Obscure Gastrointestinal Bleeding Research Articles

A wrong path

Background and Aim: Obscure GI bleed in patients with cirrhosis is usually due to portal hypertension. Bleeding resulting from extrahepatic arterioportal fistulas (APFs) is extremely rare. We present a case of Obscure GI bleed secondary to APF and portal vein thrombosis successfully managed with coil embolization.

Ileal neuroendocrine tumor as an uncommon cause of obscure gastrointestinal bleeding.

Neuroendocrine tumors (NETs) are heterogeneous, slow-growing tumors whose most common locations are lung, gastrointestinal tract, and pancreas.

Small-Bowel Capsule Endoscopy-Optimizing Capsule Endoscopy in Clinical Practice.

The small bowel is the longest organ within the gastrointestinal tract. The emergence of small bowel capsule endoscopy (SBCE) over the last 20 years has revolutionized the investigation and diagnosis of small bowel pathology. Its utility as a non-invasive and well-tolerated procedure, which can be performed in an outpatient setting, has made it a valuable diagnostic tool. The indications for SBCE include obscure gastrointestinal bleeding, small bowel Crohn’s disease, and, less frequently for screening in polyposis syndromes, celiac disease, or other small bowel pathology. Currently, there are several small bowel capsules on the market from different manufacturers; however, they share many technological features. The European Society of Gastrointestinal Endoscopy (ESGE) only recently developed a set of key quality indicators to guide quality standards in this area. Many of the technical aspects of capsule endoscopy still feature a degree of uncertainty in terms of optimal performance. Incomplete studies due to slow transit through the bowel, poor imaging secondary to poor preparation, and the risk of capsule retention remain frustrations in its clinical utility. Capsule review is a time-consuming process; however, artificial intelligence and machine learning offer opportunities to improve this. This narrative review examines our current standing in a number of these aspects and the potential to further the application of SBCE in order to maximize its diagnostic utility.

P2Y12 Inhibitors Exacerbate Low-dose Aspirin-induced Small Bowel Injury in Dual Antiplatelet Therapy.

Objective Antithrombotic drugs are being used increasingly frequently to prevent cardiovascular diseases. Few studies have evaluated small bowel mucosal injury induced by dual antiplatelet therapy (DAPT). The aim of the present study was to evaluate small bowel mucosal injury induced by DAPT compared with other antithrombotics using video capsule endoscopy (VCE). Methods The study included chronic users of antithrombotics who underwent VCE for obscure gastrointestinal bleeding between January 2007 and July 2018. We evaluated the instances of small bowel injury classified into erosions and ulcers. Results Overall, 183 patients (114 men and 69 women; mean age, 73.6 years old) were enrolled, and the study groups comprised 49 patients taking low-dose aspirin (LDA) only, 50 taking anticoagulants only, 37 being treated with DAPT, 33 on combined LDA and anticoagulants, and 14 taking P2Y12 inhibitors. Small bowel erosions and ulcers were most frequently observed in the DAPT group, with frequencies of 78.4% and 37.8%, respectively. Exacerbating factors of small bowel ulcers were DAPT [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.2-7.7] and age over 80 years old (OR 2.4, 95% CI 1.1-5.4). Conclusion P2Y12 inhibitors seem to exacerbate LDA-induced small bowel injury. Preventive strategies for small bowel injury induced by LDA, especially DAPT, are urgently required.

Factors Affecting Route Selection of Balloon-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study.

