Treatment Of Gastrointestinal Bleeding Research Articles

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Causes of gastrointestinal bleeding in children based on endoscopic evaluation at a tertiary care center in Bahrain.

Gastrointestinal bleeding (GIB) is a serious health problem worldwide, particularly during childhood. This can be an alarming sign of an underlying disease. Gastrointestinal endoscopy (GIE) is a safe method for the diagnosis and treatment of GIB in most cases. To determine the incidence, clinical presentation, and outcomes of GIB in children in Bahrain over the last two decades. This was a retrospective cohort review of the medical records of children with GIB who underwent endoscopic procedures in the Pediatric Department at Salmaniya Medical Complex, Bahrain, between 1995 and 2022. Demographic data, clinical presentation, endoscopic findings, and clinical outcomes were recorded. GIB was classified into upper (UGIB) and lower (LGIB) GIB according to the site of bleeding. These were compared with respect to patients' sex, age, and nationality using the Fisher's exact, Pearson's χ 2, or the Mann-Whitney U tests. A total of 250 patients were included in this study. The median incidence was 2.6/100000 per year (interquartile range, 1.4-3.7) with a significantly increasing trend over the last two decades (P < 0.0001). Most patients were males (n = 144, 57.6%). The median age at diagnosis was 9 years (5-11). Ninety-eight (39.2%) patients required upper GIE alone, 41 (16.4%) required colonoscopy alone, and 111 (44.4%) required both. LGIB was more frequent (n = 151, 60.4%) than UGIB (n = 119, 47.6%). There were no significant differences in sex (P = 0.710), age (P = 0.185), or nationality (P = 0.525) between the two groups. Abnormal endoscopic findings were detected in 226 (90.4%) patients. The common cause of LGIB was inflammatory bowel disease (IBD) (n = 77, 30.8%). The common cause of UGIB was gastritis (n = 70, 28%). IBD and undetermined cause for bleeding were higher in the 10-18 years group (P = 0.026 and P = 0.017, respectively). Intestinal nodular lymphoid hyperplasia, foreign body ingestion, and esophageal varices were more common in the 0-4 years group (P = 0.034, P < 0.0001, and P = 0.029, respectively). Ten (4%) patients underwent one or more therapeutic interventions. The median follow-up period was two years (0.5-3). No mortality was reported in this study. GIB in children is an alarming condition, whose significance is increasing. LGIB, commonly due to IBD, was more common than UGIB, commonly due to gastritis.

Interventional endoscopic ultrasound.

To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.

Embolization for acute gastrointestinal bleeding

Purpose: To retrospectively evaluate the clinical success and complication rates following interventional embolization for treatment of acute gastrointestinal bleeding (GIB) at a tertiary care centre. The secondary purpose was to evaluate results of practice change whereby multiphase CT angiography was requested prior to conventional angiograms.&#x0D; Methods: A retrospective chart review and analysis of 38 patients undergoing Interventional Radiology guided embolization for acute GIB was performed. Clinical success was defined as patient stability 30 days’ post embolization and complications included subsequent bleeding requiring endoscopy, surgery or additional embolization, or death.&#x0D; Results: Overall clinical success rate was 86.8% (33/38). Complications included 14 patients (36.8%) experiencing continued bleeding, 6 patients (15.8%) requiring repeat endoscopic evaluation, 8 patients (21.1%) requiring surgery, 3 patients (7.9%) requiring repeat embolization, and 4 deaths (10.5%). These results were not inferior to clinical success rates reported in the literature for GIB regardless of location. Positive predictive value for multiphase CT angiogram was 92.3% and the negative predictive value was 57.1%.&#x0D; Conclusions: Interventional angiography and embolization is an effective treatment for GIB with the most common complication being recurrent bleeding which may require additional endoscopic evaluation, surgical intervention or additional embolization. Clinical success and complication rates at this centre are similar to those reported in the literature. Continued evaluation of the utility of multiphase CT angiography prior to conducting embolization should be considered to determine its impact on rates of negative angiogram studies.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives.

