Source Of Gastrointestinal Bleeding Research Articles

Pediatric upper gastrointestinal bleeding in children: etiology and treatment approaches

Objective: Upper gastrointestinal bleeding (UGB) is one of the most important and serious cause of emergency admission in childhood. The aim of the study was to evaluate the etiological factors and the treatment approaches in patients with UGB. Methods: In this retrospective study, children with UGB admitted to emergency clinics of Istanbul Health Sciences University Kanuni Sultan Suleyman Research and Training Hospital, Istanbul Bakirkoy Sadi Konuk Research and Training Hospital and Diyarbakir Children’s Hospital were evaluated between January 2014 and August 2017. Results: Of the 198 children, 14.6% had non-steroid anti-inflammatory drug (NSAID) history, and 12.6% had chronic liver disease. We detected esophagitis, esophagus varices and peptic ulcer with upper gastrointestinal endoscopic evaluation (47%, 11.1%, 18.1%, respectively). Helicobacter pylori was found in 61.6% of patients. Endoscopic therapeutic procedures (band ligation therapy, sclerotherapy, and adrenaline injection) were appied in 11.1% of patients. Eighty-four (42.4%) patients were hospitalized, and erythrocyte transfusion (ET) was ordered in 29 (14.6%) patients. Conclusion: Approximately in 20% of the pediatric patients, the source of gastrointestinal bleeding is the upper gastrointestinal system. The cause of UGB varies with age. Appropriate diagnostic and therapeutic approaches are very important for management and to reduce mortality.

Risk factors for bleeding from gastrointestinal angiodysplasia: acase-control study in patients with bleeding and non-bleeding angiodysplasia.

Angiodysplasia (AD) is a common source of gastrointestinal bleeding. Yet, little is known about factors forwarding bleeding in these vascular malformations. The presented study aims to determine risk factors for bleeding that occurs only in patients with symptomatic, but not with asymptomatic, AD. Case-control study in patients with AD and either a positive or a negative history of gastrointestinal bleeding in Munich, Germany. Groups were compared by clinical, laboratory, and endoscopic features. 80 patients with (58, f 31, med. age 72) or without bleeding AD (22, f 12, med. age 61) were included. Bleeding from AD was significantly associated with the total number of AD (OR 1.4 (95 % CI 1.1-1.7) p = 0.01) and closure time in PFA/collagen-epinephrine test (OR 1.0 (95 % CI 1.0-1.0) p < 0.01). The total number of AD correlated significantly with age (r = 0.36; p = 0.01). AD were mainly detected in the upper small intestine (> 30 %). Although patients with aortic stenosis suffered not significantly more frequently from bleeding from AD, they demonstrated a loss of high molecular multimers of VWF. The amount of AD is clearly correlated to the age of the patient. A higher number of ADs and inhibition of primary hemostasis increase the risk of bleeding.

Study of the benefit of blood urea nitrogen/creatinine ratio and some other parameters to detect site, cause, and severity of gastrointestinal hemorrhage noninvasively

Background and aim Gastrointestinal (GI) bleeding is a common medical condition that may lead to emergent endoscopy. The aim of our study was to design pre-endoscopic scores for GI bleeding to clarify the source of GI bleeding, to differentiate variceal and nonvariceal cases, and to identify complications and high-risk patients requiring urgent clinical management. Patients and methods One hundred patients with hematochezia or melena were enrolled in this study. Blood urea nitrogen (BUN)/creatinine ratio score, upper GI bleeding etiological score, C-WATCH score, and Glasgow-Blatchford score (GBS) were calculated. Upper GI endoscopy was performed by the consultant within 72 h, and lower endoscopy was done if indicated. Results This prospective study was done on 83 patients presented with upper gastrointestinal tract (GIT) bleeding and 17 patients presented with lower GIT bleeding. BUN/creatinine ratio was significantly higher in upper than lower GIT bleeding (P=0.019). Sensitivity of upper GI score was 45%, specificity was 86.96%, positive predictive value was 90.0%, and negative predictive value was 37.7%, with accuracy of 81.6%. Sensitivity and specificity of C-WATCH score were 38.33 and 78.26, respectively, and for GBS were 61.6 and 69.5%, respectively. Conclusion BUN/creatinine ratio had higher effectiveness in detecting upper than lower GI bleeding. Upper GI etiological score was significantly higher in diagnosis of variceal bleeding than nonvariceal bleeding. GBS is highly sensitive but not specific to anticipate complications of upper GIT bleeding; however, C-WATCH score can anticipate severity and complications of upper GI bleeding.

