Overt Gastrointestinal Bleeding Research Articles

Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta-analysis.

To systematically identify predictors of gastrointestinal (GI) bleeding in adult intensive care unit (ICU) patients. We conducted a systematic review and meta-analysis of cohort studies including trial cohorts. We searched MEDLINE, EMBASE, and trial registries up to March 2019. Eligible studies assessed potential predictors of clinically important GI bleeding (CIB; primary outcome) or overt GI bleeding (secondary outcome), had > 20 events, and presented adjusted effect estimates. Two reviewers assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence using GRADE. We meta-analysed adjusted effect estimates if data from ≥ 2 studies were available. We included 8 studies (116,497 patients). 4 studies (including 74,456 patients) assessed potential predictors of CIB, and we meta-analysed 12 potential predictors from these. Acute kidney injury (relative effect [RE] 2.38, 95% confidence interval [CI] 1.07-5.28, moderate certainty) and male gender (RE 1.24, 95% CI 1.03-1.50, low certainty) were associated with increased incidence of CIB. After excluding high risk of bias studies, coagulopathy (RE 4.76, 95% CI 2.62-8.63, moderate certainty), shock (RE 2.60, 95% CI 1.25-5.42, low certainty), and chronic liver disease (RE 7.64, 95% CI 3.32-17.58, moderate certainty) were associated with increased incidence of CIB. The effect of mechanical ventilation on CIB was unclear (RE 1.93, 0.57-6.50, very low certainty). We identified predictors of CIB and overt GI bleeding in adult ICU patients. These findings may be used to identify ICU patients at higher risk of GI bleeding who are most likely to benefit from stress ulcer prophylaxis.

Local instilation of antibiotics through nasocystic catheter for the treatment of infected pancreatic necrosis: Can necrosectomy be avoided?

Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment.To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts.Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21–38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts.All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients.Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

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Society of abdominal radiology gastrointestinal bleeding disease-focused panel consensus recommendations for CTA technical parameters in the evaluation of acute overt gastrointestinal bleeding.

To formulate consensus recommendations for CT angiography technical parameters used to evaluate overt gastrointestinal (GI) bleeding. An electronic questionnaire consisting of 17 questions was sent to a panel of 16 radiologists with expertise on the imaging of GI bleeding from the Society of Abdominal Radiology GI Bleeding disease-focused panel to obtain consensus agreement on issues related to CTA technical parameters for imaging overt GI bleeding. A multi-round Delphi method of voting was performed to obtain consensus which was defined as ≥ 80% agreement. Consensus agreement was reached in 15/17 (89%) of the questions including the technique for the administration of IV contrast, the number of phases, scan timing, and image reconstruction. A panel of experts on the imaging of GI bleeding from the Society of Abdominal Radiology was able to reach consensus on the majority of technical parameters used for CTA of overt GI bleeding. These recommendations should improve the quality of patient care by adopting these minimal technical requirements for optimal exam performance and lead to less variation in the performance of these exams which will facilitate collecting and comparing published data from different centers. These recommendations will need revisions as additional scientific data become available.

613 Comparison of Clinical Outcomes in Traditional Gastrointestinal Hemorrhage Work-Up Versus Direct Utilization by Push Enteroscopy in Patients With a Left Ventricular Assist Device

