Related Gastrointestinal Bleeding Research Articles

Risk factors for anticoagulant-associated gastrointestinal hemorrhage: a systematic review and meta-analysis.

There may be many predictors of anticoagulation-related gastrointestinal bleeding (GIB), but until now, systematic reviews and assessments of the certainty of the evidence have not been published. We conducted a systematic review to identify all risk factors for anticoagulant-associated GIB to inform risk prediction in the management of anticoagulation- related GIB. A systematic review and meta-analysis were conducted to search PubMed, EMBASE, Web of Science, and Cochrane Library databases (from inception through January 21, 2022) using the following search terms: anticoagulants, heparin, warfarin, dabigatran, rivaroxaban, apixaban, DOACs, gastrointestinal hemorrhage, risk factors. According to inclusion and exclusion criteria, studies of risk factors for anticoagulation-related GIB were identified. Risk factors for anticoagulant-associated GIB were used as the outcome index of this review. We included 34 studies in our analysis. For anticoagulant-associated GIB, moderate-certainty evidence showed a probable association with older age, kidney disease, concomitant use of aspirin, concomitant use of the antiplatelet agent, heart failure, myocardial infarction, hematochezia, renal failure, coronary artery disease, helicobacter pylori infection, social risk factors, alcohol use, smoking, anemia, history of sleep apnea, chronic obstructive pulmonary disease, international normalized ratio (INR), obesity et al. Some of these factors are not included in current GIB risk prediction models. such as anemia, co-administration of gemfibrozil, co-administration of verapamil or diltiazem, INR, heart failure, myocardial infarction, etc. The study found that anemia, co-administration of gemfibrozil, co-administration of verapamil or diltiazem, INR, heart failure, myocardial infarction et al. were associated with anticoagulation-related GIB, and these factors were not in the existing prediction models. This study informs risk prediction for anticoagulant-associated GIB, it also informs guidelines for GIB prevention and future research.

A combination of single-balloon enteroscopy-assisted laparoscopy and endoscopic mucosal resection for treating gastrointestinal venous malformations in blue rubber bleb nevus syndrome: a case report

BackgroundBlue rubber bleb nevus syndrome (BRBNS) is a rare congenital disease characterized by multifocal venous malformations. It remains a considerable challenge in treating the gastrointestinal (GI) venous malformations due to multiple lesions throughout the GI tract, and the likelihood of recurrence. We report a case study of BRBNS in the GI tract, in which GI venous malformations and related GI bleeding were successfully treated with a combination of multiple endoscopic procedures.Case presentationA 17-year-old man was admitted to our hospital for dizziness and hypodynamia. The symptoms persisted for nearly 1 year. The laboratory tests revealed iron-deficiency anemia with abnormally low hemoglobin (Hb), and a strong positive fecal occult blood test. A total of four hemangiomas were detected: one in the stomach, one in the descending colon, and two in the small intestines with a high risk of hemorrhage. Under gastroendoscopy, enteroscopy, and video capsule endoscopy (VCE) throughout the GI tract, the patient underwent surgical treatment. Endoscopic mucosal resection was initially performed in the stomach and colon, and the lesions in the small intestine were resected with laparoscopy auxiliaried by single-balloon enteroscopy (SBE), during which SBE assisted in identifying the lesions. The patient well-tolerated the procedures, and had a favorable prognosis.ConclusionThe combination of single-balloon enteroscopy-assisted laparoscopy and endoscopic mucosal resection was effective for the present case, which could be considered for patients with similar clinical conditions.

Digoxin Restores Angiogenic Equilibrium in CF- LVAD Patients

Purpose Gastrointestinal bleeding (GIB) in patients supported by Continuous-Flow Left Ventricular Assist Devices (CF-LVAD) is most commonly caused by gastrointestinal angiodysplasia (GIAD). It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients can cause splanchnic submucosal hypoperfusion and activate a Hypoxia Inducible Factor (HIF)1-alpha /Angiopoietins (Ang) signaling cascade that triggers pathological neoangiogenesis. Specifically, it has been established in CF-LVAD recipients that the increased levels of Ang-2, decreased Ang-1 and resultant increase in the ratio of Ang-2/Ang-1, presents angiogenic switch that may favor GIAD development. We have recently shown that use of digoxin, a potent inhibitor of HIF1-alpha, is associated with a significant reduction in GIAD related GIB in CF-LVAD patients. We now hypothesize that dysregulation of Ang-2 and Ang-1 levels in patients with CF-LVADs can be restored by digoxin treatment. Methods Blood samples were collected from 10 patients supported with CF-LVAD before and 2 weeks after they were started on digoxin. Ang-1 and Ang-2 was measured in patients’ serum by ELISA. Statistical difference between the groups was tested with paired t-test. Results Digoxin treatment in CF-LVAD patients decreased Ang-2 (14.1 to 8.8 ng/ml, p=0.015) and increased Ang-1 levels (11.6 to 29.8 ng/ml, p=0.002), reversing angiogenic switch (Fig.1). Conclusion Digoxin may restore angiogenic equilibrium in patients supported by CF-LVADs. The relevance of this finding for development of GIB needs to be prospectively studied.

Resolution of Recurrent Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement in a Patient with Heydeʼs Syndrome

Purpose: Bleeding from gastrointestinal angiodysplasia (GA) in patients with aortic stenosis (AS) has been recognized for several decades. Aortic valve replacement (AVR) in patients with symptomatic AS is associated with favorable outcomes and is recommended in recurrent GA related gastrointestinal bleeding (GIB), especially when associated with symptomatic AS. Treatment options are limited for patients who are poor surgical candidates. It is this subset of patients that might benefit the most from a minimally invasive treatment of AS. We present a case of Heyde's syndrome in a poor surgical candidate who was treated with Transcatheter Aortic Valve Replacement (TAVR) for symptomatic severe calcific AS and experienced complete resolution of recurrent GIB. An 86 year old male with a past medical history of recurrent syncope, multiple episodes of AVM-associated intestinal blood loss, Hodgkin's lymphoma, and prostate cancer was evaluated for syncope. Physical exam revealed a harsh, late peaking crescendo-decrescendo murmur best heard in the aortic area. Laboratory values revealed a microcytic anemia but were otherwise unremarkable. An echocardiogram obtained soon thereafter was consistent with severe calcific AS with a calculated valvular area of 0.7 cm square and a transvalvular gradient of 56 mmHg. The patient developed a lower GI bleed while in the hospital. A colonoscopy revealed multiple bleeding AVM's with successful hemostasis. Considering the high risk for invasive surgery, a decision was made to proceed with a TAVR. The patient has not had any further episodes of gastrointestinal bleeding since his discharge form the hospital. The association of AS and bleeding from GA was first postulated by Heyde in 1958. Since then, there have been numerous cases reported in medical literature worldwide. There is evidence that suggests a functional vWF deficiency as a precipitating cause of GA associated bleeding. AVR appears to offer the best results for long term resolution of AS related GIB. With the increasing prevalence of AI and AS with age, it is likely that there will be an increasing number of patients with Heyde's syndrome who are poor surgical candidates. Moving forward, it is conceivable that minimally invasive procedures like TAVR might be of significant benefit in this patient population. TAVR was recently approved for the treatment of severe symptomatic calcific AS in patients that are poor surgical candidates. Thus far, there has been only one other report of a patient with suspected Heyde's syndrome benefiting from TAVR. As our case demonstrates, this option should be strongly considered to ameliorate recurrent GI bleeding in patients with AS who are not surgical candidates.