Diagnosing Absolute Iron-Deficiency Anemia in Patients on Hemodialysis in a Tertiary Care Centre: A Retrospective Chart Review

Introduction: The gold standard for the diagnosis of absolute iron-deficiency anemia (IDA) in hemodialysis patients is a bone marrow aspirate with iron staining. Many clinicians use peripheral iron indices instead because they are non-invasive. Previous studies suggested that a serum ferritin &lt; 200 ng/mL was a reliable indicator of absolute iron deficiency in the hemodialysis population. However, the sensitivity of serum ferritin for the diagnosis of IDA in hemodialysis patients is poor. Methods: The primary objective of this study was to identify the optimal ferritin value to diagnose patients with absolute iron deficiency, as assessed on bone marrow aspiration, in the renal dialysis population. Secondary endpoints included the rate of clinically relevant findings on gastrointestinal investigation according to iron status. Research Ethics Board approval was obtained from Queen's University for this retrospective chart review. Hematopathology laboratory records were used to determine all individuals who had bone marrow examination at Kingston Health Sciences tertiary referral center between 2008 January 1 and 2018 August 21. This list was cross-referenced with the Nephrology dialysis database to identify the pre-specified study cohort; those who were receiving concurrent hemodialysis or peritoneal dialysis. Iron deficiency was defined as reduced or absent iron stores on bone marrow aspirate with Perl's Prussian blue stain. Anemia was defined as hemoglobin &lt;130 g/L in males and &lt;120 g/L in females. Additional parameters collected included ferritin (normal range 22 - 275 ng/mL male and 4 - 205 ng/mL female), transferrin saturation (TSAT, normal range 20-55%), vitamin B12, folate, albumin, CRP and thyroid function tests. Peripheral iron indices over six months were analyzed; statistical analysis was performed with t-tests and Mann-Whitney U tests. ROC curves were generated to determine the sensitivity and specificity of various threshold values for serum ferritin and TSAT. Results: Between 2008 January 1 and 2018 August 21, 4234 patients underwent bone marrow examination, of whom 28 had received renal dialysis replacement therapy at some point. Fifteen patients concurrently at the time of bone marrow testing receiving hemodialysis form the study population (Table 1). Among these fifteen patients, 6 (40%) were female, median age was 70.5 (range 39 - 80) years and all were anemic (Hb range 73 - 110 g/L). Four of these individuals were absolutely iron-deficient with reduced or absent iron stores by bone marrow evaluation. The mean ferritin and TSAT values for individuals with absolute iron deficiency by bone marrow aspiration was 273.5 ng/mL (n=4; median 224.5 ng/mL; range 158-539 ng/mL) and 22.0% (n=3; median 20%; range 20-26%), respectively. All four commenced erythropoietin stimulating agents; two received oral iron supplementation. Eight patients, including two of those determined to be absolutely iron deficient on bone marrow, had endoscopic investigation. Two were identified to have sources of gastrointestinal bleeding, both with ferritin values in the 100-200 range (106 and 189 ng/mL). With the limited sample size, the sensitivity and specificity of ferritin to identify absolute iron deficiency in this hemodialysis population was 50% and 85%, respectively, at a threshold of 198 ng/mL. Discussion: Ferritin and TSAT are not sensitive markers for absolute iron deficiency in hemodialysis patients. Bone marrow examination is performed in a minority. The small sample size in this study precludes definitive determination of an optimal ferritin cut-off to diagnose iron deficiency in the dialysis population. Uncertainty about actual iron status may result in alternative invasive testing, such as colonoscopy, to investigate the cause of their anemia. Newer tests such as reticulocyte hemoglobin content and percent hypochromic red blood cells are more accurate and may guide diagnosis and management of IDA in hemodialysis patients. However they are not always routinely available. Further studies are needed to compare the utility of these peripheral iron indices to the gold standard bone marrow examination in a larger population, to allow identification of patients with absolute or functional IDA, and minimize invasive and potentially unnecessary investigation. Disclosures Hay: AbbVie: Research Funding; Kite: Research Funding; Janssen: Research Funding; Seattle Genetics: Research Funding; Celgene: Research Funding; MorphoSys: Research Funding; Roche: Research Funding; Novartis: Research Funding; Gilead: Research Funding; Takeda: Research Funding.

3138 Unusual Gastrointestinal Petechial Bleeding of the Small Bowel Associated With Newly Diagnosed Chronic Myeloid Leukemia