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Survival Impact and Clinical Predictors of Acute Gastrointestinal Bleeding in Patients With Bloodstream Infection.

The impact of gastrointestinal bleeding (GIB) on outcomes of patients with bloodstream infection (BSI) has not been studied. We aim to evaluate the risk factors and survival impact of GIB on the outcome of BSI. This study was conducted prospectively at National Taiwan University Hospital Yunlin Branch between January 1, 2015, and December 31, 2016. Patients aged ≥18 years for who BSI was confirmed by blood cultures were enrolled and followed for 90 days. Risk factors of GIB were identified by univariable and multivariable logistic regression models. The survival impact of GIB on BSI was evaluated with the Cox proportional hazards model with inverse probability of treatment weighting. Of the 1034 patients with BSI, 79 (7.64%) developed acute GIB. We identified 5 independent predictors of GIB. Patients with BSI complicated with GIB had an increased 90-day mortality compared to patients without GIB (hazard ratio 1.74, 95% confidence interval: 1.14, 2.65). Gastrointestinal bleeding had an adverse impact on the short-term survival in patients with BSI. The clinical predictors may help identify patients who may benefit from active prevention and treatment of GIB.

The Effect of Hemostasis Powder® on Treatment of Bleeding from Benign Ulcers of Upper Gastrointestinal Tract; A Pilot Study.

BACKGROUND Gastrointestinal (GI) bleeding is one of the most prevalent internal medical emergencies. Despite using several methods of treatment, effective treatment cannot be achieved in some patients. Hemostasis powder® is a mineral-herbal product. This emulsion was able to coagulate blood in, in vitro studies and also was effective in the treatment of mucosal and cutaneous bleeding in animal studies, without any toxicity. We decided to compare its effect on the treatment of human GI bleeding with the other common method for treatment of GI bleeding "argon plasma coagulation plus epinephrine injection" in a pilot randomized clinical trial. METHODS The patients with GI bleeding who were admitted to the emergency wards of Ghaem and Imam-Reza Hospitals in Mashhad were randomized to treatment with Hemostasis powder® or "argon plasma coagulation plus epinephrine injection" method, with randomized doctors, after complete testimonial sheet. The patients underwent re-endoscopy to evaluate the ulcers 3 days later, and were under observation for 3 months. After achieving the number of patients that was planned (20 patients), all data were entered to SPSS software version 20 and were analyzed with parametric and non-parametric tests. RESULTS The treatment success was 95% in both groups. There was no complication after treatment of GI bleeding in the two groups after 3 months. No rebreeding was reported in Hemostasis powder® group but 10 % was reported in "argon plasma coagulation plus epinephrine injection" group. CONCLUSION It seems that if the successful results occur in the future complimentary studies, Hemostasis powder® can be used as a new, effective, available, and inexpensive measure in the treatment of GI bleeding and also in the GI bleedings that cannot be treated with common available methods.

Endoscopic Management of Gastrointestinal Bleeding

Background Gastrointestinal bleeding (GIB) represents a significant cause of morbidity and mortality. The primary diagnostic and therapeutic tool is endoscopy. New devices are being developed and employed that facilitate the management of this pathology. In this review, we show the status of endoscopic management of digestive hemorrhage, current practices, and future directions. Methods We explore the management of patients with GIB (upper and lower). Besides, we analyzed the diagnostic methods in occult digestive hemorrhage. We show the evidence collected so far, and how each therapeutic method can be applied. Results GIB constitutes a challenge for the attending physician. Different therapeutic procedures are available. Less invasive devices have a role in the diagnosis but not therapy. The use of risk stratification is well established for upper bleeding, but for lower bleeding, there is still no evidence to support the use of these scores. Knowledge of altered anatomy is crucial in special populations. Conclusion A variety of procedures are available for the treatment of GIB. Emphasis should be placed on less invasive diagnostic techniques as well as on new and more efficient therapies. Attention should be given to the initial management, with timely diagnosis and effective resuscitation to decrease the morbidity and mortality.