INTRODUCTION: Patients with left ventricular assisted devices (LVADs) are at considerable risk of gastrointestinal bleeding (GIB) of about 23%. A significant portion of GIB occur in the stomach, duodenum or small intestine as compared with lower intestinal tract. The traditional workup for such patients usually starts with an EGD ± colonoscopy, then proceeds with a small bowel evaluation if the initial workup is negative. This approach requires considerable time and effort which may lead to longer hospitalizations and multiple procedures. Our goal is to compare the traditional work up GIB with an innovative approach of performing push enteroscopy (PE) as the first diagnostic/therapeutic procedure. METHODS: This is a retrospective study was performed in Henry Ford Hospital in Detroit, MI. ICD-9 and ICD-10 diagnosis codes were used to generate a list of LVAD patients who were admitted with an overt GIB or worsening anemia in the period from 1/1/2013 to 12/25/2018. Our primary outcomes were the rate of detection of GIB lesion and all-cause mortality. Secondary outcome was the length of hospitalization. RESULTS: A total of 227 patients were reviewed. 89 patients were included (Mean age 61.36 years old, 75.28% were males). Most patients presented with either melena or worsening anemia without overt GIB. A total of 71 patients underwent the traditional approach at the first index endoscopy, whereas 18 patients started with PE ± colonoscopy. The source of GIB was detected at the first index endoscopy in 51 patients (36 traditional approach and 15 in PE approach). Arteriovenous malformation was the most common lesion detected and the two most common sites of bleeding were gastroduodenal followed by the small bowel. The PE approach was associated with a higher rate of GI site detection, OR 4.861 (95% CI (1.293-18.271), P 0.012), this was true, especially when patients presented with worsening anemia without overt bleeding, OR 11.2 (95% CI (1.202-104.33), P 0.015). There was no statistically significant difference between both approaches in terms of all-cause mortality (P 0.163). Patients in the PE approach did have a shorter hospital stay (x̅ (SD) 10.78 (13.97) days compared to 18.8 (25.58) days for the traditional approach) with P 0.034. CONCLUSION: PE is a safe procedure. It increases the GIB site detection and shortens the length of hospital stay when considered on the initial evaluation of LVAD patients presenting with GIB in general and worsening anemia in specific.

Machine Learning to Predict Outcomes in Patients with Acute Gastrointestinal Bleeding: A Systematic Review.

Risk stratification of patients with gastrointestinal bleeding (GIB) is recommended, but current risk assessment tools have variable performance. Machine learning (ML) has promise to improve risk assessment. We performed a systematic review to evaluate studies utilizing ML techniques for GIB. Bibliographic databases and conference abstracts were searched for studies with a population of overt GIB that used an ML algorithm with outcomes of mortality, rebleeding, hemostatic intervention, and/or hospital stay. Two independent reviewers screened titles and abstracts, reviewed full-text studies, and extracted data from included studies. Risk of bias was assessed with an adapted Quality in Prognosis Studies tool. Area under receiver operating characteristic curves (AUCs) were the primary assessment of performance with AUC ≥ 0.80 predefined as an acceptable threshold of good performance. Fourteen studies with 30 assessments of ML models met inclusion criteria. No study had low risk of bias. Median AUC reported in validation datasets for predefined outcomes of mortality, intervention, or rebleeding was 0.84 (range 0.40-0.98). AUCs were higher with artificial neural networks (median 0.93, range 0.78-0.98) than other ML models (0.81, range 0.40-0.92). ML performed better than clinical risk scores (Glasgow-Blatchford, Rockall, Child-Pugh, MELD) for mortality in upper GIB. Limitations include heterogeneityof ML models, inconsistent comparisons of ML models with clinical risk scores, andhigh risk of bias. ML generally provided good-excellent prognostic performance in patients with GIB, and artificial neural networks tended to outperform other ML models. ML was better than clinical risk scores for mortality in upper GIB.

Hemobilia: Historical overview, clinical update, and current practices.

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosisof hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Risk factors for small bowel bleeding in an overt gastrointestinal bleeding presentation after negative upper and lower endoscopy.

IntroductionA small bowel source is suspected when evaluation of overt gastrointestinal (GI) bleeding with upper and lower endoscopy is negative. Video capsule endoscopy (VCE) is the recommended next diagnostic test for small bowel bleeding sources. However, clinical or endoscopic predictive factors for small bowel bleeding in the setting of an overt bleeding presentation are unknown. We aimed to define predictive factors for positive VCE among individuals presenting with overt bleeding and a suspected small bowel source.MethodsWe included consecutive inpatient VCE performed between September 1, 2012 to September 1, 2015 for melena or hematochezia at two tertiary centers. All patients had EGD and colonoscopy performed prior to VCE. Patient demographics, medication use, and endoscopic findings were retrospectively recorded. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. The secondary outcome of interest was the performance of a therapeutic intervention. Data were analyzed with the Fisher exact test for dichotomous variables and logistic regression.ResultsTwo hundred forty-three VCE were reviewed, and 117 were included in the final analysis. A positive VCE (P2) was identified in 35 (29.9%) cases. In univariate analysis, a positive VCE was inversely associated with presence of diverticula on preceding colonoscopy (OR: 0.44, 95% CI: 0.2–0.99), while identification of blood on terminal ileal examination was associated with a positive VCE (OR: 5.18, 95% CI: 1.51–17.76). In multivariate analysis, only blood identified on terminal ileal examination remained a significant risk factor for positive VCE (OR: 6.13, 95% CI: 1.57–23.81). Blood on terminal ileal examination was also predictive of therapeutic intervention in both univariate (OR: 4.46, 95% CI: 1.3–15.2) and multivariate analysis (OR: 5.04, 95% CI: 1.25–20.32).ConclusionAmong patients presenting with overt bleeding but negative upper and lower endoscopy, the presence of blood on examination of the terminal ileum is strongly associated with a small bowel bleeding source as well as with small bowel therapeutic intervention. Presence of diverticula on colonoscopy is inversely associated with a positive VCE and therapeutic intervention in univariate analysis.

