Recurrence Of Gastrointestinal Bleeding Research Articles

«Арбузный» желудок — редкая причина хронической железодефицитной анемии

Aim. Demonstration of the rare in general medical practice cause of iron deficiency anemia in a patient with acute and chronic blood loss from vascular ectasias of the gastric mucosa. Key points. Iron deficiency anemia is one of the most common diseases in the world. The most common cause of anemia in gastroenterological practice is chronic or acute blood loss. Gastric antral vascular ectasia, or GAVE syndrome, is the cause of 4% nonvariceal bleeding from the upper gastrointestinal tract. Diagnosis of the disease requires careful endoscopic and histological examination to differentiate GAVE from similar changes (e.g. portal hypertensive gastropathy) and to choose the correct treatment ways. The presented clinical case demonstrates the difficulties of diagnosing the disease in a polymorbid patient, refractory to endoscopic treatments. Conclusion. GAVE syndrome is a rare but clinically significant cause of bleeding from the upper gastrointestinal tract. GAVE syndrome may be asymptomatic or accompanied by a clinical picture of anemia or obvious bleeding. Endoscopic treatment using argon plasma coagulation is considered first-line therapy in patients with GAVE syndrome, but most authors confirm the high rate of recurrence of gastrointestinal bleeding after the procedure. The presented clinical case clearly demonstrates a difficult path to the diagnosis of GAVE syndrome, which was finally verified after 7 years of follow-up of a patient with severe, refractory to the therapy iron deficiency anemia, only when a typical endoscopic picture of vascular ectasias in the antrum of the stomach organized in radial bands — the “watermelon” stomach was formed. At the same time, even the use of modern endoscopic treatment methods was not effective. Keywords: iron deficiency anemia, gastrointestinal bleeding, “watermelon” stomach, GAVE syndrome.

Improvement in gastrointestinal bleeding after septal myectomy for hypertrophic cardiomyopathy

ObjectivePatients with obstructive hypertrophic cardiomyopathy may have occult gastrointestinal bleeding. In this study, we analyzed outcomes of septal myectomy in patients who had a history of gastrointestinal bleeding preoperatively to understand patient characteristics and impact of septal reduction on recurrent gastrointestinal bleeding. MethodsWe analyzed 73 adult patients who had a history of gastrointestinal bleeding before transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and compared outcomes to 219 patients without gastrointestinal bleeding preoperatively. ResultsPatients with preoperative history of gastrointestinal bleeding were older (median (IQR) age, 65 (59-69) years, P < .001) and were more likely to have systemic hypertension (70% vs 53%, P = .020) and coronary artery disease (25% vs 13%, P = .026). Preoperatively, patients with gastrointestinal bleeding had a larger left atrial volume index (median, 53 mL/m2; interquartile range, 42-67; P = .006) and greater right ventricular systolic pressure (median, 36 mm Hg; interquartile range, 32-49; mm Hg, P = .005) but no significant difference in severity of outflow tract obstruction (P = .368). There were no perioperative deaths. The estimated 5- and 10-year survivals were 96.6% and 81.8%, respectively. At a median of 3.4 (interquartile range, 1.9-9.1) years after septal myectomy, 11 patients (15%) had recurrence of gastrointestinal bleeding, which was attributed to angiodysplasia or unknown causes in 6 patients (8%). ConclusionsPatients with a preoperative history of gastrointestinal bleeding have favorable short- and long-term outcomes after septal myectomy for obstructive hypertrophic cardiomyopathy. Remission of gastrointestinal bleeding was observed in 85% of patients postprocedure, and only 8% of the patients had recurrent gastrointestinal bleeding due to angiodysplasia or unknown causes.