No catheter angiography is needed in patients with an obscure acute gastrointestinal bleed and negative CTA

PurposeTo evaluate the negative predictive power of computed tomography angiography (CTA) for the identification of obscure acute gastrointestinal (GI) bleeding (GI bleeding not visualized/treated by endoscopy) on subsequent mesenteric angiography (MA) with the intention to treat. Materials and methodsA retrospective chart review of patients was performed who underwent mesenteric angiography for the evaluation/treatment of acute GI bleeding between November 2012 and July 2016. Patients with negative CTA examinations that proceeded to MA were identified. Negative predictive value (NPV) was calculated. Results20 patients (14 male, 6 female; average age: 73.1±12.8years) underwent 20 negative CTA examinations for the evaluation and treatment of GI bleeding followed by mesenteric angiography. Eighteen of 20 patients had negative subsequent MA (negative predictive value, NPV=90%). Both false negative cases were upper GI bleed (vs 0 lower GI bleed); this difference was significant (p<0.05). ConclusionsThe high NPV of CTA for the evaluation of GI bleeding suggests utility for excluding patients that are unlikely to benefit from MA and subsequent endovascular therapy. CTA may be considered for the first line diagnostic study for the evaluation of obscure GI bleeding.

Novel Use of Thalidomide in Recurrent Gastrointestinal Tract Bleeding in Patients with Left Ventricular Assist Devices: A Case Series

Bleeding is an important and common complication of left ventricular assist devices (LVADs). One of the common causes of gastrointestinal bleeding is arteriovenous malformations. However, the source of bleeding is often hard to identify. Thalidomide is efficacious in treatment of gastrointestinal (GI) bleeding in non-LVAD patients. We report our experience of the use of thalidomide in the treatment of GI bleeding in four patients with LVAD. Four patients who had recurrent GI bleeding from May 2009 to December 2014 were started on thalidomide. All of them responded to treatment and had no further gastrointestinal bleeding while on thalidomide. One patient developed constipation, requiring thalidomide to be stopped. Another patient developed symptomatic neuropathy, that resolved with reduction of dosage. Thalidomide appears safe and efficacious in LVAD patients with recurrent gastrointestinal bleeding.

Outcomes of Endoscopic Intervention for Gastrointestinal Bleeding in the Setting of Severe Thrombocytopenia

Outcomes of Endoscopic Intervention for Gastrointestinal Bleeding in the Setting of Severe Thrombocytopenia

Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives

Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. The rate of major GIB related to the use of some direct acting oral anticoagulant drugs (DOACs), is higher than that detected in warfarin users. Current strategies in the treatment of GIBs in patients receiving warfarin or DOACs (vitamin K, activated charcoal; hemodialysis; recombinant factor VIIa; [activated] prothrombin complex concentrates) including indications for the treatment of bleeding based on different degrees of severity of the episodes, is reported in this article. Potential preventive strategies to mitigate the risk of GIBs (e.g. upper endoscopy/biopsy, colon cancer screening; eradication of Helicobacter pylori prior to starting anticoagulation; use of proton-pump inhibitors, identification of risk factors for bleeding) are also reported as well as the fact that some of them have not been tested so far in patients receiving DOACs.Antidotes that experimentally reverse the anti-coagulant effect of dabigatran (Idarucizumab; BI 655075; Boehringer Ingelheim); of rivaroxaban, apixaban, or edoxaban (Andexanet alfa, r-Antidote, PRT064445; Portola Pharmaceuticals) or of all DOACs (Aripazine, PER-977, ciraparantag; Perosphere Inc.) are discussed. Likewise, population pharmacokinetics modeling related to the rate of major DOACs-related GIBs is presented. It is also emphasized that the occurrence of GIB reflects the presence of patients at the highest risk for adverse outcomes. Finally, the implications of the concept that patient characteristics and the severity of illness (i.e. comorbidities) exert a greater impact on the risk of GIB than the type of antithrombotic agent employed, are analyzed.

