASIS, OR OVER-THE-SCOPE-CLIP (OTSC)?

Non-variceal UGI hemorrhage (NVUGIH) is common but 26-28% of high risk patients with bleeding peptic ulcers (PUB’s) or Dieulafoy’s lesions (DL) rebled after standard, visually guided endoscopic hemostasis in 2 recently reported randomized controlled trials (RCT’s). See references in Table. These were separate comparisons of Doppler probe assisted hemostasis (DEP) or OTSC with STANDARD endoscopic hemostasis, but the 3 have never been compared in a head-to-head study before. Our purposes were to compare rates of recurrent bleeding and other 30 day clinical outcomes after endoscopic treatment with DEP, OTSC or STANDARD hemostasis of patients with severe NVUGIH. Individual patient data from 2 successive RCT’s were analyzed. Only patients with PUB’s & DL’s were included in 3 treatment groups: 69 DEP, 24 OTSC, & 101 STANDARD patients. We utilized SAS for data management & a biostatistician for the statistical analyses (JG). Patients were randomized if they had either major stigmata of hemorrhage – SRH (spurting arterial bleeding, non-bleeding visible vessel, or adherent clot) or lesser SRH (oozing bleeding or flat spot). In all treatments of spurting arterial bleeding or adherent clots, epinephrine injection was used prior to hemostasis with hemoclips (HC) &/or multipolar electrocoagulation (MPEC), or OTSC. DEP patients had visually guided hemostasis & if still positive for residual blood flow, more MPEC or HC’s was applied to obliterate underlying arterial blood flow, if feasible & safe. All patients received high dose proton pump infusions – PPI’s - X 72 hours & then BID PPI’s. Patients & their healthcare teams were blinded to endoscopic treatments & made all decisions after randomization about transfusions, further intervention for rebleeding, & level of care. Patients in the 3 treatment groups had similar baseline risk factors. However, there were significantly higher rates of 30 day rebleeding for STANDARD vs. DEP or OTSC (25.7% vs. 10.1% vs. 4.2%). The numbers needed to treat (NNT) for OTSC vs. STANDARD are 4.6 & for DEP vs. STANDARD are 6.4. Severe complications, number of RBC’s after randomization & number of bleeding episodes were also significantly higher in the STANDARD group – See Table & Kaplan-Meier Curves (p = 0.0141 for overall difference). For patients with severe UGIH from PUB’s or Dieulafoy’s lesions treated by the same investigators in 2 consecutive RCT’s: 1. STANDARD hemostasis resulted in significantly higher rates of further bleeding than DEP assisted hemostasis or OTSC. 2. Post-randomization rates of severe complications, units of RBC transfused, & number of bleeds were also significantly higher in the STANDARD treatment group. Either DEP assisted or OTSC are recommended as the new initial treatments of choice for severe NVUGIH from PUB’s or DL’s.Legend: Kaplan-Meier curves of time to first rebleed. Overall p = 0.0141 by log rank test.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding.

Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08-0.81; I = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09-0.86; I = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference -4.15 min; 95% CI -4.83 to -3.47; I= 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.