Balloon-assisted enteroscopy (BAE) is an important diagnostic modality for ongoing obscure gastrointestinal bleeding (OGIB). However, it is difficult to determine the optimal insertion route. We retrospectively analyzed the records of patients with OGIB contained in a multicenter enteroscopy database of 1108 balloon-assisted enteroscopy (BAE) procedures (875 patients) to find out factors affecting BAE route selection in patients with OGIB. A total of 603 BAE procedures in 512 patients were investigated: there were 392 (65.0%) bidirectional and 211 (35.0%) unidirectional procedures. Overt OGIB was more frequent in the latter group (p = 0.024). Computed tomography (CT) was more frequently performed in the unidirectional group (p < 0.001). Capsule endoscopy and a small bowel barium study were performed more frequently in the bidirectional group (p < 0.001 and p = 0.039, respectively). Multivariate analysis showed that occult OGIB, capsule endoscopy and a small bowel barium study were independently associated with use of the bidirectional approach (p = 0.011, p = 0.013 and p = 0.046, respectively). Conversely, CT was associated with use of the unidirectional approach (p < 0.001). Conclusion: CT can aid the selection of an optimal insertion route in OGIB patients. However, capsule endoscopy and small bowel barium study are unhelpful.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy.

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn’s disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Risk factors for rebleeding in patients with obscure gastrointestinal bleeding from southern China.

BackgroundTo identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China.MethodsThis retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated.ResultsRebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients.ConclusionOur data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.

S2299 Mysterious Bleeding in a Patient With Roux-en-Y Gastrectomy

Introduction: Obscure gastrointestinal bleeding (GIB) accounts for 5% of admissions for GIB. Management of recurrent obscure GIB is problematic and costly, requiring repeat hospitalizations, various imaging modalities and multiple endoscopies with bleeding often ceasing at time of endoscopy, only to recur at a later time. Angiography can be diagnostic and therapeutic, but may be complicated by kidney damage and ischemia. Nuclear medicine bleeding scan is time consuming and often unreliable. Surgical intervention is a last resort, carries significant morbidity, and may not be a permanent solution as in the case of bleeding from angioectasias. Case Description/Methods: A 39 year old woman with gastric bypass 15 years ago initially presented to outside hospital with reports of rectal bleeding and anemia requiring transfusions. At that time, ileocolonoscopy and push enteroscopy were performed, and were unrevealing for etiology of bleeding. She presented to our institution a month later with same complaints. Nuclear bleeding scan suspected bleeding in the colon; repeat colonoscopy was again unrevealing. Small bowel capsule endoscopy was planned, but patient returned to the hospital with symptomatic anemia (Hgb 4.9 g/dL) and rectal bleeding. CT-angiography was unrevealing. After a discussion with the patient, endoscopy with heparin provocation was planned. After colonoscope was advanced into terminal ileum, IV Heparin 10,000u was administered. Terminal ileum and colon were carefully examined with two passes of the scope; no blood or etiology of bleeding identified. Push enteroscopy was then performed up to jejuno-jejunal anastomosis, where fresh blood was encountered. Active oozing from large bed of vascular ectasias was apparent. Protamine Sulfate 50mg IV was administered and ectasias were treated with Argon Plasma Coagulation and hemoclips placement with successful cessation of bleeding. The patient was discharged home and had no further hospitalizations for GIB. Discussion: Heparin provocation has been used in rare cases of obscure GIB to provoke bleeding and identify responsible site at time of endoscopy. This is useful in patients with recurrent overt obscure bleeding, especially in poor surgical candidates. Heparin provocation has been controversial due to fear of inducing a life-threatening bleed. However, as this case demonstrates, such procedures can be performed safely and effectively even in a community hospital setting with proper preparation and use of Protamine to reverse anticoagulation effects.Figure 1.: 1. J-J anastomosis filled with blood 2. J-J anastomois with active bleeding 3. Status post treatment with cautery and hemoclip placement.

