Significant Gastrointestinal Bleeding Research Articles

Management Of Therapy of Anticoagulants and Antiplatelets in Acute Gastrointestinal Bleeding and In the Periendoscopic Period

Management of anticoagulant and antiplatelet therapy is a common clinical problem in case of urgent or elective gastrointestinal endoscopic procedures. Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. It’s recommended temporary interruption of anticoagulants in clinically significant gastrointestinal bleeding. For the antiplatelet therapy the decision is when to stop and restart the therapy, depending on whether it’s for primary or secondary cardiovascular prevention. Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. It’s recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures with high risk for bleeding and to consider the use of “bridging” therapy with LWMH for patients on vitamin K antagonists who are at high thrombotic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore collaboration with a cardiologist is of great importance, at least for some patients.

Adverse Reaction Profiles Related to Gastrointestinal Bleeding Events Associated with BCR-ABL Tyrosine Kinase Inhibitors.

Background and Objectives: The aim of this study is to investigate the characteristics of gastrointestinal bleeding events associated with BCR-ABL tyrosine kinase inhibitor (TKI) treatment, using the reporting odds ratio (ROR) of the adverse event reports submitted to the Japanese Adverse Drug Event Report database between 2004 and 2020, and to examine the number of reported TKI-related gastrointestinal bleeding cases according to sex and age, as well as the actual number of TKI prescriptions issued in Japan. Materials and Methods: The RORs and 95% confidence intervals (CIs) of gastrointestinal bleeding events related to TKIs were calculated using the data of the 595,121 included cases. Results: Significant gastrointestinal bleeding events were detected for dasatinib (crude ROR: 4.47, 95% CI: 3.77–5.28) and imatinib (crude ROR: 1.22, 95% CI: 1.01–1.46). In multiple logistic regression analyses, significant gastrointestinal bleeding events were detected for dasatinib (adjusted ROR: 8.02, 95% CI: 5.75–10.2), imatinib (adjusted ROR: 1.81, 95% CI: 1.2–2.72), age (≥60 years, adjusted ROR: 2.22, 95% CI: 2.1–2.36), reporting year (adjusted ROR: 1.04, 95% CI: 1.04–1.05), and male sex (adjusted ROR: 1.47, 95% CI: 1.37–1.57). Interaction analysis revealed that the association of gastrointestinal bleeding with dasatinib was affected by age (≥60 years) and sex (female), with the number and proportion of dasatinib-related gastrointestinal bleeding cases increasing among those aged ≥60 years. Conclusions: Specific TKIs and patient characteristics were associated with gastrointestinal bleeding. Our results aid the prompt identification and treatment of TKI-related gastrointestinal bleeding.

The frequency of ulcerative-erosive defects and ulcerative bleeding of the gastroduodenal zone in patients with coronavirus infection COVID-19

Aim : to determine the frequency of erosive and ulcerative defects and ulcerative bleeding of the gastroduodenal zone in patients with COVID-19 infection. Materials and methods . Fibroesophagogastroduodenoscopy was performed in patients in the hospital for the COVID-19 infection treatment when they had heartburn, dyspepsia, or signs of gastrointestinal bleeding among patients. In total, endoscopy was performed in 387 patients (116 men and 271 women, mean age 65.4 years). Erosive esophagitis was assessed according to the Los Angeles classification (1994), candidiasis esophagitis according to the Kodsi classification (1976), esophageal varices according to K. J. Paquet (1983), classification of ulcerative bleeding according to J. A. Forrest (1974). Results . Erosions in the esophagus was found in 25.3% of the examined patients, gastric and duodenal erosions—in 44.4% of persons, gastric and duodenal ulcers — in 10.1% of patients. Gastroduodenal bleeding was determined in 5.7% of the examined patients and was associated with ulcerative defects in 81.8% of cases. Male gender was a strong risk factor for erosions, ulcers, and bleeding from the upper gastrointestinal tract. Conclusion . In patients with COVID-19, complications from the gastrointestinal tract, manifested by ulcerative defects and bleeding from the gastroduodenal zone, are a significant problem. It seems rational to propose to treat patients with COVID-19 infection receiving massive anti-inflammatory, anthrombocytic, anticoagulant therapy in the same way as is customary in the management of cardiological and rheumatological patients for the prevention of NSAID-gastropathy.