No significant difference in clinically relevant findings between Pillcam® SB3 and Pillcam® SB2 capsules in a United States veteran population.

BACKGROUNDCapsule endoscopy (CE) allows for a non-invasive small bowel evaluation for a wide range of gastrointestinal (GI) symptoms and diseases. Capsule technology has been rapidly advancing over recent years, often improving image frequency and quality. The Pillcam® SB3 (SB3) capsule is one such technology that offers an adaptive frame rate advantage over the previous versions of the capsule the Pillcam® SB2 (SB2). Some have proposed that this improvement in capsule technology may lead to increased diagnostic yields; however, real world clinical data is currently lacking.AIMTo evaluate the clinically relevant findings of SB3 and SB2 capsules in a population of United States veterans.METHODSA retrospective analysis of 260 consecutive CE studies was performed including 130 SB3 and 130 SB2 capsule studies. Recorded variables included: age, gender, type of capsule, body mass index, exam completion, inpatient status, opioid use, diabetes, quality of preparation, gastric transit time, small bowel transit time, indication, finding, and if the exam resulted in a change in clinical management. The primary outcome measured was the detection of clinically relevant findings between SB3 and SB2 capsules.RESULTSMean age of the study population was 67.1 ± 10.4 years and 94.2% of patients were male. Of these 28.1% were on opioid users. The most common indications for capsule procedure were occult GI bleeding (74.6%) and overt GI bleeding (14.6%). Rates of incomplete exam were similar between SB3 and SB2 groups (16.9% vs 9.2%, P = 0.066). The overall rate of clinically relevant finding was 48.9% in our study. No significant difference was observed in SB3 vs SB2 capsules for clinically relevant findings (46.2% vs 51.5%, P = 0.385) or change in clinical management (40.8% vs 50.0%, P = 0.135).CONCLUSIONOur study found no significant difference in clinically relevant findings between SB3 and SB2 capsules.

Prevalence and Predictors of Adenomas in the 40-49 Year Old Patients Undergoing Colonoscopy

Background: Recently the American Cancer Society made a qualified recommendation to start screening for colorectal cancer (CRC) at 45 years of age in all average risk individuals. In this study, our primary aim is to calculate the prevalence and also evaluate the predictors of increased prevalence of detected adenomas in the 40 to 49-year-old individuals undergoing colonoscopy. Methods: A retrospective cross sectional study was performed using our electronic endoscopy database. Study subjects included all 40 to 49-year-old patients undergoing their first colonoscopy at our institution from January 1, 2010 to September 30, 2017. Exclusion criteria included patients who underwent colonoscopy for overt gastrointestinal bleeding, inflammatory bowel disease, a history of familial adenomatous polyposis, hereditary non polyposis CRC. Univariate analysis and multivariate analysis was performed to identify factors associated with increased adenoma detection rate (ADR). Findings: A total of 2059 patients were included in the study and 317 of these patients had family history (FH) of CRC. Patients with FH of CRC had significantly higher ADR (27.8% versus 19.7%, p=0.001) as compared to those without family history of CRC. There was no significant difference in ADR in patients between 40-44-years versus 45-49-years of age (17.7% vs 21.4%, p=0.058). On a multivariate analysis while adjusting for multiple patient and procedural variables; FH of CRC, male gender, BMI > 30 kg/m2, chronic kidney disease, and age were associated with high ADR. Interpretation: Our study shows that in addition to FH of CRC, age, male gender, BMI, and CKD are independent predictors of increased ADR in patients between 40 to 49 years of age. Funding Statement: The authors state: No funding sources to be declared. Declaration of Interests: The authors report no conflicts of interest. Ethics Approval Statement: The study protocol was approved by the institutional review board (IRB) at the University of Texas Medical Branch, Galveston, TX.