S551 Efficacy and Safety of Double- versus Single-Balloon Retrograde Enteroscopy

Introduction: Previous studies have reported conflicting results on the outcomes of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE). We aimed to compare efficacy and safety of DBE to SBE via retrograde approach. Methods: We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large, tertiary referral center from 2008 to 2018. Data was collected on demographics, baseline comorbidities, antiplatelet and anti-coagulation use. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion and procedural duration. The analysis was done using SPSS software. Results: A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 in DBE and SBE group, respectively. There was no difference in gender, comorbidities, smoking history, clopidogrel, anti-coagulation use, platelet count, and laboratory parameters between both groups. Aspirin use was significantly higher in DBE group (40.8% vs. 29.9%, P = 0.03) (Table 1). The indication for enteroscopy was obscure gastrointestinal bleeding (OGIB) in 66.5% and 55.8% of DBE and SBE procedures, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95) and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) but higher maximal depth of insertion from ileo-cecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). In addition, proximal ileum was reached in 22.6% of DBE procedure as compared to 6% in SBE (P < 0.001). On subgroup analysis based on OGIB indication, DBE again had significantly higher depth of insertion (113.1 ± 87.07 cm vs. 79.9 ± 66.5 cm, P = 0.02) and rates of proximal ileum reach (23.7% vs. 7.1%, P = 0.006) as compared to SBE but there was no statistically significant difference in diagnostic yield (34.5% vs. 26.9%, P = 0.23) and therapeutics (20.3% vs. 14.9%, P = 0.31). Safety events were rare and similar in both groups (Table 2). Conclusion: Retrograde DBE is associated with significantly higher depth of insertion and shorter procedural duration but similar diagnostic yield and technical success as compared to.Figure:: Baseline and Demographics factors for both groupsTable 2.: Outcomes comparing DBE and SBE

S3375 Utility of Double Balloon Enteroscopy in Patients with Orthotopic Liver Transplant with Hepaticojejunostomy: Observational Study

Introduction: Double Balloon enteroscopy ( DBE ) in patients with altered anatomy can be technically challenging, however offers both diagnostic and therapeutic useful modality. We describe the patients with h/o orthotopic liver transplant with hepatic jejunostomy who underwent DBE with regards to indications, and readmissions Methods: From a large database of patients who underwent DBE, patients with h/o orthotopic liver transplant with hepatic jejunostomy were identified and their charts were reviewed. Results: We found total of 9 DBE procedures performed on 6 patients (males = 5, female = 1). Readmission within 30 days was seen in 2 patients and readmission from 30 days- 6 months was seen in 1 patient and they underwent repeat DBE again. Indications for DBE was biliary strictures (n = 2), GI bleed (n = 2). All the patients were classified as either ASA class 3 (n = 8) or ASA class 4 (n = 1) and underwent general anesthesia. DBE was performed predominantly for indications of pancreatico-biliary interventions requiring ERCP (n = 7) or obscure GI bleeding (n = 2). Positive diagnostic yield was 88 % with major abnormal findings includes strictures with or without CBD dilation (n = 4), anastomotic ulcers (n = 3). Therapeutic yield was noted in 55 % cases and the common therapies utilized were for biliary interventions modalities (n = 5), hemoclipping, epinephrine injections (n = 1) and no intervention performed in 4 patients. No intra-procedural adverse events were noted. Conclusion: DBE in patients with Orthotopic liver transplant with hepaticojejunostomy has a high diagnostic and therapeutic yield. DBE is a useful modality for GI intervention, especially in the patients who underwent such procedures.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms.

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.

S558 Artificial Intelligence and Capsule Endoscopy: Automatic Detection of Gastric Vascular Lesions Using a Convolutional Neural Network