S2558 An Unusual Cause of Upper Gastrointestinal Bleed: Temporary Epicardial Pacing Wire

Introduction: A temporary epicardial pacing wire (TEPW) is frequently placed during cardiac surgery to treat postoperative arrhythmias. Gastrointestinal (GI) complications from TEPW are rare, and only a few have been described. Here we describe a rare case of upper GI bleed from TEPW traversing the stomach. Case Description/Methods: A 76-year-old male with a past medical history of coronary artery disease (CAD) status posts two stents, myocardial infarction, chronic kidney disease, hypertension, and stroke presented to the emergency department with chest pain. The patient had a non-ST-elevation myocardial infarction (NSTEMI); coronary angiography showed multivessel CAD. He underwent coronary artery bypass grafting (CABG), following which the patient had 1200cc dark blood drained through the nasogastric tube. The patient underwent esophagogastroduodenoscopy (EGD), which showed a significant amount of fresh blood (Figure A) and a suspicious linear object entering and exiting the gastric body (Figure B). He underwent a celiac and left gastric artery angiogram with embolization of the injured branch of the left gastric artery. The foreign body removed from the stomach was identified as right ventricle TEPW. Repeat EGD showed no active bleeding. Discussion: Epi-myocardium of the atria and ventricle are common sites for TEPW placement during cardiac surgery. They are tunneled to the outside through the left subcoastal margin. Poor sensing or capture, dislodgement, or retention are the most common complications. Other complication include bleeding from the right ventricular laceration with tamponade, avulsion of a side branch from a saphenous vein coronary bypass graft, and perforation of the superior epigastric artery. GI complications from this procedure are rare. Few reports of bowel perforation presenting as acute abdomen have been described. A case of dyspepsia due to gastric wall injury caused by the migration of TEPW into the gastric cavity has been described. To our knowledge, no case of upper GI bleed secondary to pacemaker wire misplacement has been described. Post-cardiac surgery patients are usually in the ICU. Therefore, if signs of GI bleeding are present in the postoperative period, EGD should be performed for diagnostic purposes. However, rarely displaced pacemaker wire may be one of the causes of GI bleeding, which should be on the physician's radar.Figure 1.: (A) EGD showing pooled blood in stomach giving definitive evidence of upper GI bleed. (B) EGD showing pacemaker wire traversing the stomach.

S3692 What the Heil? H. heilmanni Causing Peptic Ulcer Disease and Severe GI Bleeding

Introduction: Helicobacter pylori (H. pylori) has a well-known association with peptic ulcer disease (PUD) and gastritis. However, other helicobacter species cause similar diseases. We present a case of a patient with H. heilmanni infection causing PUD and significant gastrointestinal (GI) bleeding. Case Description/Methods: A 63-year-old man with CAD s/p stent on aspirin and recent root canal procedure who was taking ibuprofen for several weeks presented with a one day history of mixed melena and hematochezia. He had no prior history of PUD or GI bleeding. EGD revealed two Forrest class III gastric ulcers and three duodenal ulcers including a 7 mm Forrest class IIc ulcer. Gastric biopsies were taken. He required 3 units of packed red blood cells (PRBCs), and was discharged on pantoprazole BID with a Hgb of 8 g/dl and biopsy results pending. The following day, he presented with similar symptoms, requiring ICU admission for Hgb 5.4 g/dl and blood pressure 77/52 mm Hg. He required 5 units PRBCs without pressor support. Repeat EGD revealed a 12 mm Forest class IIb duodenal ulcer (image 1) which was injected with epinephrine, and a single hemoclip was placed with hemostatic control. Prior EGD biopsy results showed chronic gastritis and helicobacter-like species found to be Helicobacter heilmanni by genotyping, and negative for concurrent H. pylori. The patient was treated with triple therapy with pantoprazole, amoxicillin and clarithromycin. Repeat EGD 2 months after treatment confirmed eradication of H. heilmanni and healing of all ulcers. Discussion: H. heilmanni was first described as an organism causing gastritis in humans in 1987 under its former name Gastrospirillum hominis. H. heilmanni is found in less than 1% of patients undergoing EGD for upper GI symptoms compared to H. pylori which is found in as many as 60% of patients with similar symptoms. Complications of H. heilmanni infection in patients include: 82% developing gastritis, 16% PUD, 2% gastric cancer, and, in our patient’s case, severe GI bleeding. Concurrent infection with H. pylori and H. heilmanni infection is uncommon and identification of H. heilmanni via H. pylori via stool antigen or rapid urease testing has unclear efficacy. Our case highlights the need for H. heilmanni to be recognized as a potential cause of PUD and further testing might need to be considered when H. pylori testing is negative. Ultimately, definitive diagnosis is done via genetic PCR amplification, and treatment is possible using the same antibiotic regimen as H. pylori.Figure 1.: Duodenal ulcer with adherent clot (Forest class IIb).