INTRODUCTION: Chronic myeloid leukemia (CML) often is diagnosed in the chronic phase based off routine laboratory analysis in asymptomatic patients with findings include splenomegaly, anemia, leukocytosis, and thrombocytosis. Patients less commonly present with bleeding due to platelet dysfunction. In the case presented, a patient presented with unusual petechial bleeding of the small bowel found on video capsule endoscopy (VCE) as the initial symptom of undiagnosed CML which is highly atypical. CASE DESCRIPTION/METHODS: A 79-year-old Caucasian male with a past medical history significant for atrial flutter status-post ablation (not on anti-coagulation) presented to the emergency room with maroon colored stools for 2 days with no other complaints. He denied abdominal pain, nausea, vomiting, or weight loss. Physical exam was benign with vital signs within normal limits. Laboratory analysis revealed white blood cell count of 84.9 t/cmm with 89.9% segmented neutrophils and hemoglobin (HGB) of 10.2 g/dL (previous HGB 14.4 g/dL). The patient was admitted for gastrointestinal (GI) bleeding and malignancy work up. HGB down trended to 7.7 g/dL and an esophagogastroduodenoscopy (EGD) was performed showing no abnormalities. Due to the continued drop in HGB, a colonoscopy was performed which showed old blood in the colon with no identifiable source of bleeding. VCE, interestingly, showed multiple clustered pinpoint petechiae in the ileum. Concurrently, it was suspected that the patient had underlying CML given absence of infection and findings of 1% blasts, basophilia, and eosinophilia. Bone marrow biopsy showed hypercellular bone with myeloid hyperplasia with FISH positive for BCR/ABL confirming CML. It was unknown if the VCE findings may have been related to the patient's newly diagnosed CML. DISCUSSION: Anemia is observed in about a third of the patients with newly diagnosed CML depending on the degree of tumor burden. Due to platelet dysfunction, patients may present with bleeding. Because of the significant HGB drop and melena, GI bleeding work up was initiated and ultimately identified a highly unusual source of bleeding. The VCE yielded unexpected images of petechial hemorrhage within the small bowel which was most likely secondary to the underlying malignancy. The case highlights the importance of ruling out sources of GI bleeding in the setting of severe anemia rather than anchoring on the diagnosis of CML. To our knowledge, these VCE findings have not been documented in CML.

2587 Never Too Old for Meckel's: A Unique Presentation of an Uncommon Source of Gastrointestinal Bleeding in Adults

INTRODUCTION: Meckel's diverticulum is a common gastrointestinal congenital malformation, affecting approximately 2% of the population. Related complications such as bleeding commonly occurs in the pediatric age group; although, in adults it is often missed. We present a case of recurrent obscure-overt gastrointestinal (GI) bleeding secondary to a Meckel's diverticulum which remained elusive after multiple diagnostic studies. CASE DESCRIPTION/METHODS: 30-year-old male with history of recurrent GI bleeding, presents to the outpatient GI clinic for further evaluation after being admitted to the intensive care unit (ICU) 3 weeks prior with massive hematochezia requiring several blood transfusions for a drop-in hemoglobin from 14 gm/dL to &lt;7 gm/dL. The patient had undergone endoscopy, colonoscopy, and video capsule endoscopy (VCE) three years prior for similar symptoms without an identifiable source. A nuclear tagged red blood cell scan was performed showing bleeding in the proximal colon. CT angiography following showed contrast extravasation in the distal jejunum and ileum which was treated with gel foam. The patient had no further episodes of hematochezia and was discharged. After the clinic visit, the patient underwent a Meckel's scan which did not show ectopic gastric mucosa but revealed colonic bleeding proximal to the hepatic flexure. Ileocolonoscopy was normal. Subsequent VCE showed abnormal mucosa in the distal small bowel. He finally underwent a retrograde balloon enteroscopy which revealed a distal small bowel diverticulum with a single adjacent, nonbleeding ulcer (Figure 1). Biopsies of the ulcer showed gastric foveolar metaplasia. Based on the findings, he was referred for a small bowel resection which revealed a jejunal Meckel's diverticulum with gastric oxyntic heterotopia on histology (Figures 2 and 3). DISCUSSION: This case highlights the potential morbidity and possible mortality of Meckel's diverticulum as a source of lower GI bleeding. Recent studies have recommended against prophylactic surgical resection in the absence of certain risk factors including age less than 40, male gender, and macroscopic mucosal alteration. Given this patient's significant hematochezia, transfusion requirements, and gross peri-diverticular ulceration, we opted for small bowel resection. Meckel's diverticulum should always be included in the differential for occult or overt GI bleeding, especially in young patients when no other sources of bleeding are readily identifiable.

1867 A Case of Mistaken Identities: Impact of Kayexalate on the Colon

INTRODUCTION: End stage renal disease (ESRD) affects nearly 750,000 Americans each year. Kayexalate (sodium polystyrene sulfonate) is commonly used to manage hyperkalemia in ESRD. Kayexalate is a nonspecific cation exchange resin that acts in the large intestine to allow for the exchange of sodium for any cation (potassium, calcium or magnesium). Kayexalate has an inherent lattice structure. Addition of calcium ions can lead to crystal formation that appears basophilic, rhomboid/triangular with a fish-scale appearance on Hematoxylin and Eosin (H&amp;E) stain. Studies show that the combination of kayexalate and sorbitol, an osmotic laxative, may lead to osmotic shifts and ischemic damage. However, the impact of kayexalate alone in gastrointestinal tract is less established. We present a case of kayexlate crystal deposition appearing as a pseudo-polyp in the appendiceal orifice. CASE DESCRIPTION/METHODS: A 51-year-old woman with a past medical history significant for systemic lupus erythematosus, radical nephrectomy for renal mass complicated by dialysis dependent ESRD, mitral and aortic valve replacement on Coumadin, presented to the hospital for hyperkalemia requiring emergent dialysis. The patient developed melena in the setting of supratherapeutic INR. Colonoscopy revealed a non-obstructing 10mm yellow mass protruding from, and tethered to, the appendiceal orifice. The pseudo-polyp appeared to be on a stalk. Resection was performed using a biopsy forceps at the base. Pathology revealed foreign crystalline material that was suggestive of kayexalate deposition. The source of gastrointestinal bleeding was later identified as a jejunal arteriovenous malformation. DISCUSSION: Reports of kayexalate effects on the gastrointestinal tract are somewhat limited, but include findings of acute inflammatory tissue injury in as early as 24 hours, potentially with colonic ulceration. Kayexalate can also cause mechanical obstruction secondary to the development of crystalline structures in the colon. Prolonged uses of this medication can likewise lead to reversible crystal deposition within the esophagus, stomach and duodenum. This case highlights the potential for crystal resin deposition to appear as a pseudopolyp. Gastroenterologists should carefully review medication history when approaching a patient with a mechanical obstruction or colon ulceration in the setting of ESRD.