The clinical applicability of percutaneous splenic vein stent implantation for pancreatic portal hypertension

BackgroundPancreatic portal hypertension (PPH) is a type of extrahepatic portal hypertension. We compared the clinical efficacy of different treatment methods for PPH caused by splenic vein stenosis in chronic pancreatitis.MethodsThis article retrospectively analyzed the PPH cases that were caused by splenic vein stenosis after chronic pancreatitis. Patients were divided into three groups according to the different treatments: splenic vein stent implantation (stent group), splenectomy, and only medications (conservative group). The treatment effects from each group were compared.ResultsA total of 33 patients were retrospectively analyzed in this study (9, 12, and 12 patients in each group respectively). All the procedures were successful in the stent and splenectomy groups. During the follow-up, no patient had gastrointestinal bleeding recurrence in the stent and splenectomy groups. However, in the conservative group, the incidence of portal hypertensive gastropathy and upper gastrointestinal bleeding were 50% and 25%. In the stent group, all the varicose veins at the base of the stomach had shrunk by varying degrees, and the red color signs regressed. The stent patency rate was 100%. No major complication occurred. The average platelet count at 1, 3, 6-months postoperatively were all significantly higher than the preoperative value (P < 0.05). The average postoperative hospital stay duration was significantly shorter than that of the splenectomy group (3.1 ± 1.4 days vs. 16.1 ± 8.1 days; P < 0.05). In the splenectomy group, postoperative fever occurred in 4 patients. Postoperative infection occurred in 2 patients (one with abdominal cavity infection and the other with incision infection). Delayed abdominal bleeding occurred in one patient. Portal vein thrombosis occurred in 2 patients during follow up.ConclusionPercutaneous splenic vein stent implantation for PPH treatment reduces the risk of gastrointestinal bleeding with minimal invasive. It has a high safety and reliable efficacy and is worthy of further clinical promotion.

Coronavirus Associated Bleeding Esophageal Ulcerations

A 95-year-old woman developed hematemesis during her hospitalization for severe coronavirus disease 2019 (COVID-19) infection. She had been diagnosed 16 days prior and treated with remdesivir, dexamethasone, and tocilizumab. Her comorbidities included chronic kidney disease stage 4, atrial fibrillation (not on anticoagulation), and chronic systolic heart failure. Patient was hypotensive (96/45 mmHg) and tachycardic (110 bpm). Laboratory studies demonstrated hemoglobin 8.5 g/dL (normal, 11.6–15.0 g/dL), compared with 11.2 g/dL 2 days prior. An esophagogastroduodenoscopy was performed and showed a 7-cm hiatal hernia and multiple cratered ulcers in the upper and middle esophagus, with the largest lesion measuring 15 mm. One of the ulcerations had an adherent clot (Figures A and B) with an underlying bleeding visible vessel (Figure C), which was treated with epinephrine injection and bipolar cauterization (Figure D). Biopsies taken from the center and periphery of esophageal ulcerations were negative for cytomegalovirus and herpes simplex virus but had detectable severe acute respiratory syndrome–associated coronavirus RNA. She had no recurrence of gastrointestinal bleeding. This case highlights that esophageal ulcerations should be considered as a possible etiology of upper gastrointestinal bleeding in patients with COVID-19 infection.

S2335 An Unusual Source of Massive Upper GI Bleed

Introduction: Pseudoaneurysms affecting main abdominal arteries can manifest as massive gastrointestinal (GI) bleed that carries a high mortality. We report a case of massive upper GI bleed due to splenic artery pseudoaneurysm. Case Description/Methods: A 72-year-old female with a history of Roux-en-Y gastric bypass presented to the emergency department with an episode of hematemesis. During initial evaluation, the patient was unresponsive and pulseless. An orogastric tube returned 100 cc of bloody gastric contents. The patient was started on PPI drip, vasopressors, packed red blood cells transfusion and admitted to intensive care unit. The patient continued to pass large, maroon bowel movements. EGD demonstrated a large adherent clot at gastrojejunal (GJ) anastomosis, and two non-bleeding cratered gastric ulcers with no stigmata of bleeding in the gastric pouch. Repeat EGD for worsening anemia despite transfusions showed fresh blood at the GJ anastomosis and two discrete oozing ulcers, each about 1cm in the gastric pouch. Both lesions were treated with endoscopic therapy. However, the patient continued to have melanotic stools. Third EGD demonstrated an adherent clot at GJ anastomosis. Underneath the clot, was a cratered ulcer with a fistulous tract. Endoscope passed into the fistulous opening with ease, but only a blood clot could be visualized and the scope was withdrawn. The patient remained hypotensive and continued to pass melena. Fourth EGD revealed fresh blood in the entire examined stomach and at the anastomosis site. A source of rapid bleeding could not be identified. Emergent angiogram demonstrated a pseudoaneurysm in the midportion of the splenic artery. A coil and glue embolization of the splenic artery was performed. Post angiogram, there was no recurrence of GI bleeding. After a prolonged hospital course, the patient was discharged to a skilled nursing facility. Discussion: A pseudoaneurysm is a communicating sac within the lumen of the artery. In contrast to true aneurysms, which are usually asymptomatic, pseudoaneurysms are nearly always symptomatic and carry a high risk of rupture. A vascular-enteric fistula is usually found either on endoscopic examination or via angiography. Therapy with angiographic embolization of the pseudoaneurysm is almost always indicated due to high risk of recurrence of severe hemorrhage. If access to the splenic artery fails, endoscopic ultrasound guided coil and glue has recently become an accepted treatment method.Figure 1.: A suspected 11 mm jejunal fistula found in the ulcerated GJ site through which the endoscope was passed, but only blood clot could be visualized.