S1790 Portal Biliopathy in a Patient Who Underwent a Whipple Procedure With Portal Vein Reconstruction

Introduction: Portal biliopathy is a condition that is defined as abnormalities in the biliary tract due to portal hypertension. Some patients may present with abdominal pain, fever, jaundice, or pruritis. Rarely, portal hypertension secondary to portal vein abnormalities cause peri-biliary varices. We report a case of a patient with a peri-biliary variceal bleed due to portal hypertension from acquired portal vein stenosis. Case Description/Methods: A 59-year-old female with a past medical history of pancreatic ductal adenocarcinoma presented to the hospital with 5 days of Black tarry stools. Two years prior, she was diagnosed with pancreatic head adenocarcinoma and underwent a pancreaticoduodenectomy with portal vein reconstruction. Subsequent CT scans demonstrated post surgical portal vein stenosis. On admission, she denied fevers, abdominal pain, or hematemesis. Labs were notable for a hemoglobin of 5.7 g/dl, INR of 1.6, and bilirubin of 1.0 mg/dl. Physical exam demonstrated an abdominal fluid wave and melena on digital rectal exam. CT abdomen showed post Whipple anatomy, severe portal vein stenosis, large volume ascites, and extensive upper abdominal collaterals including peri-portal and peri-biliary varices. Upper endoscopy revealed blood in the afferent jejunal limb. Bleeding was found to be originating from the choledochojejunostomy. Multiple large visible vessels with stigmata of recent bleeding were visualized within the common bile duct. A single hemostatic clip was placed on one of the vessels, resulting in increased bleeding. Hemostasis was achieved with cyanoacrylate injection. The patient was transferred to the interventional radiology suite, where she underwent portal venography confirming severe stenosis of the porto-mesenteric confluence. Interventional radiology performed portal vein balloon dilation and stent placement. The patient had no further bleeding following the procedure (Figure). Discussion: Bleeding from peri-biliary varices is a rare cause of upper GI bleeding. In this case, non cirrhotic portal hypertension from acquired portal vein stenosis after pancreaticoduodenectomy led to clinically significant gastrointestinal bleeding. Portal biliopathy is an uncommon and late presentation in patients with extrahepatic portal vein obstruction. In many cases, patients present with signs and symptoms of biliary obstruction. Treatment of PB should involve a multidisciplinary discussion among various subspecialties including gastroenterology, interventional radiology, and hepatobiliary surgery.Figure 1.: A. Choledochojejunostomy with visible varices. B. Hemostatic clip placement with subsequent bleeding. C. Injection of cyanoacrylate glue with hemostasis. D. Portal venography demonstrating portal vein stenosis at the porto-mesenteric confluence.

