Lower gastrointestinal bleeding in the elderly

DA-9601 extracted from Artemisia asiatica contains a bioactive compound - eupatilin - that can protect against gastric mucosal damage through anti-inflammatory and anti-oxidative properties and is approved for treating acute and chronic gastritis in Korea, but their ability to protect gastrointestinal (GI) bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) is unclear. We aimed to compare the protective effects of DA-9601 to those of proton pump inhibitors (PPI) and rebamipide against upper and lower GI bleeding in patients with rheumatoid arthritis (RA) undergoing long-term NSAIDs therapy using the Korean Health Insurance Review and Assessment database. In this nationwide retrospective cohort study, we evaluated patients with RA who concurrently received NSAIDs for >3 months with DA-9601, PPI, or rebamipide between January 2015 and December 2017. The index date was the date of NSAIDs initiation, and all patients were followed up until December 2020 to detect upper and lower GI bleeding. In total, 24,258 patients with RA were eligible, and 5468 (22.5%), 4417 (18.2%), and 14,373 (59.3%) received DA-9601, PPI, or rebamipide, respectively, on the index date. During follow-up, upper and lower GI bleeding occurred in 508 (2.1%) and 402 (1.6%) patients with RA, respectively. The incidence rate of upper and lower GI bleeding was 615/100,000 and 485/100,000 person-years, respectively. Among patients with RA receiving DA-9601, PPI, or rebamipide, the frequencies of NSAIDs-induced upper GI bleeding were 0.5%, 0.4%, and 1.2%, respectively. The frequencies of NSAIDs-induced lower GI bleeding were 0.4%, 0.4%, and 0.9%, respectively. The incidence of NSAIDs-induced upper GI bleeding in patients with RA receiving DA-9601, PPI, and rebamipide was 601/100,000, 705/100,000, and 596/100,000 person-years, respectively, while the incidence of NSAIDs-induced lower GI bleeding in the same groups was 449/100,000, 608/100,000, and 465/100,000 person-years, respectively. In the multivariate Cox regression analysis, no significant difference was observed in lower and upper GI bleeding hazards between patients with RA using DA-9601, PPI, and rebamipide. Our results suggest that DA-9601 may exhibit protection against NSAIDs-induced GI bleeding that is comparable to those of PPI and rebamipide in patients with RA.

We report our experience of the detection of ectopic gastric mucosa by means of perfusion Tc-99m pertechnetate disodium scintigraphy in patients with lower gastrointestinal bleeding. Gastric mucosa may be present in Meckel's diverticulum and is associated with peptic ulcer disease and lower gastrointestinal (GI) bleeding; Tc-99m pertechnetate scintigraphy can help to make the diagnosis of ectopic gastric mucosa. Seventy-nine children (40 boys, 39 girls, aged 1 - 17, mean age 8 years) underwent Tc-99m pertechnetate scintigraphy in the last thirteen years. All patients had melena or hematochezia. Morphology imaging and endoscopy were negative in all patients. Dynamic scintigraphy of the abdomen was started immediately after i. v. administration of Tc-99m pertechnetate. The static image of the abdomen was performed subsequently. Where necessary, SPECT was additionally performed to improve the sensitivity, specificity and spatial specification. Three patients (two boys: two and ten years old; one girl: four years old) had positive scintigraphy results. All 3 patients underwent surgery and Meckel's diverticulum with ectopic gastric mucosa found (histology). GI bleeding stopped spontaneously in patients with a negative scintigraphy. These patients did not undergo intraoperative enteroscopy or surgery. Tc-99m pertechnetate scintigraphy can help to detect ectopic gastric mucosa in the abdomen and improve the management of patients with lower gastrointestinal bleeding.

Risk Factors for Adverse Outcomes in Patients Hospitalized With Lower Gastrointestinal Bleeding

INTRODUCTION: Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database. METHODS: Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016. RESULTS: Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies. CONCLUSION: The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.

Introduction Lower gastrointestinal bleeds (LGIB) are defined by having a bleeding point in the gastrointestinal tract beyond the ligament of Treitz. The most common causes include diverticular bleeds, tumours, and colitis. There are noNational Institute for Health and Care Excellence (NICE) guidelines regarding safe discharge of patients with LGIB. The aim of this study was to investigate the effectiveness and safety of the Oakland score, as suggested by the British Society of Gastroenterology (BSG) guidelines, in patients presenting with LGIB at William Harvey Hospital. Methods Patients with LGIB who presented to Accident & Emergency or inpatient referral from January to December 2023 were included in this retrospective study. Data was extracted from patients' Sunrise documentation. The Oakland score for each patient was calculated. Those with a score of ≤8 were deemed safe for discharge; those with a higher score were deemed unsuitable. Patients' admission, discharges, and adverse outcomes, such as representation, blood transfusion, or further intervention, were investigated. Patients with no adverse outcomes were deemed to have had a safe discharge. The area under the receiver-operating characteristic curve (AUROC) for the Oakland score and adverse outcome (and therefore safe discharge) were calculated. Results A total of 123 patients were included. These led to a total of 144 LGIB presentations to the hospital. Twenty-nine patients had an Oakland score of ≤8; 21 (72.4%)cases were initiallydischarged with four representations (19.0%) and eight (27.6%) were admitted although none of these suffered from any adverse outcomes. For those who scored ≤8, 25 (86.2%) were therefore deemed to have had a safe discharge. A total of 115 had a score >8; 43 (37.4%) were initiallydischarged, 72 (62.6%) admitted and 41 (35.7%) experienced at least one adverse outcome including 16 (13.9%) representations, 21 (18.3%) blood transfusions, three (2.6%) surgical interventions and one (0.9%) endoscopic haemostasis. Out of the 115 cases which scored >8, 74 (64.3%) were deemed to have had a safe discharge. The AUROC for safe discharge was 0.84. Conclusion The Oakland score seems to be a safe and reliable tool for identifying LGIB patients who could be safely discharged home without hospital intervention. However, further research is required to assess whether a score of >8 could be used as many patients with a higher score did not experience adverse outcomes.