Outcomes in Patients with Left Ventricular Assist Devices, Pacemakers, and Implantable Cardioverter Defibrillators Undergoing Single Balloon Enteroscopy

Obscure overt gastrointestinal bleeding can be challenging to evaluate in patients with electronic cardiac devices such as continuous flow left ventricular assist devices (LVADs), pacemakers (PPMs), and implantable cardioverter defibrillators (ICDs). Limited data exist on the utility and safety of single balloon enteroscopy (SBE) in patients with cardiac devices. We aimed to evaluate the safety, efficacy, diagnostic, and therapeutic outcomes of the aforementioned devices in patients undergoing SBE. A retrospective study was performed using the medical records of 57 patients undergoing SBE at our institution from 2010 to 2014. Patients were divided into two groups: those with cardiac devices and those without. Data on comorbidities, complications, findings, diagnostic, and therapeutic yield were compared. t Test and logistic regression assessed the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and standard deviation. For dichotomous data, the results were summarized as odds ratio and 95% confidence intervals. The overall age in patients with cardiac devices was 67.89 ± 6.96 versus 66.03 ± 11.95 years in the control. The cardiac device group was composed of 42.1% women; the control comprised 21.1% women. There were 19 patients with cardiac devices; 8 (LVAD + ICD), 1 (LVAD + PPM + ICD), 2 (PPM + ICD), 6 (PPM), 2 (ICD); 38 patients were in the control group. Patients with cardiac devices were hospitalized more often than patients without devices; this finding was not statistically significant (odds ratio 1.826, 95% confidence interval 0.544-6.128, P = 0.389). Procedure times were longer in the cardiac device group, 65.16 ± 49.92 minutes, when compared with the control, 57.40 ± 20.42, but it also did not reach statistical significance (mean difference 7.758, 95% confidence interval -11.360 to 26.876, P = 0.049). There was no statistically significant difference in major or minor events between patients with cardiac devices and the control group. Diagnostic and therapeutic yield and rebleeding rates were similar across both groups. Patients in the cardiac device group did not appear to be at any more significant risk than those without cardiac devices. Furthermore, diagnostic and therapeutic yield and rebleeding rates appear to be similar across both groups. Clinicians may perform SBE in these patients safely and effectively, with good overall outcomes.

Plummer-Vinson Syndrome With Concomitant Factor VII Deficiency

Background: Plummer-Vinson syndrome (PVS), a rare disorder characterized by dysphagia, iron deficiency anemia, and esophageal webs, has principally been described in middle-aged women. This disorder is uncommon in the 21st century because of the abundance of iron-fortified foods. Clotting factor deficiencies are also rare. Factor VII deficiency is a bleeding disorder characterized by the absence of a critical protein in the coagulation cascade. Case Report: We present a case of PVS associated with factor VII deficiency in a 26-year-old African American female. The patient had a history of anemia that was repeatedly attributed to menstrual bleeding and dysphagia for 10 years. She presented with symptomatic anemia requiring transfusion. She reported a history of food getting stuck in her chest, and workup revealed esophageal webs with no evidence of overt luminal gastrointestinal bleeding. Coagulation laboratory tests revealed the incidental finding of a borderline increased prothrombin time. Hematologic studies confirmed the presence of factor VII deficiency. Conclusion: To our knowledge, no case has been published about a patient diagnosed with PVS and concomitant factor VII deficiency. Our case illustrates several learning points: (1) PVS is an uncommon disorder that may still be diagnosed in a developed country in the 21st century; (2) PVS requires close follow-up and esophageal surveillance because of the increased risk of esophageal cancer; (3) factor VII exhibits a high degree of phenotypic variability; (4) phenotype in factor VII deficiency does not always correlate with factor VII activity, although life-threatening spontaneous bleeding is not expected with levels >2%.