The risk of variceal bleeding during endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely performed procedure. However, the risk of variceal bleeding during ERCP has rarely been assessed. This study aims to evaluate the risk of variceal bleeding in patients with esophageal varices (EV) undergoing ERCP. From October 2010 to November 2017, the study retrospectively enrolled 75 cirrhotic patients who received elective ERCP. The patient's risk of gastrointestinal (GI) and variceal bleeding and other procedure-related adverse events within 30 days of ERCP were evaluated. Among the 75 patients, 45 patients (60.0%) had EV. Most of the patients were males (65.3%), and there were high rates of viral hepatitis B-related cirrhosis (36.0%), Child-Pugh B (49.3%), and an indication of choledocholithiasis (40.0%). Thirty-three of 45 (73.3%) patients had high-risk EV, and nine (20.0%) patients had concomitant gastric varices. There was no esophageal variceal bleeding; however, one patient had gastric variceal bleeding after ERCP. Nonvariceal significant GI bleeding occurred in three patients with EV and one without EV ( p = 0.529). Post-ERCP pancreatitis occurred in three patients with EV and five without EV ( p = 0.169). No perforation or procedure-associated mortality was noted. The risk of esophageal variceal bleeding within 30 days of ERCP is neglectable, except for a patient who suffered from gastric variceal bleeding. Other complications, such as nonvariceal bleeding and pancreatitis, are also no higher in patients with EV. Therefore, ERCP is generally a safe procedure for a patient with high-risk esophageal varices.

Polypoid arteriovenous malformation of the rectum: A case report

BackgroundIntestinal arteriovenous malformation is an abnormal connection between arteries and veins that bypasses the capillary system and may be a cause of significant lower gastrointestinal bleeding. On endoscopy, arteriovenous malformations are usually flat or elevated, bright red lesions. Overall, rectal localization of arteriovenous malformations is rare. The same may be said about polypoid shape arteriovenous malformations. Herein, we present a case of a large rectal polypoid arteriovenous malformations.MethodsClinical, diagnostic, and treatment modalities of the patient were reviewed. Pre- and post-operative parameters were collected and analyzed. The clinical English literature is also reviewed and discussedResultsA 60-year-old female patient was admitted to our emergency department for rectorrhagia and anemia. Rectoscopy revealed a polypoid lesion in the rectum and the biopsy showed fibrosis, necrosis areas, and hyperplastic glands. A total body contrast-enhanced computed tomography (CT) was performed revealing a parietal pseudonodular thickening with concentric growth and contrast enhancement, extending for about 53 mm. The mass wasn't removed endoscopically due to concentric growth, sessile implant, and submucosal nature. The patient underwent an uneventful laparoscopic anterior rectal resection. The postoperative hospitalization was free of complications. Histology showed the presence of a polypoid AVM composed of dilated arteries, veins, capillaries, and lymphatics, engaging the submucosa, muscularis, and subserosa layer.ConclusionAfter a review of the current English literature, we found only one case of rectal polypoid AVM. The scarcity of documented cases encumbers optimal diagnostic and treatment approaches.

Clinical Characteristics of Hospitalized COVID-19 Patients Who Have Gastrointestinal Bleeds Requiring Intervention: A Case-Control Study.