2122 Novel Use of EndoRotor® Device to Clear Large Obscuring Clot in Patient With Upper Gastrointestinal Bleed

INTRODUCTION: Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools and promotility agents are available to disrupt clots and increase visibility with varying degrees of success. The EndoRotor® device is a non-thermal, automated endoscopic resection system designed to remove benign mucosal tissue throughout the gastrointestinal tract. Here, we present a challenging case where standard endoscopic techniques failed to clear a large obscuring gastric clot and how novel application of the EndoRotor® allowed successful localization of the culprit lesion. CASE DESCRIPTION/METHODS: A 79 year old woman with a history of end stage renal disease and liver fibrosis presented with coffee ground emesis and melena. On admission, initial labs were notable for Hgb 9.7, Plts 129, INR 1.1. Patient was treated with IV pantoprazole and octreotide. EGD was notable for nonbleeding esophageal varices and a moderate size blood clot in the lesser curvature and fundus of stomach obscuring visualization and the procedure was terminated. Patient continued to pass melena with Hgb drop to 5.8 requiring 3 units pRBC and metoclopramide was added to her regimen to try to clear the large clot. Repeat EGD revealed an interval increase in size of blood clot. Despite irrigation and suction, area could not be cleared. Use of cold snare or Roth net removal were not feasible due to clot size and use of BioVac® was ineffective. A repeat EGD was performed the following day using the EndoRotor®. The combination of the EndoRotor device’s rotating cold blade and suctioning enabled the large clot to be liquefied. Fibrous tissue intermittently clogged the EndoRotor® suction channel but was easily cleared with flushing. After about 30 minutes, the large obstructing clot was completely cleared revealing a bezoar. The patient was kept NPO and continued on IV metoclopramide for 48 hours to clear the bezoar. An EGD was then repeated which revealed a 5 mm cratered ulcer in the posterior gastric wall with a nonbleeding visible vessel. Bipolar probe was applied successfully for hemostasis. DISCUSSION: Our case illustrates the challenges associated with a large clot obscuring visualization. Standard use of promotility agents with supportive care were not successful as the patient continued to intermittently bleed increasing the clot size . Our case is the first reported application of the EndoRotor® to safely to clear large blood clots in upper GI bleeding as an adjunct to our standard therapies.

1681 Achieving Hemostasis in a Gastric Tumor With Color Doppler-Endoscopic Ultrasound Guided Cyanoacrylate Glue

INTRODUCTION: Up to 5 percent of upper gastrointestinal bleeds are due to tumors and re-bleeding is common. Most patients with severe hemorrhaging esophageal and gastric tumors have a poor prognosis, resulting in death within 1 year. Currently, there are no well-defined guidelines regarding the implementation of cyanoacrylate glue in bleeding gastrointestinal tumors. Our primary aim is to demonstrate a novel technique for achieving hemostasis in a tumor bleed. CASE DESCRIPTION/METHODS: A 63-year-old male with a past medical history of smoking, non-insulin dependent diabetes mellitus type 2, and hypertension presented with melena and early satiety. The patient denied the use of NSAIDS and alcohol. Evaluation by EGD demonstrated a gastric tumor with stigmata of recent hemorrhage in the form of a non-bleeding visible vessel. EUS was then used to locate this feeding vessel. Color doppler was then employed to confirm the target vessel and to subsequently guide the precise injection of cyanoacrylate glue into the vessel. The cessation of doppler flow after glue embolization confirmed hemostasis of the feeding blood vessel. During this procedure EUS-FNA was also utilized to extract a sample of tissue for diagnostic purposes with a 19-gauge needle. DISCUSSION: Color doppler-EUS guided cyanoacrylate glue injection is a cost-effective therapy that may successfully achieve hemostasis in tumor bleeds. It can be utilized to confirm hemostasis of the targeted vessel after embolization, during an endoscopic procedure. Endoscopic confirmation may reduce the likelihood of re-bleeding and additional procedures, thus, improving the quality of care. Watch the video: http://bit.ly/2M5YAE1.