Heyde syndrome: prevalence and outcomes in patients undergoing transcatheter aortic valve implantation

BackgroundHeyde syndrome (HS) is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. Data on the prevalence of HS and results after TAVI remain scarce.Methods2548 consecutive patients who underwent TAVI for the treatment of AS from 2008 to 2017 were evaluated for a history of GIB and the presence of HS. The diagnosis of HS was defined as a clinical triad of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. These patients (Heyde) were followed to investigate clinical outcomes, bleeding complications and the recurrence of GIB and were compared to patients with GIB unrelated to HS (Non-Heyde).ResultsA history of GIB prior to TAVI was detected in 190 patients (7.5%). Among them, 47 patients were diagnosed with HS (1.8%). Heyde patients required blood transfusions more frequently compared to Non-Heyde patients during index hospitalization (50.0% vs. 31.9%, p = 0.03). Recurrent GIB was detected in 39.8% of Heyde compared to 21.2% of Non-Heyde patients one year after TAVI (p = 0.03). In patients diagnosed with HS and recurrent GIB after TAVI, the rate of residual ≥ mild paravalvular leakage (PVL) was higher compared to those without recurrent bleeding (73.3% vs. 38.1%, p = 0.05).ConclusionA relevant number of patients undergoing TAVI were diagnosed with HS. Recurrent GIB was detected in a significant number of Heyde patients during follow-up. A possible association with residual PVL requires further investigation to improve treatment options and outcomes in patients with HS.Graphic abstract

Incidence, predictors, and clinical impact of bleeding recurrence in patients with prior gastrointestinal bleeding undergoing LAAC.

Gastrointestinal bleeding (GIB) is associated with a high recurrence rate and a prior GIB episode is common in real-world left atrial appendage closure (LAAC) recipients. The present study sought to evaluate the clinical characteristics and outcomes of patients with prior GIB undergoing LAAC, and to determine the factors associated with and clinical impact of GIB recurrence. Multicenter study including 277 consecutive patients who underwent percutaneous LAAC and had prior GIB. All-cause death, all bleeding, GIB recurrence, and clinical ischemic stroke were recorded. After a median follow-up of 17 (interquartile range: 6-37) months post-LAAC, the rates of death, bleeding, GIB recurrence, and ischemic stroke were 14.0 per 100 person-year (PY), 29.3 per 100 PY, 17.7 per 100 PY, and 1.1 per 100 PY, respectively. GIB recurrence occurred within 3 months post-LAAC in 55.8% of patients. A previous lower GIB (vs. upper or unclassified) (HR: 1.76; 95% CI: 1.09-2.82; p=.020) and eGFR<45mL/min (HR: 1.70; 95% CI:1.04-2.67; p=.033) determined an increased risk of GIB recurrence. By multivariable analysis, eGFR<45mL/min (HR: 2.72; 95% CI: 1.70-4.34; p<.001), GIB recurrence following LAAC (HR: 2.15; 95% CI: 1.33-3.46; p=.002), diabetes mellitus (HR: 1.77; 95% CI: 1.10-2.84; p=.018), and age (HR: 1.06; 95% CI: 1.03-1.10; p<.001) were associated with an increased mortality. Patients with prior GIB undergoing LAAC exhibited a relatively low rate of GIB recurrence, and prior lower GIB and moderate-to-severe chronic kidney disease determined an increased risk. GIB recurrence was associated with an increased mortality.

Thalidomide for refractory gastrointestinal bleeding from vascular malformations in patients with significant comorbidities.