Clinical characteristics of hereditary hemorrhagic telangiectasia - case series and review of the literature

Introduction. Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder with estimated prevalence of one in 5,000 to 10,000. The disease has age-related penetrance and the HHT signs and symptoms occur and worsen with age. A diagnosis of HHT is based on the Curacao`s criteria. Case report. We report a case series of 6 patients diagnosed with HHT, 5 with definite and one with probable diagnosis according to the Curacao criteria. In 5 patients, the recurrent epistaxis occurred in adolescence as the first presentation while one patient presented with melena. The diagnosis was delayed in 5 patients and the presence of HHT was diagnosed during or after the fifth decade. In 4 patients, the overt gastrointestinal bleeding occurred in the later course of the disease. The asymptomatic pulmonary circulation arteriovenous malformations were detected in 2 patients. The cerebral arteriovenous malformations were not detected. Conclusion. Hereditary hemorrhagic telangiectasia is a rare disorder affecting multiple organs. It should be considered in the adolescents with recurrent epistaxis and in the differential diagnosis of anemia with signs of the gastrointestinal bleeding in order to shorten the delay in the diagnosis and subsequently improve the outcome of the disease.

Non-small bowel lesion detection at small bowel capsule endoscopy: A comprehensive literature review.

Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal (GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.

Rare Case of Intestinal Lipomatosis Presenting With Hemorrhage

Introduction Diffuse intestinal lipomatosis is a very rare disease characterized by multifocal infiltration of mature adipose tissue into the intestinal submucosal or subserosal layers. The disease is mostly asymptomatic but complications like intussusceptions, obstruction, bleeding or perforation have been reported. Gastrointestinal (GI) lipomas occur in colon, small bowel, stomach and esophagus in decreasing frequency. Lipomas >2cm size are more prone to having complications. We here in describe a very rare care of diffuse intestinal lipomatosis presenting with hemorrhage. Case Report A 59-year-old Caucasian woman with hypothyroidism presented with worsening shortness of breath and dark stools for few days. Physical exam was remarkable for mucosal pallor. Laboratory studies showed severe anemia with hemoglobin of 4.7 gm/dL. Diagnostic upper endoscopy showed a large friable mass with overlying small old clot in second portion of duodenum (D2) adjacent to the ampulla. There were multiple other submucosal mass lesions in the entire examined small bowel. Colonoscopy also showed multiple (˜20) submucosal lesions throughout the colon suggestive of likely diffuse intestinal lipomatosis. Endoscopic ultrasound (EUS) done for elucidation of nature of D2 lesion revealed an oval hyperechoic lesion measuring 39×24mm arising from the submucosal layer without involving muscularis propria. Fine needle biopsy of the lesion revealed adipocytes. Discussion Solitary lipomas of GI tract are common accounting up to 8% of all GI tumors. However GI lipomatosis is very rare with an incidence of 0.04%. It's etiopathogenesis is unclear. Anomalies in embryonic development, fat dysmetabolism, chronic inflammation, alcohol use and hamartomatous syndromes have been implicated. Ileum is the most common site of enteric lipomas (25% of all GI tract lipomas) with duodenum being least frequent (4%). Endoscopic signs suggestive of lipomas include: tenting sign, cushion sign and the ‘naked fat’ sign (fat protruding from the biopsy site). A lipoma rarely can present with overt GI bleeding from apical ulceration. Ulceration results from pressure atrophy of mucosa and necrosis of the overlying epithelial layers due to abnormal peristalsis. Ulceration can be extensive with profuse bleeding requiring aggressive endoscopic, radiological or surgical management. Endoscopic modalities of managment include snare / endoloop resection and submucosal dissection.1870_A Figure 1. Multiple rounded submucosal lesions in the small bowel with positive cushion sign consistent with lipomas (A); large submucosal mass lesion in D2 adjacent to the ampulla (B).1870_B Figure 2. EUS showing an oval hyperechoic, heterogenous lesion measuring arising from the submucosal layer1870_C Figure 3. Fine needle biopsy showing adipocytes and mucosal epithelial cells

A Unique Presentation of Jejunal Submucosal Pancreatic Heterotopia as Overt Obscure Gastrointestinal Bleeding

A Unique Presentation of Jejunal Submucosal Pancreatic Heterotopia as Overt Obscure Gastrointestinal Bleeding

Adenoma Detection Rates in Patients in the 40-49 Year Age Group Across Different Ethnicities: Presidential Poster Award