Introduction: Capsule endoscopy (CE) is the main diagnostic modality for the investigation of obscure gastrointestinal bleeding. Although it is designed to identify small bowel pathology, lesions (particularly vascular lesions) are frequently documented in locations within reach of conventional endoscopy. However, the performance of CE for detection of gastric lesions has been shown to be suboptimal. Studies on the development of artificial intelligence (AI) systems, particularly convolutional Neural Networks (CNN), for automatic analysis of CE images have provided promising results. To date, performance of these automated algorithms for detection of gastric vascular lesions in CE images has not been evaluated. We aimed to develop and test a CNN-based algorithm for automatic detection of gastric vascular lesions (angiectasia, gastric antral vascular ectasia, varices, and red spots). Methods: A total of 1275 CE images were included for construction of the CNN, 470 containing vascular lesions and 805 showing normal mucosa. For automatic detection of gastric lesions, these images were inserted into a CNN model with transfer learning. A training dataset comprising 80% of the total pool of images was defined. Subsequently, we evaluated the performance of the network using an independent test dataset (20% of total image pool). The output provided by the CNN was compared to a consensus classification provided by two endoscopists experienced in CE (more than 1000 CE videos each). We calculated the sensitivity, specificity, accuracy, positive predictive and negative predictive values (PPV and NPV, respectively), and area under the curve (AUC). Results: After optimization of the neural architecture of the algorithm, our model was able to detect detected gastric vascular lesions with a sensitivity, specificity, PPV and NPV of 86.2%, 98.1%, 96.4% and 92.4%, respectively. The algorithm had an overall accuracy of 93.7%. The AUC was 0.97. The CNN read the validation dataset in 6 seconds (average processing speed of 45 images per second). Conclusion: This is the first report of a deep learning system for automatic detection of gastric vascular lesions in CE images. The implementation of these systems may potentiate the ability of CE for exploration of suspected upper gastrointestinal disease, which may be particularly helpful in patients with limited tolerance to EGD.

S2356 Hiding in Plain Sight: A Challenging Case of Obscure GI Bleeding Due to Appendiceal Endometriosis in a Postmenopausal Female Patient

S2356 Hiding in Plain Sight: A Challenging Case of Obscure GI Bleeding Due to Appendiceal Endometriosis in a Postmenopausal Female Patient

Cryptogenic Multifocal Ulcerous Stenosing Enteritis

Crytpogenic multifocal ulcerous setnosing enteritis is an unusual cause of gastrointestinal bleed. The objective of this report is to highlight small bowel ulcerations as a cause of anemia and the role of wireless capsule endoscopy in the diagnosis of CMUSE. We present here two young women who had been evaluated for anemia with normal gastroscopy, colonoscopy and contrast CT's and requiring multiple blood transfusions over the years. Both patients had wireless capsule endoscopy which showed multiple ulcerations with stenosis in the small intestine, resulting in capsule retention in the small intestine which was retrieved. Both patients improved with steroids and azathioprine. To summarize CMUSE could be cause of obscure GI bleed, when CMUSE is a consideration as the cause of GI bleed wireless capsule endoscopy should be used in caution.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

DIEULAFOY’S LESION OF JEJUNUM PRESENTING AS AN OBSCURE GASTROINTESTINAL BLEEDING: A CASE REPORT

Obscure gastrointestinal bleeding has been designated as bleeding of unknown origin that persist or recurs after a negative initial or primary endoscopy (colonoscopy and upper endoscopy). We present a case of 16 years old male who was admitted at our hospital with presentation of black tarry hard foul-smelling stool associated with weakness, dizziness and loss of consciousness for 10-15 minutes. Physical examination showing pallor. Upper GI Endoscopy, colonoscopy and double balloon Enteroscopy (DBE) failed to find out the cause of bleeding whereas, CT angiography shows a prominent submucosal vessel with blush of contrast enhancement seen at mid-jejunum and suggestive of a Dieulafoy’s lesion. As the lesion was not identified properly during both anterograde and retrograde Double Balloon Enteroscopy we decided to go for the conservative management and treated the patient on close monitoring.