BACKGROUNDRefractory gastrointestinal bleeding (GIB) secondary to gastrointestinal vascular malformations (GIVM) such as gastrointestinal angiodysplasia (GIAD) and gastric antral vascular ectasia (GAVE) remains challenging to treat when endoscopic therapy fails. Recently thalidomide has been suggested as a treatment option for refractory GIB.AIMTo determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.METHODSIRB approved, single center, retrospective review of electronic medical records from January 2012 to November 2018. Patients age > 18 years old, who had > 3 episodes of GIB refractory to medical or endoscopic therapy, and who had been treated with thalidomide for at least 3 mo were included. The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.RESULTSFifteen patients were included in the study, all with significant cardiac, hepatic, or renal comorbidities. The cause of GIB was GIAD in 10 patients and GAVE in 5 patients. Two patients were lost to follow up. Of the 13 patients followed, 38.5% (n = 5) had no recurrent GIB or transfusion requirement after treatment with thalidomide. Furthermore, 84.6% (n = 11) of patients had a reduction in transfusion requirements and hospitalizations for GIB. Thalidomide was discontinued in 2 patients due to cost (n = 1) and medication interaction (n = 1). Reported adverse reactions included fatigue (n = 3), neuropathy (n = 2), dizziness (n = 1), and constipation (n = 1). Six patients died during follow up due to unknown cause (n = 4) and sepsis (n = 2).CONCLUSIONThalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

P1848Prevalence and outcomes in patients with Heyde syndrome after transcatheter aortic valve implantation, a single centre experience

Abstract Introduction Heyde syndrome is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. To date only few data exist regarding the prevalence of Heyde syndrome and results after transcatheter aortic valve implantation (TAVI) for the treatment of AS. Purpose We sought to evaluate the prevalence of Heyde syndrome in a routine clinical cohort of patients undergoing TAVI and analyze the effectiveness of treatment of AS regarding recurrent GIB in these patients. Methods We conducted a retrospective single-center analysis of 2545 consecutive patients who underwent TAVI for the treatment of AS in 2008–2017. Patients with a history of GIB were identified. The diagnosis of Heyde syndrome was defined as a clinical triad of presence of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. GIB of unknown origin or related to other causes was defined as bleeding unrelated to angiodysplasia. Clinical outcomes of patients with Heyde syndrome were evaluated with emphasis on bleeding complications and recurrence of GIB. Results A history of GIB prior to TAVI was detected in 190 patients (7.5%) of the TAVI cohort. Among them, 143 patients had a GIB unrelated to angiodysplasia (5.6%) and 47 patients (1.8%) were diagnosed with Heyde syndrome. Median age and STS-PROM were 80.7 (75.3, 84.0) years and 4.7 (2.7, 9.0) respectively in Heyde patients. TAVI was successfully performed in all cases (66% endovascular access, 34% transapical access). The effective orifice areas increased from 0.8±0.1 cm2 to 2.1±0.5 cm2. Periprocedural major/life-threatening bleeding was found in 6 patients (12.8%), mainly access-related and none due to GIB. In 51% of Heyde-patients transfusion of 4.5±5.7 packed red blood cells was required during the index hospitalisation. During a mean follow-up of 12 months, recurrent GIB after TAVI was detected in 32% of patients with Heyde syndrome. In contrast only 18% of patients with GIB unrelated to angiodysplasia (Non-Heyde) had recurrent GIB after TAVI. In patients diagnosed with Heyde syndrome and recurrent GIB after TAVI the rate of residual mild or moderate paravalvular regurgitation was higher compared to those with an unremarkable course (73% vs. 37%, p=0.045). Figure 1. 1-year Follow-Up Conclusions A relevant number of patients presenting for treatment of AS can be diagnosed with Heyde syndrome. In these patients TAVI can be successfully performed with moderate incidence of periprocedural bleeding complications but significant transfusion rates. Regardless of successful treatment of AS, recurrent GIB was detected in a significant number of Heyde patients during follow-up. The possible association with residual paravalvular regurgitation requires further investigation to improve treatment options in patients with Heyde syndrome.