1924 Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding

INTRODUCTION: Anorectal melanoma is a rare malignancy that can present as hematochezia similar to other gastrointestinal bleeding sources. The diagnosis of anorectal melanoma may be challenging given its rarity, nonspecific presentation, and need for histopathology, but accurate and timely diagnosis is essential given that associated bleeding may not respond to conventional treatments. CASE DESCRIPTION/METHODS: An 88-year-old male was admitted for septic shock after being found lethargic at his nursing facility. He was started on intravenous antibiotics and vasopressors and intubated for airway protection. Though slowly improving overall, on hospital day 6, he had 4 episodes of large red clots per rectum. Rectal examination showed bright red blood and a rubbery mass palpable on the posterior rectal wall without visible hemorrhoids. Due to the acute drop in hemoglobin to 6.3 g/dL, the patient was transfused 2 units of packed red blood cells, empirically started on intravenous pantoprazole, and administered parenteral Vitamin K and a dose of desmopressin. Over the next two days, the patient continued to have multiple bowel movements with blood clots requiring additional blood transfusions. Given these findings, the patient underwent flexible sigmoidoscopy. DISCUSSION: Flexible sigmoidoscopy revealed a 3 cm ulcerated mass in the distal rectum which involved the dentate line. Endoscopic hemostasis was not feasible, but a biopsy was obtained which showed malignant melanoma invading the lamina propria and muscularis with associated ulceration. Considering the patient's age, clinical status, and advanced dementia, the medical team and unrepresented patient committee agreed that it was ethically appropriate to not pursue further work-up or treatment of the patient's melanoma. Following medical stabilization, the patient was transitioned to home comfort care. This case illustrates a rare etiology of bright red blood per rectum and the importance of additional investigation in the setting of clinically significant anemia and/or inadequate response to conservative measures. Anorectal melanoma, similar to other rare disorders which can mimic internal hemorrhoidal bleeding, frequently requires endoscopic techniques for diagnosis and management. Despite this patient's clinical course and the generally poor prognosis of anorectal melanoma, early diagnosis can allow for surgical excision and/or adjuvant therapies that may provide a potentially curative outcome or delay disease progression and mitigate bleeding complications.

3131 Rectal Dieulafoy's Lesion: A Rare Cause of Massive Lower GI Bleed

INTRODUCTION: Dieulafoy's lesions can be a life-threatening source of gastrointestinal bleeding. While most commonly seen in the stomach, they have been described throughout the GI tract, including the rectum. These lesions consist of a persistent caliber, submucosal artery that can be difficult to identify on endoscopic evaluation. Rectal Dieulafoy's lesions are a rare source of lower GI bleeding that can present with large volume hematochezia requiring prompt management. Two cases of bleeding secondary to a rectal Dieulafoy's lesion are reviewed. CASE DESCRIPTION/METHODS: Case 1: A 94-year-old man with multiple cardiompulmonary comorbidities presented initially for sepsis secondary to osteomyelitis and developed hematochezia during admission. Hgb went from 10.0 g/dL to 7.1 g/dL, but he remained hemodynamically stable and bleeding self-resolved. Colonoscopy was deferred due to patient preference. The patient was readmitted to the hospital 8 days later with continued hematochezia and found to have Hgb 6.3 g/dL. Colonoscopy showed a visible Dieulafoy's lesion that was injected with 2 mL 1:10,000 epinephrine and then treated with 2 hemostatic clips. After intervention, bleeding resolved. Case 2: A 91-year-old man with a history of dementia and COPD was admitted for two days of hematochezia. On admission, he was transiently hypotensive with a SBP in the 50s and a Hgb of 9.4 g/dL with a baseline of 13-14 g/dL. Hgb eventually reached a nadir of 7.4 g/dL. Flexible sigmoidoscopy showed a visible Dieulafoy's lesion. Three hemostatic clips were placed in setting of active oozing with control of bleeding. DISCUSSION: Dieulafoy's lesions were first described in 1884 and are now more commonly described given advances in endoscopy. These lesions account for only 1-2% of GI bleeds, however this number may be underrepresented due to the difficulty of diagnosis. The rectum is involved in only about 2% of cases of Dieulafoy's lesions. The etiology of these lesions is unclear, but likely have some relationship to age, co-morbidities, and NSAID use. Endoscopy is the main method of diagnosis, though EUS, VCE, or angiography are also useful. Hemostasis is usually achieved through thermal therapy, injection with epinephrine, or banding/hemoclip with dual modality being preferred. The cases above represent two examples of a rectal Dieulafoy's lesion, a rare etiology of lower GI bleeding. Management of these bleeds requires prompt evaluation with endoscopy and can be successfully treated via multiple modalities.