BackgroundCoronavirus disease 2019 (COVID-19) is widely recognized as a disease that affects the respiratory system, although it can also present with significant extrapulmonary symptoms. Very few studies have suggested an increased risk of gastrointestinal (GI) bleeding. This study aimed to elucidate the incidence, etiology, risk factors, and outcomes of clinically significant GI bleeding requiring endoscopic intervention in patients with COVID-19.MethodsThis is a case-control (1:2) retrospective analysis of all hospitalized adult patients with COVID-19 infection admitted between March 1, 2020, and January 5, 2021, in which we compared patients with upper and lower GI bleeds to those without. Cases are defined as patients hospitalized with COVID-19 who had a GI bleed requiring intervention while controls are defined as patients hospitalized with COVID-19 who did not have a GI bleed. Of 1002 patients admitted to the Albany Medical Center with COVID-19 infection, there were 76 confirmed cases of GI bleeding. These patients were compared to a control group composed of randomly selected patients with COVID-19 infection who were admitted to Albany Medical Center over the same time period. We assessed patients for in-hospital mortality, ventilator-free days on day 28, ICU-free days on day 28, and hospital-free days on day 28. Additional information collected included demographic information, comorbid conditions, COVID-19 treatments received, endoscopy findings, endoscopic treatment received, and if the patients required a packed red blood cell transfusion.ResultsOut of 1007 patients hospitalized with COVID-19, 76 (8%) had a GI bleed requiring endoscopic intervention. Peptic ulcer disease in the stomach or duodenum was the most common finding. The use of steroids, antiplatelet agents, and anticoagulation was not associated with an increased risk of GI bleed in COVID-19 patients. The GI bleed group required ICU care in 37% (28/76) compared with 21% (32/152) in the control group, which was statistically significant (p=0.012; chi-square test). Length of hospital stay was longer in the GI bleed group (median 16 days IQR: 8 to 29 versus 7 days, IQR:4 to 16; p<0.001, Mann Whitney test).ConclusionLength of hospital stay and ICU level of care was higher in the GI bleed group of patients with COVID-19. ICU level of care was noted to be associated with an increased risk of GI bleeding. A GI bleed in COVID-19 patients could be from the virus's direct effect on the gut mucosa or stress-induced bleeding like any other severely sick ICU patient; however, this needs to be explored in future studies.

Portal Hypertension and Current Endoscopic Management

AbstractPortal hypertension is a difficult to treat sequelae of end stage of liver disease, and is associated with a variety of complications. Notably, it can lead to significant gastrointestinal bleeding, which carries a high risk of mortality. Sources of portal hypertensive bleeding include esophageal and gastric varices, portal hypertensive gastropathy and ectopic varices. Fortunately, endoscopic techniques are effective in both prevention and management of acute bleeding, and their application and expansion has led to improved outcomes. Endoscopy plays a pivotal role as it allows for direct visualization and diagnosis as well as immediate intervention. There are several endoscopic techniques available for the treatment of esophageal varices including band ligation, glue therapy and sclerotherapy. There are, however, gray areas within the management of portal hypertensive bleeding such as the management of portal hypertensive gastropathy and gastric variceal bleeding, both of which can be more challenging to treat endoscopically. Thus, there is growing interest regarding how novel advanced therapeutic techniques can address these areas with a focus on endoscopic ultrasound guided therapies. This article will review both traditional and novel endoscopic techniques used in the management and prevention of portal hypertensive associated bleeding.

Endovascular Treatment of Gastrointestinal Hemorrhage.

Background and Objectives: Severe non-variceal gastrointestinal bleeding is a life-threatening condition with complicated treatment if endoscopic therapy fails. In such cases, transcatheter arterial embolization is recommended. The technical and clinical effects of this technique were analyzed in this group of patients, as well as its complication rate and 30-day mortality. Materials and Methods: Patient data over a one-decade period (from 2010 to 2019) were analyzed retrospectively; 27 patients (18 men and 9 women; median age 61 years) treated by endovascular embolization in our institution, with clinically significant gastrointestinal hemorrhage after unsuccessful or impossible endoscopic treatment, were identified, and their data were collected. Results: The source of bleeding was found in 88% of patients, but embolization was performed in 96% of them. The overall technical success rate was 96.8%, and the clinical success was 88.5%. Re-bleeding occurred in eight cases, five of whom had re-embolization that was technically successful in four cases. The incidence of re-bleeding was significantly higher in patients with two or more comorbidities (p = 0.043). There was one serious complication (4%) in the group, and minor difficulties occurred in 18% of patients; 30-day mortality reached 22%. Mortality was significantly higher in the group of patients with re-bleeding (p = 0.044). Conclusions: Transcatheter arterial embolization is a mini-invasive method with high technical success in patients with endoscopically untreatable gastrointestinal bleeding; it is also suitable for high-risk cases. Mortality (to a significant extent) depends on the occurrence of re-bleeding and the patient’s comorbidities.