PWE-037 Role of ct angiography in the management of acute gi bleeding

Introduction Gastrointestinal (GI) bleeding cannot always be controlled or identified at endoscopy (OGD), therefore guidelines recommend radiological intervention in an unstable patient. The options are fluoroscopic angiogram (FA) which is time consuming, requires significant expertise, and has significant radiation exposure. Alternatively a CT angiogram (CTA) may offer a sensitive, rapid diagnosis of the source of GI bleeding to allow definitive treatment. Data on the role and diagnostic yield of CTA are lacking. We present the largest international study to assess the impact of CTA in upper GI bleeding. Method A retrospective analysis of endoscopy and radiology databases was used to identify patients who underwent radiological intervention for GI bleeding at Sheffield Teaching Hospitals between 2003 and 2013. A control group of 757 patients (who did not undergo FA or CTA) from the South Yorkshire GI bleed audit 2011 was used for comparison. Pre-endoscopy Rockall scores, routine haematology and biochemistry results taken prior to endoscopy and inpatient mortality rates were compared. Results 59 patients (35 male, mean age 69.3) underwent imaging for upper GI bleeding during the study period. In 49/59 (mean age=68.3, mean Rockall = 3.8, mean Hb = 84.7) a source was initially identified at OGD but with continued bleeding. CTA was performed in 31 with the other 18 having immediate FA. For patients having a CTA first a source was identified in 15 (48%) requiring embolization in 10. 4 patients who did not have an abnormality seen on CTA subsequently required FA and embolization and 2 of these patients died. For the other 10/59 (16.9%) (mean age 74.3 mean Rockall=4, mean Hb=84.2) no source was identified at OGD and they underwent CTA identifying 8 bleeds which proceeded to FA and then embolization in 6. Inpatient mortality in this group was 50% which was significantly higher than 14.3% for those patients with an identified source for upper GI bleed (p = 0.02). Patients who underwent CTA were older (p = 0.039) and presented with higher median pre-endoscopy Rockall scores (p = 0.003) than controls. Both CTA and ‘direct to FA patients’ presented with lower Hb (p Inpatient mortality rates were higher in those who underwent CTA prior to FA (22%) compared to those who went directly to FA (11%) but this was not significant (p = 0.5). Conclusion Radiological imaging resulted in embolization in 55.9% of patients referred. Patients requiring radiological intervention for GI bleeds have more significant bleeding with lower haemoglobin and higher Rockall scores. Patients with no source of bleeding on OGD have higher inpatient mortality despite radiological intervention. Disclosure of interest None Declared.

Severe Gastrointestinal Bleeding in a Patient With Subvalvular Aortic Stenosis Treated With Thalidomide and Octreotide: Bridging to Transcoronary Ablation of Septal Hypertrophy

Gastrointestinal bleeding (GB) due to angiodysplasias can cause severe, recurrent bleeding, especially in elderly patients. Angiodysplastic bleedings in the gastrointestinal tract have been associated with aortic stenosis and, more recently, hypertrophic obstructive cardiomyopathy, caused by an acquired coagulopathy known as Heyde’s syndrome. Multiple factors are involved in the pathogenesis of angiodysplastic bleeding including genetic factors and increased levels of vascular intestinal growth factor at tissue levels. Endoscopic coagulation therapy is the primary treatment but often fails to resolve bleeding, especially in patients with large numbers of angiodysplasias. In patients with aortic stenosis and GB, the main treatment is aortic valve replacement but the patients may be unfit to undergo surgery due to the complicating anemia. In this case story, we present a patient with severe, GB due to hypertrophic subvalvular obstructive cardiomyopathy. Endoscopic procedures with argon beaming were performed without effect on bleeding. The patient was treated with a combination of both thalidomide and octreotide. Within 3 months, the patient recovered from the anemia and was able to undergo transcoronary ethanol ablation. No further bleeding episodes occurred, and thalidomide and octreotide were arrested. To our knowledge, this case report is the first to describe how this new drug combination therapy is an effective treatment of GB from angiodysplasias and can be used to bridge to surgical or endovascular treatment.

Endoscopic Evaluation of Upper and Lower Gastro-Intestinal Bleeding.