622 Economic Burden of Bleeding Gastrointestinal Angioectasias

INTRODUCTION: Angioectasias are dilated, thin-walled blood vessels resulting from degenerative changes in capillary vascular structure. They can occur anywhere within the gastrointestinal tract and are the most common source of small intestinal bleeding in patients over age 50. Small bowel angioectasias have the highest re-bleeding rates when compared to other sources. It is assumed that angioectasias complicated by bleeding result in consumption of a large volume of medical resources but this consumption has not yet be quantified in the medical literature. METHODS: A retrospective cross-sectional study was performed using Medicare data base analysis of ICD-10-DM codes for patients diagnosed with anemia and/or gastrointestinal hemorrhage during 2016 and 2017. A Crosswalk analysis of ICD-10-DM codes pertaining to primary gastrointestinal bleeding and primary anemia from angioectasias converted these codes into corresponding DRG (inpatient) and CPT (outpatient) codes. These codes of interest were followed throughout 2016 and 2017 in order to determine the cost of medical care for symptomatic angioectasias. RESULTS: In 2016, 38,250 Medicare services were provided in the management of angioectasias at a total cost of roughly $240 million. Hospitalizations accounted for 48% of total service volume but 95% of total costs at an average expense of $12,391 per inpatient stay. Outpatient services accounted for 52% of all services provided but only 5% of total annual costs in this analysis. Average costs for individual outpatient services were broken down into categories of therapeutic endoscopy ($922), diagnostic endoscopy ($805), injections ($522), blood transfusions ($261), and outpatient clinic visits ($261). Therapeutic endoscopy was the most expensive outpatient service category, accounting for 64% of all outpatient costs. A separate analysis of 2017 Medicare data validated our findings from the previous year with a steady total cost and only slightly (5%) increase in volume of individual services. CONCLUSION: Angioectasias are a common source of gastrointestinal bleeding and are associated with high recurrence rates as well as substantial morbidity. This study confirms that a large volume of medical resources are consumed in that management of bleeding angioectasias. In recognition of these findings, additional research is justified to improve upon our understanding and management of this disease process.

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.

Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study.

Finding easily accessible and non-invasive methods for differentiating various sources of gastrointestinal (GI) bleeding before performing endoscopy and colonoscopy is of great interest. The present study was designed with the aim of evaluating the screening performance characteristics of blood urea nitrogen (BUN) to Creatinine (Cr) ratio in this regard. The present diagnostic accuracy study was performed on patients with acute GI bleeding presenting to emergency department from 2011 to 2016, in a retrospective manner. BUN/Cr ratio was calculated for all patients and its accuracy in differentiation of upper and lower GI bleedings, confirmed via endoscopy or colonoscopy, was evaluated. A total of 621 patients with the mean age of 59.49±17.94 (5 - 93) years were studied (60.5% male). Area under the receiver operating characteristic (ROC) curve of BUN/Cr ratio for predicting the source of GI bleeding was 0.63 (95% CI: 0.57 - 0.68). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of BUN/Cr ratio at 35 cut-off point were 19.63% (95%CI: 16.69 - 23.45), 90.16% (95%CI: 83.11 - 94.88), 89.09 (95%CI: 81.35 - 93.98), 21.53 (95%CI: 18.09 - 25.39), 8.16 (95%CI:4.76 - 13.98), and 3.65 (95%CI: 3.44 - 3.87), respectively. Considering the relatively proper specificity and positive predictive value of BUN/Cr ratio, in cases that bleeding source cannot be determined using other non-invasive methods, values higher than 35 can predict upper GI bleeding with high probability. However, due to the low sensitivity, values less than 35 are not diagnostic.

Tu1087 LONG TERM REBLEEDING OUTCOMES AFTER ENDOSCOPIC THERAPY WITH BALLOON ASSISTED ENTEROSCOPY FOR SMALL BOWEL VASCULAR LESIONS: A META-ANALYSIS

The entry of balloon-assisted enteroscopy (BAE) has revolutionized our approach to obscure gastrointestinal bleeding (OGIB). While current literature has focused primarily on diagnostic and therapeutic yields for BAE in the treatment of small bowel vascular lesions (SBVL), little is known about the long term clinical outcomes for these patients. Confounding factors, such as the treatment of “suspected” vs “definitive” causes of bleeding, lesion mix, and proportion treated surgically may skew short-term outcomes but may lead to no overall benefit for patients. Therefore, this meta-analysis was performed to evaluate the long-term rebleeding outcomes after endoscopic intervention with BAE for small bowel sources of gastrointestinal bleeding and represents the largest meta-analysis of its kind to date.