Meckel Diverticulum Carcinoid Tumor Complicated by Ileal Invagination. About One Case at Vichy Hospital

Meckel’s diverticulum is a common pathology in children and rare in adults. We present a case of a 79-year-old patient in which a significant gastrointestinal bleeding, whose paraclinical explorations confirmed a fatty tumor of the terminal ileum. The exploratory coelioscopy revealed a tumor of the Meckel diverticulum complicated of intestinal invagination, resected at the same time with resection and extracorporeal anastomosis by mini coelio-guided laparotomy. Histology confirmed the presence of heterotopical tissue of the duodenal mucosa with Brunner cells and a carcinoid tumor. In conclusion, this clinical case shows that coelioscopy can be considered a very important diagnostic and therapeutic tool in this pathology especially in the elderly.

Случай рецидива травматической гемобилии после селективной эмболизации сегментарной печеночной артерии

The article describes a rare case of recurrent hemobilia after previously performed selective embolizationof a segmental hepatic artery. A 33-year-old man underwent open (laparotomic) suturing of the injury dueto a rupture of segments VI-VII of the liver, but 3 weeks after the operation, the patient developed signs ofgastrointestinal bleeding. According to the results of ultrasound, duodenoscopy, MSCT and celiacography, afalse aneurysm of the segmental artery of the VII-VIII segments of the liver was revealed, in connection withwhich the embolization of the feeding artery was performed, and hemobilia was stopped. Two weeks afterembolization, a recurrence of hemobilia was noted; repeated celiacography revealed an arteriobiliary fistulathrough the wall of a false aneurysm. Selective catheterization of the artery of the right lobe of the liver wasperformed and embolization was performed - a complete shutdown of the target artery was achieved, however,there was a flow of contrast into the aneurysm through collaterals from the arteries of the left lobe of the liver,which required additional embolization of the artery of the left lobe of the liver. After the procedure, the signsof gastroduodenal bleeding stopped.

A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT.

Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.

S2312 Acute Gastrointestinal Bleeding Due to a Duodenal Hamartomatous Polyp: A Case Report

Introduction: The small bowel accounts for less than 4% of tumors involving the gastrointestinal (GI) tract. Benign small bowel lesions could be mucosal or submucosal. Polypoid mucosal lesions include Brunner’s glands hyperplasia, nodular lymphoid hyperplasia, adenomas, and hamartomas with 20% arising in the duodenum. Submucosal tumors include lipomas, leiomyomas, lymphangiomas and neurofibromas. We report a case of a large duodenal hamartomatous polyp causing significant occult GI bleeding, requiring blood transfusion and urgent endoscopic intervention. Case Description/Methods: A 65-year-old African American male with a history of colon cancer and right hemicolectomy, atrial fibrillation, end stage renal disease, and chronic anticoagulation with apixaban was admitted for generalized weakness and found to have a hemoglobin (Hgb) of 5.5 g/dL without report of overt GI bleeding. The patient was diagnosed with a large duodenal polyp three years prior with biopsy showing adenoma and Brunner’s gland hyperplasia. He had been referred to a tertiary center for endoscopic removal of the polyp, which was deferred due to his multiple major co-morbidities. After resuscitation and transfusion of two units of packed red blood cells, an esophagogastroduodenoscopy (EGD) was performed which showed the presence of the pedunculated polyp in the second portion of duodenum, measuring 2.5 cm in size with active oozing. The rest of the EGD was normal. Using a polyloop and injection of 2cc of 1:10,000 epinephrine into the peduncle, the polyp was resected using a snare and endocut. The final histological diagnosis of the polyp was hamartomatous polyp with features of Peutz-Jeghers polyp and areas of chronic inflammation. After resection of the duodenal polyp, the patient's Hgb returned to normal limits at follow up. Discussion: GI bleeding due to a duodenal polyp is very rare. As a result, there is limited data on the management of duodenal polyps regarding surveillance and resection. As demonstrated in this case, the polyp was initially not resected due to absence of symptoms and major comorbidities, but the patient later presented with significant bleeding requiring urgent endoscopic intervention. The case highlights the necessity of careful evaluation and resection of duodenal polyps > 1cm before they become symptomatic as in this case of acute GI bleeding.Figure 1.: Acute gastrointestinal bleeding due to a 2.5 cm pedunculated polyp, pathology consistent with hamartoma, within the second portion of the duodenum with active oozing of blood.