Prediction and feature selection for fatal gastrointestinal bleeding recurrence in hospital via machine learning

To propose a method of prediction for fatal gastrointestinal bleeding recurrence in hospital and a method of feature selection via machine learning models. 728 digestive tract hemorrhage samples were extracted from the first aid database of PLA General Hospital, and 343 patients among them were diagnosed as fatal gastrointestinal bleeding recurrence in hospital. A total of 64 physiological or laboratory indicators were extracted and screened. Based on the ten-fold cross-validation, Logistic regression, AdaBoost and XGBoost were used for classification prediction and comparison. XGBoost was used to search sequence features, and the key indicators for predicting fatal gastrointestinal bleeding recurrence in hospital were screened out according to the importance of the indicators during training. Logistic regression, AdaBoost and XGBoost all get better F1.5 score under each feature input dimension, among which XGBoost had the best effect and the highest score, which was able to identify as many patients as possible who might have fatal gastrointestinal bleeding recurrence in hospital. Through XGBoost iteration results, the Top 30 indicators with high importance for predicting fatal gastrointestinal bleeding recurrence in hospital were ranked. The F1.5 scores of the first 12 key indicators peaked at iteration (0.893), including hemoglobin (Hb), calcium (CA), red blood cell count (RBC), mean platelet volume (MPV), mean erythrocyte hemoglobin concentration (MCH), systolic blood pressure (SBP), platelet count (PLT), magnesium (MG), lymphocyte (LYM), glucose (GLU, blood gas analysis), glucose (GLU, blood biochemistry) and diastolic blood pressure (DBP). Logistic regression, AdaBoost and XGBoost could achieve the purpose of early warning for predicting fatal gastrointestinal bleeding recurrence in hospital, and XGBoost is the most suitable. The 12 most important indicators were screened out by sequential forward selection.

Rebleeding vs Thromboembolism After Hospitalization for Gastrointestinal Bleeding in Patients on Direct Oral Anticoagulants

Little is known about outcomes of patients hospitalized for gastrointestinal bleeding (GIB) while they are taking direct oral anticoagulants (DOAC). We aimed to determine the frequency at which patients resume DOAC therapy following hospitalization for GIB in a real-world setting, and the risks and benefits. We conducted a retrospective analysis of medical claims data from the Truven Health Marketscan Commercial Claims and Encounters Database, from January 1, 2010, through December 31, 2014. We collected data on 1338 adults treated with DOACs and hospitalized for GIB (dabigatran, n= 679; rivaroxaban, n= 608, apixaban, n= 51). Patients who developed GIB within 1 year of DOAC initiation, and had a DOAC claim filled within 1 month of GIB, were included in the analysis. Postdischarge readmissions due to thromboembolism and recurrent GIB within 90 days were reviewed. We used proportional hazards to identify factors associated with thromboembolism and recurrent GIB. The median age of patients who did not resume DOAC therapy was older (79 vs 78 y for patients who did resume DOAC therapy; P= .0005). Higher proportions of patients who did not resume DOAC had heart failure (25% vs 20% who did resume DOAC therapy; P= .01), received blood (36% vs 24%; P < .0001), and required intensive care (18% vs 12%; P= .003). Restarting DOAC therapy within 30 days was not associated with thromboembolism within 90 days (hazard ratio [HR], 0.98; 95% CI, 0.37-2.21) or recurrent GIB (HR, 1.44; 95% CI 0.72-2.68). On multivariate regression, prior venous thromboembolism was associated with postdischarge thromboembolism (HR, 3.30; 95% CI, 1.29-7.38), and thienopyridine use was associated with recurrent GIB (HR, 3.12; 95% CI, 1.55-5.81). A higher proportion of patients who resumed treatment with rivaroxaban, compared with other DOACs, had recurrence of GIB (log rank, P= .04). In a retrospective analysis of medical claims data from adults treated with DOACs and hospitalized for GIB, we found that older patients who require blood and intensive care were less likely to restart treatment with DOACs after GIB. Resuming DOAC therapy was not associated with thromboembolism within 90 days or recurrence of GIB; a history of venous thromboembolism and thienopyridine use were associated with a risk of subsequent thromboembolism and GIB respectively.