Safety and Efficacy of Transcatheter Arterial Embolization for Lower Gastrointestinal Bleeding: A Single-center Experience with 112 Patients

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

Introduction: Colonic Diverticula are one of the most common findings in colonoscopies and are a common cause of lower GI bleed. They are most commonly seen in the large bowel - with 64% in the sigmoid colon, 8% in the descending colon or splenic flexure, 7% in the transverse colon, and 20% in the ascending colon or hepatic flexure. Small bowel diverticula are rare but they carry a risk of serious complications. This case report describes a 66 years old Male who presented to the emergency department with an acute lower GI bleed and was found to have a bleeding terminal ileum diverticulum, which was stopped with endoscopic intervention. Case Description/Methods: A 66 years old Male presented to the Hospital with an Acute Lower GI bleed with hemodynamic instability, for which a decision was made to obtain a CT Angiogram, that showed active bleeding into a diverticulum of the terminal ileum from a distal branch of the superior mesenteric artery. Colonoscopy was performed, and terminal ileum intubation showed a single small bleeding diverticulum. For Hemostasis, hemostatic clips were successfully placed, and there was no bleeding at the end of the procedure. The patient recovered uneventfully and had no further gastrointestinal bleeding. Discussion: Diverticulosis refers to the presence of small outpouchings that develop in the wall of the gastrointestinal tract. It is thought to be caused by abnormal intermittent high pressure in the colon due to muscle spasms or straining with stool at weak spots in the colon wall in the large intestine. An acquired diverticulum in the small intestine is a rare condition and may be a serious cause of lower GI bleed due to the technical difficulty with endoscopic intervention given its unusual anatomic location. Historically, approaches like changing the patient's position, attaching a transparent hood at the distal end have been tried. Hemostasis is usually achieved by injection, hemoclip, coagulation, thrombin spray, or combination. In the diverticula that are unable to be accessed by endoscopic intervention, other options include therapeutic angiography and embolization of the bleeding vessel or surgical treatment consisting of resection of the intestinal segment containing the diverticula. Thus, clinicians must be vigilant that although colonoscopy can define the cause in most patients with lower gastrointestinal bleeding, no bleeding site is identified in 10 %– 20 % of cases. In such cases, an important cause may be an incomplete workup that overlooked the ileocecal region.Figure 1.: Active Hemorrhage into a Diverticulum of the Terminal Ileum

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding

IntroductionThere are no unified criteria to risk stratify patients under 50 with lower gastrointestinal bleed (LGIB) for endoscopic investigations. We evaluated this cohort to identify predictors for significant bowel disease...

The use of vasopressin infusion or arterial embolization in the treatment of 87 patients with gastrointestinal hemorrhage is reviewed. A bleeding point was identified angiographically in 46 patients (53%), with a higher success rate in those with upper gastrointestinal hemorrhage (63%) than in those with lower (39%) gastrointestinal hemorrhage. Vasopressin infusion in 33 patients completely stopped hemorrhage in 14 and slowed hemorrhage pending surgery in another 5. Gelfoam embolization was successful as definitive therapy in 12 of 15 patients. Mortality as a result of hemorrhage or its sequelae was 40% in patients with upper gastrointestinal hemorrhage and 21% in those with lower gastrointestinal hemorrhage.

IntroductionGastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results.MethodsThe aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling.ResultsFourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (− 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03–2.93).ConclusionTXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system. This review contains 9 figures, 8 tables, and 103 references.

BackgroundThe drug treatment that patients receive for upper and lower gastrointestinal (GI) bleeds at surgical wards is not always in accordance with the guidelines. Patients sometimes stay on intravenous (IV)...

Introduction Lower gastrointestinal (LGI) bleeding is a frequent presentation to acute surgical teams. It can range in severity from mild to life-threatening, and most commonly presents with haematochezia. This data explores the implementation of the British Society of Gastroenterology’s guidelines at a District General Hospital lacking a management pathway for LGI bleeding. Method Data was collected on all patients presenting to the Emergency Department with per rectal (PR) bleeding. This was retrospectively collected from July to August 2023. Data collected included shock index at presentation, details for Oakland Scoring, hospital admission, complications, and follow up. Results All minor LGI bleeds (Oakland score of ≤8) were discharged with no readmission within 28 days. In July, four of 45 major bleeds were unstable, with one undergoing CT angiogram, compared to two of 27 in October with one undergoing CT angiogram. Of the 45 major bleeds in July, 32 were admitted (71.1%) and 13 were discharged (28.9 %), 5 without endoscopy. In October, 15 of 27 major bleeds were admitted (55.6%) and 12 discharged (44.4%), all with endoscopy. In July, three patients (23.1%) were re-admitted within 28 days, compared to one patient (8.3%) in October. Conclusions Despite integration efforts, there was minimal improvement in Oakland Scoring compliance, with many major LGI patients discharged. Nonetheless, all major bleed patients in cycle 2 had follow-up endoscopy organised and fewer patients were readmitted. This study could be improved upon with improved integration efforts for Oakland Scoring and Shock Index, such as providing the algorithm in a portable online format.