Surgical treatment of complicated duodenal ulcers with different variants of their localization

Purpose: To analyze and highlight the most effective methods of surgical treatment of complicated duodenal ulcer (DU) depending on its location. Material and methods. 86 patients underwent surgery for complicated combined pyloroduodenal ulcers. All patients with signs of gastrointestinal bleeding and perforation were examined according to clinical protocols. Patients were operated on by various surgical techniques depending on the location of DU. Further the analysis of different methods of surgical treatment of the pathology under study at its various localizations was carried out. Results. It has been established that in complicated combined pyloroduodenal ulcers with localization in the pyloric canal antrumectomy is the method of priority. If duodenum ulcer is complicated by bleeding, excision with pyloroplasty is the method of priority. Suture ulceration with pyloroplasty can be considered as an alternative method of treatment. It has been verified that in complicated duodenal ulcers, exteriorization and suturing of the ulcer have the lowest efficiency. The most frequently used method of duodenal ulcers of any localization treatment was excision of the ulcer with pyloroplasty. 6 (41.8 ± 0.053%).patients had been operated on by this method. In the second place in terms of universality was ulcer’s suturing with pyloroplasty - 22 patients or (25.5 ± 0.047%). The third was the method of exteriorization and suturing of ulcers, which accounted for 10 patients (11.6 ± 0.034%).

Small bowel hemorrhage from check point inhibitor enteritis: a case report

BackgroundThere is rising utilization of immune checkpoint inhibitors (ICI) for a growing number of metastatic malignancies. While gastrointestinal side effects of ICI are common, isolated ICI-induced enteritis leading to small bowel hemorrhage is rare.Case presentationA 71-year-old man with a previously resected right colon adenocarcinoma on atezolizumab and recently treated Clostridioides difficile presented with acute on chronic abdominal pain and non-bloody diarrhea. A CT scan revealed enteritis of the duodenum and jejunum without colitis. Initial endoscopic work-up revealed many clean-based non-bleeding duodenal ulcers to the third portion of the duodenum and normal rectosigmoid mucosa. The patient initially improved on steroids but was readmitted on day after discharge with hematochezia and hemorrhagic shock. Repeat CT showed improvement in enteritis; however, repeat push enteroscopy revealed multiple duodenal and jejunal ulcers, two with visible vessels requiring endoscopic intervention. He continued to have significant hemorrhage requiring transfusions despite IV methylprednisolone. Conventional angiogram revealed multiple sites of active extravasation, and he underwent small bowel resection and subsequent IR embolization due to persistent bleeding. He was then started on infliximab 10 mg/kg with resolution of his small bowel hemorrhage and diarrhea.ConclusionsSevere isolated ICI-enteritis is rare and can lead to clinically significant gastrointestinal hemorrhage. Patients with severe ICI-enteritis on endoscopy should be carefully monitored for steroid refractory disease for consideration of step-up therapy such as infliximab.

Under the Radar: A Case Report of a Missed Aortoenteric Fistula.

IntroductionAn aortoenteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal tract that develops due to a pathologic cause. It is a rare, but life-threatening, cause of gastrointestinal (GI) bleeding. Although no single imaging modality exists that definitively diagnoses AEF, computed tomography angiography (CTA) of the abdomen and pelvis is the preferred initial test due to widespread availability and efficiency.Case ReportMany deaths occur before the diagnosis is made or prior to surgical intervention. We describe a case of a patient with a history of aortic graft repair who presented with active GI bleeding.ConclusionAlthough CTA can make the diagnosis of AEF, it cannot adequately rule it out. In patients with significant GI bleeding and prior history of aortic surgery, vascular surgery should be consulted early on, even if CTA is equivocal.

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis.

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.

Proton Pump Inhibitors Versus Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Meta-analysis and Trial Sequential Analysis.

Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies. A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors. A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83±17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: -0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: -0.01-0.04) were indifferent between the groups. Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.