Introduction:A myriad of pathologies lead to gastro-intestinal bleeding (GIB). The common clinical presentations are hematemesis, melena, and hematochezia. Endoscopy aids localization and treatment of these lesions.Aims:The aim was to study the differential diagnosis of GIB emphasizing the role of endoscopy in diagnosis and treatment of GIB.Patients and Methods:A prospective study of patients with GIB referred to the Endoscopy unit of two health facilities in Port Harcourt Nigeria from February 2012 to August 2014. The variables studied included: Demographics, clinical presentation, risk score, endoscopic findings, therapeutic procedure, and outcome. Data were collated and analyzed using SPSS version 20 software.Results:A total of 159 upper and lower gastro-intestinal (GI) endoscopies were performed during the study period with 59 cases of GI bleeding. There were 50 males and 9 females with an age range of 13–86 years (mean age 52.4 ± 20.6 years). The primary presentations were hematochezia, hematemesis, and melena in 44 (75%), 9 (15%), and 6 (10%) cases, respectively. Hemorrhoids were the leading cause of lower GIB seen in 15 cases (41%). The majority of pathologies in upper GIB were seen in the stomach (39%): Gastritis and benign gastric ulcer. Injection sclerotherapy was successfully performed in the hemorrhoids and a case of gastric varices. The mortality recorded was 0%.Conclusion:Endoscopy is vital in the diagnosis and treatment of GIB. Gastritis and Haemorrhoid are the most common causes of upper and lower GI bleeding respectively, in our environment

Transcatheter Intervention for Non-variceal Gastrointestinal Bleeding: What Have We Learned in 45 Years?

Despite considerable advances in diagnostic testing, medical treatment, surgical and non-surgical interventions, therapy of gastrointestinal (GI) bleeding remains a challenge for physicians. Although GI bleeding ceases spontaneously in roughly 75 % of patients, it still carries a relatively high morbidity and mortality in our aging population [1]. When faced with a bleeding patient, clinicians initially attempt to separate hemorrhage arising in the upper gastrointestinal (UGI) tract from that originating in the lower gastrointestinal (LGI) tract, delineated by the ligament of Treitz, due to the considerable differences in diagnosis, treatment and prognosis associated with each region. Regardless of location, endovascular interventions remain important for the diagnosis and treatment of GI bleeding, likely only increasing in application and efficacy in the coming decades. Before 1968, endovascular physicians had little to offer the acutely bleeding patient. The first major therapeutic intervention for GI bleeding was catheter directed intraarterial vasopressin infusion [2]. A somewhat cumbersome procedure that has largely been abandoned in contemporary practice, vasoconstrictor infusion offered a minimally invasive therapy that could be employed in stable and unstable patients alike, for variceal and non-variceal hemorrhage [3]. In the 1970s, arterial embolization initially appeared promising, although its widespread adoption was thwarted by unacceptably high complication rates, primarily colonic ischemia [4]. When technological advances in imaging, embolic agents, and catheters caught up with physician ingenuity in the late 1990s and early 2000s, a paradigm switch occurred with arterial embolization assuming primacy for catheter-based therapy of UGI and LGI bleeding. In the past several years, numerous studies, predominantly retrospective series, have reported the safety and efficacy of arterial embolization for UGI and LGI bleeding [5–7]. Although published algorithms for the management of GI bleeding exist, the application of mesenteric angiography with transcatheter arterial embolization in the therapy of GI hemorrhage remains controversial. The study by Yap et al. [8] in this issue describes a single-center experience with transcatheter arterial embolization for non-variceal GI bleeding over a period of 8 years. The authors demonstrate a high technical success rate in keeping with other reported series and national guidelines. Of note, the data are reported without strict separation of UGI from LGI bleeding, which dilutes their conclusions. Despite this limitation, the authors provide a detailed look at patients requiring transcatheter arterial embolization, and identify important risk factors for rebleeding, notably underlying peptic ulcer disease and coagulopathy. Their experience highlights an important concept in the endovascular treatment for GI bleeding; embolization in the UGI tract can either be ‘‘targeted’’ at visualized arterial abnormalities, or ‘‘empiric’’, where the suspected culprit arterial branch is occluded despite no demonstrated angiographic abnormality. In the LGI tract, where the collateral arterial supply is tenuous, targeted embolization is recommended such as in the accompanying article, D. S. BouHaidar (&) Department of Internal Medicine, Interventional Endoscopy, Virginia Commonwealth University Health Center, Box 980341, Richmond, VA 23298-0341, USA e-mail: dsbouhaidar@vcu.edu