Introduction: Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the third leading cause of cancer related deaths in United States. Recent guidelines from the American Cancer Society (ACS) recommend starting CRC screening at 45 years in average-risk patient population in United States. Previous studies have shown an increase in incidence of CRC in African Americans less than 50 years of age. Despite this, there is limited evidence about prevalence of adenomatous polyps in this age group. We aimed to examine the prevalence of adenomas in 40 to 49 years old patients without any family history (FH) of CRC or polyps across different races. Methods: A retrospective cross sectional study was performed using our electronic endoscopy database. Study subjects included all 40 to 49-year-old patients without any FH of CRC undergoing their index colonoscopy at our tertiary care academic institution from January 1, 2010 to September 30, 2017. Exclusion criteria included patients who underwent colonoscopy for overt gastrointestinal bleeding, inflammatory bowel disease, patients who had previous colonoscopies, a history of familial adenomatous polyposis, hereditary non polyposis CRC. Results: A total of 1856 patients were included in the study. Of these 53.6 % were Caucasian, 26.9% African Americans, and 19.4 % were Hispanics. Mean age of these patients was 44.7 yrs (S.D 2.6) and 57.6 % were males. Adenoma detection rate (ADR) was 22.1 % in Caucasians, 16.0 % in African Americans, 23.3% in Hispanics (Table 1). On multivariate analysis while adjusting for possible confounding factors, African Americans had lower ADR as compared to Caucasians (adjusted Odds Ratio: 0.6, 95% CI: 0.4-0.8, P-value=0.001). Conclusion: The ADR across all races in the 40-49 year age group is lower than the previously recommended ADR in patients with average risk undergoing their screening colonoscopy at 50 years of age (i.e. 25%). With the advent of new guidelines from the ACS, new benchmarks for quality indicators in colonoscopy regarding ADR will be needed. The lower ADR in African Americans suggests that further studies are needed to look for factors beyond the traditional adenoma-carcinoma pathway to understand the increasing incidence of CRC in African Americans in the younger age group.478 Figure 1 No Caption available.

An Unusual Location for Arteriovenous Malformations

Arteriovenous malformations (AVMs) are lesions in the gastrointestinal (GI) tract which are frequently encountered in older patients. They account for up to 6% of lower GI bleeding and up to 8% of upper GI bleeding with presentation ranging from occult to overt bleeding. AVMs most frequently occur in the stomach, small intestine, and proximal colon. Esophageal AVMs are rare and have been reported twice in literature in the presence of Barrett's esophagus mucosa. We present the 3rd reported case of esophageal AVMs. A 79-year-old man was admitted to the hospital with shortness of breath and fatigue. His medical history includes long segment Barrett's esophagus and esophageal adenocarcinoma (EAC). His EAC was diagnosed 2 years ago and treated with radiation monotherapy due to other comorbidities including coronary artery disease and congestive heart failure. He denied any overt gastrointestinal bleeding, weight loss, or dysphagia. His vital signs on admission were normal. His physical exam was only significant for conjunctival pallor. Laboratory data was significant for a hemoglobin level of 7.8 g/dL with his prior hemoglobin levels being normal. Iron studies demonstrated a low serum iron and ferritin. An upper endoscopy was performed which showed a long segment of salmon colored mucosa proximal to the GEJ consistent with Barrett's esophagus. There were numerous AVMs throughout the Barrett's mucosa in a diffuse pattern that abruptly stopped where the squamous tissue began. There was no mass or lesion in the esophagus, and the stomach and duodenum were normal. Radiofrequency ablation was performed to prevent further blood loss. Our case highlights a diffuse presence of AVMs leading to occult bleeding, in contrast to the single AVMs reported in prior literature. This patient's history of radiation exposure for treatment of EAC also differentiates his case from others. Radiation changes to the esophagus typically involve an acute ulcerative process followed by a chronic fibrosis. The presence of metaplastic mucosa and lack of squamous mucosa may have caused atypical reactions to the radiation in the esophagus, analogous to rectal AVMs. Thermal therapy was the most efficacious modality for achieving hemostasis due to its shallow penetration depth and wide contact area.1826_A Figure 1. Esophageal AVM 11826_B Figure 2. Esophageal AVM 2

Is Adenoma Detection Rate Still the Quality Indicator for Screening Colonoscopy in Younger Patients?