Factors associated with false-positive fecal immunochemical tests in a large German colorectal cancer screening study.

In recent years fecal immunochemical tests (FITs) have been offered as a primary screening test for colorectal cancer (CRC) in a growing number of countries. Our study aims to identify factors associated with apparently false-positive results of FITs. In this cross-sectional study within the German population-based screening colonoscopy program, participants were invited to provide a stool sample for FIT prior to colonoscopy. Four thousand six hundred and fifty six participants aged 50-79 years with no known history of CRC or inflammatory bowel disease (IBD) and no findings of neoplasms at screening colonoscopy were included in the current analyses. Main outcome measures were rates and factors associated with apparently false-positive FIT results. Apparently false-positive FIT results were found for 378 participants (8.1%). Male sex (OR = 1.30, 95%CI 1.03, 1.62), age ≥65 years (OR = 1.27, 95%CI 1.01, 1.59), a BMI ≥30 kg/m2 (OR = 1.81, 95%CI 1.36, 2.40), current smoking (OR = 1.63, 95%CI 1.18, 2.25), use of aspirin (OR = 1.36, 95%CI 1.02, 1.82) and a new diagnosis of IBD (OR = 9.13, 95%CI 2.18, 38.19) or other non-neoplastic findings (OR = 1.86, 95%CI 1.37, 2.51) at screening colonoscopy were independently associated with significantly increased odds of a positive FIT. Although considered false positive in the context of CRC screening, the identified factors associated with apparently false-positive FIT results are known risk factors for and may point to conditions other than colorectal neoplasms that may be potential sources of gastrointestinal bleeding, potentially requiring further medical follow up.

Prevalence of splenic vein thrombosis and risk of gastrointestinal bleeding in chronic pancreatitis patients attending a tertiary hospital in western India.

Background:Splenic vein thrombosis (SVT) is most commonly caused by acute and chronic pancreatitis (CP). Variceal gastrointestinal (GI) bleeding is a potentially life-threatening event in such patients. The aim of this study was to determine the prevalence of SVT in CP patients and the risk of variceal GI bleeding.Materials and Methods:A total of 187 consecutive patients with a diagnosis of CP were assessed for the presence of SVT at the gastroenterology department of a tertiary care hospital. Thirty seven patients had evidence of SVT. Patients with portal vein thrombosis or cirrhosis were excluded. Potential factors associated with SVT were assessed.Results:Of the 187 CP patients assessed, 37 patients (19.8%) (male 33; female 4; mean age 41.9 years) had evidence of SVT. Among patients with SVT, most common etiology of CP was alcohol abuse (70.3%). Seven patients (18.9%) with SVT presented with clinically significant upper GI bleeding. The source of GI bleeding was gastric varices in three patients (8.1%) and non-variceal source in four patients (10.8%). All three patients with gastric varices were managed by splenectomy. There were no new variceal bleeding episodes in other 33 patients (89.2%) during mean follow-up of 16.4 months. On comparison of patients with and without SVT, the factors associated with significantly higher incidence of SVT were smoking (P = 0.019, odds ratio 3.021, 95% confidence interval 1.195–7.633) and presence of pseudocyst (P = 0.008, odds ratio 3.743, 95% confidence interval 1.403–9.983). Complete resolution of SVT was seen in three patients (8.1%) after resolution of underlying pseudocyst.Conclusion:SVT is a common complication of CP, particularly in patients with pseudocysts and history of smoking. Most patients remain asymptomatic and the risk of variceal bleeding is low. Splenectomy is the treatment of choice in patients with variceal bleeding. Conservative approach is preferred in other patients. Resolution of pseudocysts may lead to resolution of SVT in some patients.

Resource utilization and hospital readmission associated with gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices.

Gastrointestinal bleeding (GIB) occurs in up to 40% of patients with continuous-flow (CF) left ventricular assist devices (LVADs). We sought to identify targets to improve hospital resource utilization and decrease readmissions after GIB. We performed a single-center, retrospective analysis of LVAD-associated GIB resulting in hospital admission between July 2011 and April 2014. Follow-up data were collected through March 2015. We analyzed 57 admissions for GIB in 23 patients. One or more diagnostic imaging study was performed in 47% of admissions, with a definite or probable source of GIB identified in 23%. A total of 76 endoscopies were performed (≥ 1 endoscopy in 79% of admissions, ≥ 2 in 42%). Definite or probable bleeding sources were identified in 25% and 12% of endoscopies, respectively. Patients who underwent multiple endoscopies were no more likely to have a bleeding source identified (OR 1.48; 95% CI 0.50-4.32; p = 0.59) and had longer hospital stays (11.1 vs. 7.8days, p < 0.02). Readmission rates for GIB at 30 and 90days were 33% and 53%, respectively. A decrease in antiplatelet regimen at discharge was associated with lower rate of readmission for GIB (OR 0.16; 95% CI 0.03-0.82; p = 0.03) or any cause (OR 0.21; 95% CI 0.05-0.85; p = 0.04) at 30 and 90days. GIB in patients with CF-LVADs is associated with significant in-hospital resource utilization and high rates of readmission. Imaging and endoscopy are common, but have low diagnostic yield and infrequently result in successful intervention. Strategies to reduce resource utilization and prevent readmission are warranted.