Long-Acting Octreotide Reduces the Recurrence of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device

BackgroundRecurrent gastrointestinal bleeding is one of the most significant adverse events in patients with left ventricular assist devices (LVADs). MethodsWe enrolled LVAD patients who had received an intramuscular injection of 20 mg octreotide every 4 weeks as secondary prevention for recurrent gastrointestinal bleeding despite conventional medical therapies and repeated transfusions. The frequency of gastrointestinal bleeding and other associated clinical outcomes before and during octreotide therapy were compared. ResultsThirty LVAD patients (66.4 ± 8.8 years old, 16 men [53%]) received octreotide therapy for 498.8 ± 356.0 days without any octreotide-associated adverse events. The frequency of gastrointestinal bleeding was decreased significantly during octreotide therapy (from 3.4 ± 3.1 to 0.7 ± 1.3 events/year; P < .001), accompanied by significant reductions in red blood cell and flesh frozen plasma transfusions, days in hospital, and need for endoscopic procedures (P < .05 for all). ConclusionsOctreotide therapy reduced the frequency of recurrent gastrointestinal bleeding and may be considered for secondary prevention.

Multiple angiodysplasia diagnosed by capsule endoscopy

A 28-year-old Caucasian man was admitted in our unit for acute massive rectal bleeding. Past medical and family history was unremarkable. Hemoglobin was 7.6 g/dL. Blood transfusions were required. Computed tomography and gastrointestinal endoscopy were negative for active bleeding. When patient's hemoglobin was normalized and stable, a video capsule endoscopy was performed. Video relieved the presence of multiple digiunal and ileal angiodysplastic lesions. A double endoscopic argon plasma coagulation procedure was planned on general anaesthesia. Upper and rectal operative approach were performed. Procedure was uneventful. After 2 years follow-up patient had no recurrence of gastrointestinal bleeding.

Multiple angiodysplasia diagnosed by capsule endoscopy

A 28-year-old Caucasian man was admitted in our unit for acute massive rectal bleeding. Past medical and family history was unremarkable. Hemoglobin was 7.6 g/dL. Blood transfusions were required. Computed tomography and gastrointestinal endoscopy were negative for active bleeding. When patient's hemoglobin was normalized and stable, a video capsule endoscopy was performed. Video relieved the presence of multiple digiunal and ileal angiodysplastic lesions. A double endoscopic argon plasma coagulation procedure was planned on general anaesthesia. Upper and rectal operative approach were performed. Procedure was uneventful. After 2 years follow-up patient had no recurrence of gastrointestinal bleeding.

High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding.

Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited. To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment. A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL. Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months. Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.

Trudne wybory u pacjentów z wysokim ryzykiem powikłań zakrzepowo-zatorowych i krwotocznych — przypadek 81-letniej pacjentki z wysokim ryzykiem udaru mózgu po przebytym epizodzie krwawienia z przewodu pokarmowego

Problem powaznych powiklan krwotocznych, takich jak krwawienie z przewodu pokarmowego, stanowi glowne ryzyko związane z przewleklym leczeniem przeciwkrzepliwym, w tym za pomocą doustnych antykoagulantow niebedących antagonistami witaminy K (NOAC), u pacjentow z migotaniem przedsionkow. Prezentowany przypadek 81-letniej chorej ukazuje, ze przebycie zagrazającego zyciu epizodu krwawienia z przewodu pokarmowego nie jest przeciwwskazaniem do ponownego wlączenia NOAC, szczegolnie w przypadku wysokiego ryzyka powiklan zakrzepowo-zatorowych. Dostepne NOAC pozwalają na dobor optymalnego leczenia dla chorego z uwzglednieniem wieku, funkcji nerek oraz punktacji w skalach CHA2DS2VASc i HAS-BLED. Lekiem preferowanym u pacjentow obciązonych wysokim ryzykiem nawrotu krwawienia z przewodu pokarmowego i istotnie upośledzoną funkcją nerek jest apiksaban.

Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome.