Introduction: Recent guidelines from the American Cancer Society (ACS) recommend to start colon cancer screening at 45 years in average-risk patient population. Previously, it has been established that patients with family history (FH) of colorectal cancer (CRC) at any age should undergo screening at age 40 years. Despite these guidelines, data on the prevalence of adenomas in these patients is scant. We aimed to examine and compare the prevalence of adenomas in 40 to 49-year-old individuals undergoing colonoscopy because of FH of CRC of a first-degree relative (FDR) with CRC versus patients without any family history of CRC. Methods: A retrospective cross sectional study was performed using our electronic endoscopy database. Study subjects (cases) included all 40-49-year-old patients undergoing their index colonoscopy for diagnostic purposes (abdominal pain, diarrhea, weight loss, altered bowel habits, etc) at our center from January 2010 to September 2017. The control group consisted of all 40-49-year-old patients undergoing their index screening colonoscopy for a FDR with CRC. Exclusion criteria included patients who underwent colonoscopy for overt gastrointestinal bleeding, inflammatory bowel disease, patients who had previous colonoscopies, a history of familial adenomatous polyposis, hereditary non polyposis CRC. Results: A total of 2059 patients were included in the study. Mean age of these patients was 44.7 years, and 59.8% were males. Number of patients in the control group were 355, and number in study group was 1704. The adenoma detection rate (ADR) was 27.8% in the control group, and 19.7% (p=0.001) in the study group. The rate of neoplasia detected was 2.2% in patients with FH of CRC, and 1.3% in patients without FH of CRC (p=0.18). Conclusion: The ADR in average-risk 40-49 year old patients is less than the current recommended ADR in patients with average risk undergoing their screening colonoscopy at 50 years of age (i.e. 25%). However, the rate of neoplasia detected was comparable. This suggests that although early colonoscopy is beneficial in detecting CRC, but further studies are needed to look for factors beyond the traditional adenoma-carcinoma pathway in younger individuals. With the advent of the latest ACS guidelines, new quality benchmark for ADR will need to be established in average risk patients younger than 50 years of age undergoing screening colonoscopy. Future large multi-center prospective studies are needed to confirm this finding.225_A Figure 1 No Caption available.225_B Figure 2 No Caption available.

Re-evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario-Based Meta-Analysis.

Because recent studies have challenged the efficacy of stress ulcer prophylaxis (SUP) in the critically ill patient, our objective was to evaluate the efficacy of SUP with proton pump inhibitors (PPIs) or histamine2 -receptor antagonists (H2 RAs) against placebo, control, no therapy, or enteral nutrition alone in critically ill adults. Meta-analysis with trial sequential analysis (TSA) of 34 randomized controlled trials. A total of 3220 critically ill adults who received PPIs or H2 RAs versus placebo, control, no therapy, or enteral nutrition. A systematic review was performed using a random effects meta-analysis with TSA according to a predefined protocol. Randomized controlled trials comparing PPIs or H2 RAs with either placebo, control, no therapy, or enteral nutrition alone were identified through a comprehensive search of the literature. Two blinded reviewers independently assessed studies for inclusion, risk of bias, and extracted data using Cochrane Collaborative methodology. The predefined primary outcomes were clinically important, overt, and any (clinically important plus overt) gastrointestinal bleeding. Secondary outcomes included pneumonia, Clostridium difficile-associated diarrhea (CDAD), and mortality. Subgroup analyses were conducted for the primary outcome by PPI or H2 RA use, intensive care unit (ICU) subtype, studies published after early goal-directed therapy (EGDT), the presence of risk factors for stress ulceration, and enteral nutrition use. Of the 34 trials included, 33 were judged as high risk of bias and 1 was judged as low risk. Use of SUP significantly reduced clinically important bleeding (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.37-0.76, p<0.001; I2 =0%), overt bleeding (RR 0.55, 95% CI 0.39-0.76, p=0.0003; I2 =53%), and any bleeding (RR 0.54, 95% CI 0.41-0.71, p<0.00001; I2 =58%). TSA confirmed these findings. No significant differences in pneumonia, CDAD, or mortality were noted. Subgroup analyses revealed significant reductions in clinically important bleeding with SUP in neurosurgical patients (RR 0.37, p<0.05) but not in surgery/trauma or medical ICU patients with risk factors. SUP provided no benefit in studies published after EGDT. SUP significantly reduced clinically important bleeding regardless of the use of enteral nutrition (p<0.05). This meta-analysis demonstrated that SUP use was associated with significant reductions in bleeding but not mortality. SUP should not be abandoned until large randomized trials demonstrate the futility of this intervention.