Artificial Intelligence and Capsule Endoscopy: Automatic Detection of Small Bowel Blood Content Using a Convolutional Neural Network

Introduction: Capsule endoscopy has revolutionized the management of patients with obscure gastrointestinal bleeding. Nevertheless, reading capsule endoscopy images is time-consuming and prone to overlooking significant lesions, thus limiting its diagnostic yield. We aimed to create a deep learning algorithm for automatic detection of blood and hematic residues in the enteric lumen in capsule endoscopy exams. Methods: A convolutional neural network was developed based on a total pool of 22,095 capsule endoscopy images (13,510 images containing luminal blood and 8,585 of normal mucosa or other findings). A training dataset comprising 80% of the total pool of images was defined. The performance of the network was compared to a consensus classification provided by 2 specialists in capsule endoscopy. Subsequently, we evaluated the performance of the network using an independent validation dataset (20% of total image pool), calculating its sensitivity, specificity, accuracy, and precision. Results: Our convolutional neural network detected blood and hematic residues in the small bowel lumen with an accuracy and precision of 98.5 and 98.7%, respectively. The sensitivity and specificity were 98.6 and 98.9%, respectively. The analysis of the testing dataset was completed in 24 s (approximately 184 frames/s). Discussion/Conclusion: We have developed an artificial intelligence tool capable of effectively detecting luminal blood. The development of these tools may enhance the diagnostic accuracy of capsule endoscopy when evaluating patients presenting with obscure small bowel bleeding.

CAPSULE ENDOSCOPY IN OBSCURE GI BLEED CASES: EXPERIENCE FROM SINGLE CENTRE

Background: Capsule Endoscopy has a pivotal role in dening small bowel lesions causing overt or obscure GI bleed. The aim of our study was to study the efcacy of capsule endoscopy in diagnosing lesions causing obscure GI bleed and also to dene the common causes. 34 serial patients with obscure GI Bleed Materials and methods: underwent capsule endoscopy over a period of 18 months following normal upper GI endoscopy, normal ileocolonoscopy and normal CT enterography. 30 patients (88.2%) were Results: males and 4 (11.8%) were females. Age of presentation ranged from 14 to 86 years with median age of 43.5 years and mean age of 46.4 years. Comorbidities encountered were Coronary Artery Disease (5 patients, 14.7%), Hypertension (8 patients, 23.5%) and Diabetes Mellitus (2 patients, 5.8%). 5 patients (14.7%) were on Aspirin, 3 patients (8.8%) were on Clopidogrel, 3 patients (8.8%) were on both Aspirin and Clopidogrel and 2 patients (5.8%) were on Oral Anticoagulants (OACs). Presenting complaints were melena in 18 patients (53.1%), haematochezia in 7 patients (21.9%), hematemesis in 3 patients (8.8%), and occult blood loss only was seen in 6 patients (17.6%). Duration of symptoms ranged from 2 days to 14 years with a median of 3 months and mean of 20.4 months. 12 patients (37.5%) presented with a duration of more than 1 year while 10 patients (31.2%) presented with a duration of less than 1 month. Minimum haemoglobin ranged from 3.8 to 13 g/dl with median of 7 g/dl and mean of 7.14g/dl. Capsule endoscopy was positive in 26 patients 76.5%) and negative in 8 patients (23.5%). Telangiectasia were seen in 10 patients (29.4%), ulcers and/or erosions were seen in 5 patients (14.7%), inammatory bowel disease in 3 patients (8.8%) and worms in 1 patient (2.9%). Active bleed with no identiable lesion was seen in 4 patients (11.8%). WCE has high Conclusion: diagnostic yield, is relatively safe and is an important diagnostic tool for OGIB. Small bowel telangiectasia, Ulcers/erosions, Crohn's disease and tumours continue to be commonly recognized causes of OGIB in developing countries like India.

Deep learning and capsule endoscopy: automatic identification and differentiation of small bowel lesions with distinct haemorrhagic potential using a convolutional neural network

ObjectiveCapsule endoscopy (CE) is pivotal for evaluation of small bowel disease. Obscure gastrointestinal bleeding most often originates from the small bowel. CE frequently identifies a wide range of lesions with...

Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy.

Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.