There is paucity of data on the effect of interventions on risk of gastrointestinal bleeding (GIB) in acute pancreatitis (AP). Retrospective study of records of patients with AP and GIB. 16 (3.7%) patients (14 males; mean age 39.3 ± 12.8 years) had gastrointestinal bleeding. Two patients had peptic ulcer disease related GIB. The cause of GIB in remaining patients was: pseudoaneurysms in 5, gastrointestinal fistulization in 4, and no identifiable lesion in 5. Two patients with pseudoaneurysms were treated with angioembolisation whereas 3 needed surgery. The patients with gastrointestinal fistula had complicated course and 3 of these 4 patients died due to sepsis and multi organ failure. Rest 5 patients with no identifiable lesion were managed conservatively and there was no recurrence of GIB. Of the 14 patients with AP related GIB, a previous intervention had been done in 11(79%) patients. Fifty-three patients (12.7%) without GIB died whereas 5 (31.2%) patients with GIB succumbed to the illness (p = 0.04). The majority of our patients of AP with GIB had antecedent history of interventions. The mortality was higher in patients with GIB, which was not due to hemorrhage but to sepsis and related complications.

The role of capsule endoscopy in the evaluation and treatment of obscure-overt gastrointestinal bleeding during daily clinical practice: a prospective multicenter study

Objective. Capsule endoscopy (CE) is most commonly performed to evaluate obscure gastrointestinal bleeding (GIB). However, at present the role of CE in patients with obscure-overt GIB especially during daily clinical practice is unknown. The aim of the present study was to investigate the diagnostic yield and the impact of CE on the management of patients with obscure-overt GIB. Material and methods. Between January 2007 and December 2011 we prospectively included all patients with obscure-overt GIB who underwent CE after negative bidirectional endoscopy. CE findings revealing the cause of bleeding, type of therapeutic intervention and clinical variables associated with positive CE and recurrence of GIB were evaluated. Results. One hundred and eighteen patients with a median age of 66 years (range 8–89 years) were enrolled in the final analysis. The overall diagnostic yield of the CE was 66.9%. The most common findings were angiodysplasias (33.1%), followed by ulcer (23.7%), and tumors (6.8%). Age (p = 0.001) and cardiovascular disease (p = 0.007) were significant clinical variables predicting the higher incidence of angiodysplasias. Specific therapeutic interventions were undertaken in 54 patients with positive CE (68.4%). Recurrence of GIB was observed in one patient with negative CE (2.6%) and 16 patients with positive CE (20.3%). Univariate and multivariate analysis showed high age and no therapeutic intervention as significant factors associated with recurrent bleeding. Conclusions. CE represents a promising diagnostic method in the investigation of obscure-overt GIB, with significant impact on its clinical management in daily clinical practice.

Transjugular Endovascular Recanalization of Splenic Vein in Patients with Regional Portal Hypertension Complicated by Gastrointestinal Bleeding

Regional portal hypertension (RPH) is an uncommon clinical syndrome resulting from splenic vein stenosis/occlusion, which may cause gastrointestinal (GI) bleeding from the esophagogastric varices. The present study evaluated the safety and efficacy of transjugular endovascular recanalization of splenic vein in patients with GI bleeding secondary to RPH. From December 2008 to May 2011, 11 patients who were diagnosed with RPH complicated by GI bleeding and had undergone transjugular endovascular recanalization of splenic vein were reviewed retrospectively. Contrast-enhanced computed tomography revealed splenic vein stenosis in six cases and splenic vein occlusion in five. Etiology of RPH was chronic pancreatitis (n = 7), acute pancreatitis with pancreatic pseudocyst (n = 2), pancreatic injury (n = 1), and isolated pancreatic tuberculosis (n = 1). Technical success was achieved in 8 of 11 patients via the transjugular approach, including six patients with splenic vein stenosis and two patients with splenic vein occlusion. Two patients underwent splenic vein venoplasty only, whereas four patients underwent bare stents deployment and two covered stents. Splenic vein pressure gradient (SPG) was reduced from 21.5 ± 7.3 to 2.9 ± 1.4 mmHg after the procedure (P < 0.01). For the remaining three patients who had technical failures, splenic artery embolization and subsequent splenectomy was performed. During a median follow-up time of 17.5 (range, 3-34) months, no recurrence of GI bleeding was observed. Transjugular endovascular recanalization of splenic vein is a safe and effective therapeutic option in patients with RPH complicated by GI bleeding and is not associated with an increased risk of procedure-related complications.

Cause, Incidence, and Recurrence of Gastrointestinal Bleeding in Patients Implanted with Continuous Flow Left Ventricular Assist Devices (LVADs)

Cause, Incidence, and Recurrence of Gastrointestinal Bleeding in Patients Implanted with Continuous Flow Left Ventricular Assist Devices (LVADs)