A Case of Gastrointestinal Amyloidosis Presenting Initially as Melena

Amyloidosis is a condition in which abnormal protein folding leads to insoluble fibrillar protein deposition in extracellular tissues, resulting in diverse clinical manifestations. Herein we present a case of amyloidosis diagnosed in a patient whose first clinical symptom was that of gastrointestinal (GI) bleeding. An 86 year old female with hypothyroidism, atrial fibrillation, and chronic obstructive pulmonary disease, was admitted to an outside hospital with shortness of breath, and three months of melena. Laboratory results showed hemoglobin of 7.5 g/dL with baseline hemoglobin one-year prior of 12g/dL. Cardiac MRI there was suggestive of cardiac amyloidosis, and she was subsequently transferred to Westchester Medical Center for a right heart catheterization and biopsy. Repeat laboratory studies were consistent with iron deficiency anemia, and stool studies were positive for occult blood. She was also found to have elevated kappa and lambda free lights chains, with an elevated kappa/lambda ratio. Urine electrophoresis was notable for elevated total protein. Esophagogastroduodenoscopy (EGD) was performed and revealed innumerable fundic gland polyps, with otherwise normal gastric and duodenal mucosa. On colonoscopy, the terminal ileum was coated with black stool, though no source of gastrointestinal bleeding was found. There was a 2 cm lesion in the ascending colon-thought to be a lipoma, a 6 mm polyp in the transverse colon, and a diminutive recto-sigmoid polyp which were all either biopsied or removed. Random biopsies were taken in the rectum. On pathology, the duodenal biopsies, ascending colon ‘lipoma’, transverse colon polyp, and rectal biopsies were positive for amyloid. Clinical manifestations of gastrointestinal amyloidosis range from mild nausea to severe hemorrhage. Endoscopic findings are varied ranging from normal appearing mucosa to that of a fine granular appearance, with erosions, ulcerations or polypoid protrusions. Tissue biopsy is ideally taken from the duodenum or rectum and confirmed with positive Congo red staining or the presence of amyloid fibrils. Treatment should address symptoms and target the underlying disease; e.g., with chemotherapy in those with AL subtype and biologic therapy in those with AA amyloidosis. Heightened awareness that GI bleeding can be the first manifestation of amyloidosis along with timely endoscopic biopsies, will allow for earlier diagnosis and therapeutic treatment.2007_A Figure 1. Normal appearing duodenum, with biopsy positive for amyloid2007_B Figure 2. Ascending colon lipoma

A National Survey of the Prevalence and Demographics of Gastrointestinal Bleeding in Cirrhotic Patients

Introduction: Gastrointestinal (GI) bleeding in cirrhotic patients continues to carry a high risk for morbidity and mortality. Few studies have examined all sources of GI bleeding within this population. Given the lack of comprehensive data within the literature, we aimed to evaluate the prevalence and characteristics of GI bleeds within subsets of cirrhotic patients utilizing a national population-based dataset. Methods: Using ICD-9 codes, we analyzed patients ≥ 18 years with a discharge diagnosis of alcoholic, nonalcoholic, or biliary cirrhosis from 2000-2012. Within this population, we identified all subjects with a principal or secondary diagnosis code representing a GI bleed. We further categorized these codes into Upper (UGI), Lower (LGI), or Other GI bleeding. In addition to patient prevalence, we analyzed demographic factors, GI bleed location, liver decompensation, and overall mortality. Results: The estimated prevalence of GI bleeding within the total cirrhotic population in the US from 2000-2012 was 11.1%. Males, whites, and UGI bleeds held the highest prevalence within all cirrhotic subgroups. Biliary cirrhosis accounted for only 2.2% of the population with women representing 87% of all GI bleeds. Adjusting for age, gender and using white race as reference, Native Americans and Hispanics showed higher likelihood for UGI bleeds [OR:1.29 95%CI:1.25-1.32 vs OR:1.07 95%CI:1.06-1.08, p<0.001]. Blacks ultimately showed the strongest likelihood for LGI bleeds [OR:1.31 95%CI:1.26-1.35, p<0.001]. Females were also 24% more likely to have LGI bleeding than males [p <0.001]. Alcoholic cirrhosis was a stronger predictive factor than nonalcoholic cirrhosis for both UGI bleeds and overall mortality [OR:1.81 vs 1.10, OR:2.15 vs 1.52, p <0.001]. No positive association was revealed when comparing location of bleed and overall mortality. In contrast, signs of decompensated liver disease were strong predictors of mortality [OR 2.36 95%CI: 2.34-2.37, p <0.001]. Conclusion: While a higher prevalence of Whites, males, and UGI bleeds exist within the cirrhotic population, Hispanics and Native American patients may have been more likely to develop UGI bleeds. Furthermore, both Black and female demographics may show higher likelihood of LGI bleeding. Alcoholic cirrhosis showed the highest likelihood of mortality. Unlike the location of bleed, signs of decompensated liver disease showed a positive association with mortality. To expand on these conclusions, future studies are warranted.