3055 Solitary Rectal Ulcer Syndrome: A Rare Cause of Hematochezia

INTRODUCTION: Solitary rectal ulcer syndrome (SRUS) is an uncommon rectal disorder that may result in severe rectal bleeding. The term solitary rectal ulcer syndrome is a misnomer. Endoscopic findings in patients with SRUS can range from mucosal erythema alone to single or multiple ulcers and polypoid mass lesions. Here, we present a rare case of severe hematochezia occurring secondary to a solitary rectal ulcer. CASE DESCRIPTION/METHODS: The patient is a 37 year-old male with a medical history of alcohol abuse who presented to our emergency department complaining of three episodes of hematochezia accompanied by dizziness and lightheadedness that began the night prior. Notable workup in the emergency department included a complete blood count (CBC) showing a hemoglobin of 12.5 gm/dL. A fecal occult blood test was also done which returned positive. This was followed by a repeat CBC showing an acute drop in the hemoglobin to 9.8 gm/dL. The gastroenterology service was then consulted and performed a colonoscopy. This was done and showed a large cratered ulcer about two centimeters in size and a non-bleeding visible vessel noted approximately five centimeters from the anal verge (Figure 1). These were treated with BiCAP cautery and the three hemostatic clips. Biopsies were not taken given the high risk of bleeding and emergent nature of the procedure. After the procedure the patient remained hemodynamically stable with no further drops in hemoglobin. He was then discharged with follow up appointments for repeat colonoscopy. DISCUSSION: SRUS is an oftentimes-misdiagnosed condition. The prevalence of SRUS is not clear, but has an estimated incidence of 1 in 100,000 people per year. Its diagnosis can usually be accomplished through a combination of symptomatology, endoscopy, sigmoidoscopy, and the histologic finding of fibromuscular obliteration of the lamina propria. The pathogenesis if SRUS is not well known, but various factors contribute to its development. This includes straining, self-induced trauma, paradoxical contraction of puborectalis muscle and rectal prolapse, and intussusception. Treatment of SRUS is based on the symptoms and severity. Asymptomatic patient treatment options include dietary modification, patient education, and behavioral modification. Endoscopic treatment can be applied to control bleeding and allows the clinician to obtain a biopsy specimen. Surgical treatment is recommended for those who have full thickness and rectal prolapse.

Risk factors for delayed bleeding by onset time after endoscopic submucosal dissection for gastric neoplasm

Post-endoscopic submucosal dissection bleeding (PEB) is one of the important complications after endoscopic submucosal dissection (ESD), but still difficult to predict. The present study aimed to identify significant risk factors for PEB according to onset time. Between November 2008 and January 2016, a total of 1864 lesions resected via ESD were analyzed. PEB was classified as either early or late according to onset time (within or after 24 hours post-ESD, respectively). During second-look endoscopy, the artificial ulcer bed was subjected to Forrest classification. A high risk of stigma was defined as active spurting bleeding, oozing bleeding, and a non-bleeding visible vessel in the ulcer. The endoscopic factors and medications associated with PEB were analyzed. PEB occurred in 77 lesions (4.1%): early only in 46 (2.4%), late only in 22 (1.1%), and early and late in 9 (0.4%). Among 55 early PEB events, 25 were asymptomatic and diagnosed during second-look endoscopy. Age ≤65 years, resection size ≥30 mm, procedure time ≥20 min, lower third of the stomach, erosion, and clopidogrel use were significantly associated with early PEB. If the number of risk factors were ≤1, the risk of early PEB was 0.6%. For late PEB, the mid to upper third of the stomach, undifferentiated carcinoma, erosion, high risk of stigma during second-look endoscopy, history of early PEB, and clopidogrel use were significant risk factors. If risk factors were absent, the risk of late PEB was 0.1%. For patients at high risk of early PEB, selective second-look endoscopy might be a useful. For patients at high risk of late PEB, careful monitoring of bleeding should be considered.

Incidence of diverticular bleeding: a population-based study

Objective: To determine the incidence of diverticular bleeding (DB) and examine the time trend of the incidence. Furthermore to study prognosis with regard to therapy and rebleeding.Methods: A retrospective, population-based study of patients with DB in a National University Hospital from 2006 to 2016. Patients were identified in an electronically stored colonoscopy database. Definite diverticular bleeding was defined as active bleeding, a nonbleeding visible vessel or adherent clot. Presumptive diverticular bleeding was defined as acute painless rectal bleeding leading to hospitalization with visible diverticula but no evidence of bleeding and no other colonic lesions or bleeding sites identified on endoscopy. A 30-day re-bleeding was determined after discharge.Results: A total of 3683 colonoscopy reports were reviewed, including 345 patients (males 51%) with presumptive 95% (n = 327) or definitive 5% (n = 18) diverticular bleeding. Overall 96% were treated conservatively, 3% endoscopically and 0.3% surgically. Only 5.8% of patients had a 30-day rebleed. After exclusion, 315 patients were included in the incidence calculations. The mean cumulative incidence of diverticular bleeding was 14/100,000 inhabitants per year. A time trend analysis of the incidence of DB revealed no significant change in incidence during the study period.Conclusions: The mean incidence of colonic diverticular bleeding was found to be approximately 14 cases per 100,000 inhabitants and year. The incidence does not seem to have changed in the past decade. The vast majority of patients with diverticular bleeding did not require endoscopic therapy and could be managed with conservative treatment.

Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage.

The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage. Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula. We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test. In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage. CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.

Misinterpretation or Underestimation of the Appearance, Location, or Size of Non-bleeding Visible Vessels (Forrest Class IIa) as a Cause of Hemostasis Failure

(1) Background: Endoscopy has become the primary diagnostic and treatment technique for non-variceal upper gastrointestinal bleeding. Despite advancements in therapeutic methods and instrumentation, endoscopic hemostatic failure occurs in 10% of patients. This study aimed to analyze endoscopic findings in patients with failed hemostasis and to elucidate strategies for endoscopists and gastroenterologists to facilitate improved treatment outcomes. (2) Methods: A total of 128 patients received hemostatic treatment for non-variceal upper gastrointestinal bleeding. Endoscopic findings in three patients in whom hemostasis could not be achieved after the initial and secondary endoscopies were analyzed. (3) Results: Hemostasis failure occurred in three cases (2.3%). All three cases involved patients with gastric ulcer and belonged to the Forrest class IIa category presenting with a non-bleeding visible vessel in endoscopic findings. Misinterpretation or underestimation of the appearance, location, or size of the vessel resulted in hemostasis failure. (4) Conclusions: Our findings demonstrate that identification of a non-bleeding visible vessel and assessment of the risk of re-bleeding in such vessels is often difficult. Detailed observation of the ulcer floor with awareness of the possibility of a non-bleeding visible vessel will lead to improved hemostatic treatment. The decision regarding hemostatic treatment of a visible vessel with a diameter larger than 2 mm should be made cautiously, and treatment should be followed by an appropriate fasting period under confirmatory endoscopy.

Reassessment of Rebleeding Risk of Forrest IB (Oozing) Peptic Ulcer Bleeding in a Large International Randomized Trial.

Our aims were to assess risks of early rebleeding after successful endoscopic hemostasis for Forrest oozing (FIB) peptic ulcer bleeding (PUBs) compared with other stigmata of recent hemorrhage (SRH). These were post hoc multivariable analyses of a large, international, double-blind study (NCT00251979) of patients randomized to high-dose intravenous (IV) esomeprazole (PPI) or placebo for 72 h. Rebleeding rates of patients with PUB SRH treated with either PPI or placebo after successful endoscopic hemostasis were also compared. For patients treated with placebo for 72 h after successful endoscopic hemostasis, rebleed rates by SRH were spurting arterial bleeding (FIA) 22.5%, adherent clot (FIIB) 17.6%, non-bleeding visible vessel (FIIA) 11.3%, and oozing bleeding (FIB) 4.9%. Compared with FIB patients, FIA, FIIB, and FIIA had significantly greater risks of rebleeding with odds ratios (95% CI's) from 2.61 (1.05, 6.52) for FIIA to 6.66 (2.19, 20.26) for FIA. After hemostasis, PUB rebleeding rates for FIB patients at 72 h were similar with esomeprazole (5.4%) and placebo (4.9%), whereas rebleed rates for all other major SRH (FIA, FIIA, FIIB) were lower for PPI than placebo, but the treatment by SRH interaction test was not statistically significant. After successful endoscopic hemostasis, FIB patients had very low PUB rebleeding rates irrespective of PPI or placebo treatment. This implies that after successful endoscopic hemostasis the prognostic classification of FIB ulcers as a high-risk SRH and the recommendation to treat these with high-dose IV PPI's should be re-evaluated.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding.

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 – 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 – 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early ( MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).