Abstract No. 252 - Single center interventional radiology experience in the management of gastrointestinal bleeding in patients with ventricular assist devices

Purpose Gastrointestinal (GI) bleeding is a well-recognized complication in patients with ventricular assist devices (VADs). Possible mechanisms include use of anticoagulation and development of GI angiodysplasia. Treatment of GI bleeding in this patient population is not well-defined. We aim to study VAD patients with GI bleeding, including an in depth analysis of those patients referred to interventional radiology (IR) for further management. Materials and Methods A single center retrospective review of VAD patients between 2005 and 2011 was conducted. Patients who subsequently developed GI bleeding were identified. Covariates such as gender, age, days on support prior to first episode of bleed, and management of GI bleeding was analyzed. Patients referred to IR were analyzed in detail and the outcomes associated with intervention recorded. Results GI bleeding was common, seen in 23/154 (15%) of VAD patients. Of these, none required surgery for the treatment of recurrent bleeding, and all episodes were managed with supportive, endoscopic or endovascular management. Bleeding was more common with continuous versus pulsatile VADs (21% vs. 4%, p Conclusion GI bleeding is common in VAD patients. When the bleed is localized to the duodenum or stomach, empiric embolization of the GDA or left gastric artery may be of benefit in obtaining hemostasis. If the bleed is localized with angiography, targeted embolization can be performed. In this fragile population, appropriate management is critical to minimize interventions and prevent further recurrence. A management algorithm involving IR could be of great benefit to these patients.

The clinical effect of gastroscopy injection of norepinephrine combined with routine triple therapy on peptic ulcer patients with gastrointestinal bleeding

Objective To observe the effect of gastroscopy injection of norepinephrine combined with routine triple therapy on peptic ulcer with gastrointestinal bleeding. Methods 84 cases of gastroscopy upper gastrointestinal bleeding caused by peptic ulcer patients were randomly divided into two groups, the control group 42 cases;the observation group 42 cases, the observation group was guven endoscopic injection of norepinephrine combined conventional triple therapy,the control group was given conventional triple therapy with hemostatic therapy. Efficiency and adverse reactions were observed in patients. Results In the observation group,36 csses was significantly effective,5 cases was effective,1 case was not effective,the total effective rate was 97.6%. In the control group,21 cases was significantly effective, 16 cases was effective ,5 cases was not effective,the total effective rate was 88. 1% ,the difference of the total effective rate between the two groups was significant( x2 =5. 137, P ＜ 0. 05 ). There was no serious adverse reactions in the two groups. Conclusion Endoscopic injection of norepinephrine and routine triple therapy in treatment of gastrointestinal hemorrhage of peptic ulcer was significantly better than conventional medical treatment alone. Key words: Peptic ulcer hemo rrhage; Gastroscopy; Norepinephrine

Pharmacokinetics of intravenous omeprazole in critically ill paediatric patients

The proton pump inhibitors are first-line drugs for the treatment of a number of gastrointestinal diseases. These drugs have a good safety profile, making it possible to use them in paediatric patients. Although their pharmacokinetics in children has not been extensively studied, research performed suggests that the dose used should be varied as a function of age, as this factor affects the drug's metabolism. Proton pump inhibitors can be used in critically ill children for the prophylaxis and treatment of gastrointestinal haemorrhage, although there is still little experience with this. The most widely used proton pump inhibitor at the present time is omeprazole. As there are specific characteristics of these patients that could alter the pharmacokinetics of the drugs, studies need to be performed to determine the most suitable dose and dosage interval.