Gastro-Intestinal Tract Complications During Antithrombotic Therapy

Use of antithrombotic aids (ATA) significantly impact the prevention of life-threatening cardiovascular complications. ATA applications, however, are associated with a wide range of adverse digestive system responses. Due to, continuously growing clinical use of ATA this problem has become a current challenge of contemporary medicine.Purpose of the study was to evaluate the patterns of digestive system damage in patients receiving ATA.Materials and Methods. 672 patients were examined, 91.0% males, 46.7±17.4 years of age, who had digestive system changes that occurred due to ATA intake. 71 patients were admitted for treatment after gastrointestinal (GI) bleeding; other patients were hospitalized because of disorders of the digestive system or erosive and ulcerous changes of the digestive system detected by endoscopy. The following parameters were evaluated: GI bleeding sources, character of complaints, the endoscopic patterns due to intake of different ATAs (low doses of aspirin, warfarin, clopidogrel, dabigatran, rivaroxaban, low-molecular heparin, combined therapy), and of risk factors for GI complications.Results. The sources of GI bleeding (n=71) included gastric ulcers and/or erosions (39.4%), duodenum ulcers and/or erosions (21.1%), colon ulcers and/or erosions (28.2%), unknown (11.3%). The majority of 672 patients noticed various complaints: sensation of heaviness in epigastrium (62.8%), gastralgia (46.7%), burning sensation (34.3%). Endoscopy found erosive esophagitis (13.2%), ulcers in stomach and/or duodenum (11.6%), multiple ( 10) erosions of stomach or duodenum (17.1%), sporadic erosions of stomach or duodenum (24.4%). In 32.3% cases no erosive or ulcerous alterations were found. H. pylori was identified in 57.9% of patients. There was no significant difference in character of alterations in the upper digestive system between patients who received different ATA treatment, except of frequent erosive esophagitis in those patients who received dabigatran (16.8%). The elderly age ( 65 years), ulcer history, concomitant intake of NSAIDS, H. pylori presence, and smoking habit were associated with a higher occurrence of pathological alterations of digestive system. Presence of gastralgia did not correlate with the development of erosive and ulcerous alterations.Conclusion. In majority of patients who received ATA, the commonly observed erosive and ulcerous alterations in the digestive system might become a source of bleeding.

535 OUTCOMES OF GASTROINTESTINAL BLEEDING IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES: A TERTIARY CARE CENTER EXPERIENCE

Left Ventricular Assist Device (LVAD) placement is a therapeutic modality for patients with end-stage congestive heart failure. Gastrointestinal bleeding (GIB) is one of the most common complications after LVAD implantation. Limited data exists on the etiology, management and outcomes in these patients. To our knowledge, this is the largest single-center study reporting the risk factors, endoscopic findings, and outcomes in the management of LVAD patients presenting with GIB. We performed a retrospective chart review of all patients who underwent LVAD placement and had a subsequent GIB at our tertiary care academic referral center from January 2008 to June 2017. Patient-specific data was collected including demographics, clinical presentation at time of GIB, and comorbidities. Procedural details (endoscopic/radiologic) were also obtained. Descriptive analysis was performed utilizing SPSS software. A Cox regression model using SAS was employed to assess factors predictive of GIB. During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2%) presented with a total of 297 bleeding events. Median time to first GIB following LVAD placement was 6.5 months. Patient demographics and characteristics are summarized in Table 1. The top presenting symptom of GIB was melena (n = 134; 45.1%). At the time of GIB, 97% of patients were on an antithrombotic regimen (Table 2); the most frequent combination was warfarin plus aspirin (n = 216; 73.0%). Lab values, transfusion requirement, and medical management are summarized in Table 1. During the study period, 533 endoscopic procedures were performed for evaluation of GIB: 228 EGDs, 125 colonoscopies, 79 push enteroscopies, 68 video capsule endoscopies, 26 antegrade and 7 retrograde double balloon enteroscopies. The most common endoscopic finding was AVM (n = 121; 42.2%). GIB source was most often located in the stomach (n = 113; 39.4%). 226 endoscopic therapeutic interventions were performed for hemostasis, with the most common being APC (n = 77; 34.1%) and endoclip placement (n = 67; 29.6%). Overall success of therapeutic interventions in achieving hemostasis was 96.2%. 30-day post-procedure complications are summarized in Table 2. The overall complication rate was 6.6%. Cox model analysis revealed that older age at implant, male gender, African-American race, DM and pulmonary hypertension were statistically significant predictors of GIB during post-LVAD follow-up. GIB doubled the risk of mortality in a multivariate adjusted model. Danazol and Octreotide were associated with an increased risk of recurrent GI bleeding. LVAD patients have a high risk (36.2%) of GIB. The most common bleeding sources were AVMs located in the stomach or small bowel. These can be successfully treated endoscopically in > 95% of patients with a low complication rate.