Outpatient management of obscure gastrointestinal bleeding:A new perspective in high-risk patients

Mid-gastrointestinal bleeding accounts for approximately 5%-10%of all gastrointestinal bleeding cases,and vascular lesions represent the most frequent cause.The rebleeding rate for these lesions is quite high(about 42%).We hereby recommend that scheduled outpatient management of these patients could reduce the risk of rebleeding episodes.

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding

BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.

Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices?A retrospective study

BACKGROUND Patients with left ventricular assist devices(LVADs)are at increased risk for recurrent gastrointestinal bleeding(GIB)and repeat endoscopic procedures.We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.AIM To evaluate for an association between endoscopic intervention and subsequent GIB.Secondary aims were to assess the frequency of GIB in our cohort,describe GIB presentations and sources identified,and determine risk factors for recurrent GIB.METHODS We conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011–December 2018 and assessed all hospital encounters for GIB through December 2019.We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed.We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.RESULTS In the cohort of 295 patients,97(32.9%)had at least one GIB hospital encounter.There were 238 hospital encounters,with 55.4%(132/238)within the first year of LVAD implantation.GIB resolved on its own by discharge in 69.8%(164/235)encounters.Recurrent GIB occurred in 55.5%(54/97)of patients,accounting for 59.2%(141/238)of all encounters.Of the 85.7%(204/238)of encounters that included at least one endoscopic evaluation,an endoscopic intervention was performed in 34.8%(71/204).The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant(odds ratio 1.18,P=0.58).CONCLUSION Patients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures.In this retrospective cohort study,adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB,thus suggesting the uniqueness of the LVAD population.A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.

Efficacy and safety of over-the-scope-clips in the therapy of acute nonvariceal upper gastrointestinal bleeding:Meta-analysis

BACKGROUND Acute nonvariceal upper gastrointestinal bleeding(ANVUGIB)is a frequent lifethreatening acute condition in gastroenterology associated with high morbidity and mortality.Over-the-scope-clip(OTSC)is a new endoscopic hemostasis technique,which is being used in ANVUGIB and is more effective.AIM To summarize and analyze the effects of the OTSC in prevention of recurrent bleeding,clinical success rate,procedure time,hospital stay,and adverse events in the treatment of ANVUGIB,to evaluate whether OTSC can replace standard endoscopic therapy as a new generation of treatment for ANVUGIB.METHODS The literature related to OTSC and standard therapy for ANVUGIB published before January 2023 was searched in PubMed,Web of Science,EMBASE,Cochrane,Google,and CNKI databases.Changes in recurrent bleeding(7 or 30 days),clinical results(clinical success rate,conversion rate to surgery,mortality),therapy time(procedure time,hospital stay),and adverse events in the OTSC intervention group were summarized and analyzed,and the MD or OR of 95%CI is calculated by Review Manager 5.3.RESULTS This meta-analysis involved 11 studies with 1266 patients.Total risk of bias was moderate-to-high.For patients in the OTSC group,7-and 30-days recurrent bleeding rates,as well as procedure time,hospital stay,and intensive care unit stay,were greatly inhibited.OTSC could significantly improve the clinical success rate of ANVUGIB.OTSC therapy did not cause serious adverse and was effective in reducing patient mortality.CONCLUSION OTSC may provide more rapid and sustained hemostasis,and thus,promote recovery and reduce mortality in patients with ANVUGIB.In addition,the safety of OTSC is assured.

Shared changes in angiogenic factors across gastrointestinal vascular conditions:A pilot study

BACKGROUND Neovascularisation is common to a variety of gastrointestinal(GI)disorders with differing aetiologies and presentations;usually affecting adults above 60 years.Shared angiogenic factors modulated by disease specific elements could be a common denominator and represent novel diagnostic and therapeutic targets.As yet,assessment of angiogenic factors across several GI vascular disorders associated with recurrent bleeding and anaemia has not been reported.AIM To assess serum levels of angiogenic factors in several intestinal vascular disorders.METHODS A case control study was performed in Tallaght University Hospital in patients with endoscopically proven small bowel angiodysplasia(SBA),portal hypertensive gastropathy(PHG),gastric antral vascular ectasia(GAVE)and nonbleeding,non-anaemic controls.Using enzyme-linked immunosorbent assay,concentrations of Angiopoietin 1(Ang-1),Ang-2 and vascular endothelial growth factor(VEGF)were measured from 2 serum tubes of blood following informed consent.The relative expression of Ang-1 and Ang-2 and Ang-1/2 ratio was calculated and compared between groups.Statistical analysis was applied using a t-test,and a P value of<0.05 was considered significant.RESULTS To date 44 samples were tested:10 SBA,11 PHG,8 GAVE and 15 controls.Mean age 60(range 20-85)years and 20(45%)were males.Controls were significantly younger(49 years vs 66 years,P=0.0005).There was no difference in VEGF levels between the groups(P=0.6).SBA,PHG and GAVE Ang-1 levels were similar and were significantly lower than controls,(P=0.0002,95%CI:241 to 701).Ang-2 levels were statistically higher in PHG and GAVE groups compared to controls(P= 0.01, 95%CI: 77.8 to 668) and as a result, also had a lower Ang-1/2 ratioscompared to controls. While SBA Ang-2 levels were higher than controls, this didnot reach statistical significance. Neither age nor haemoglobin level, which wassimilar between disease groups, could explain the difference. In addition, themedian Ang-1/Ang-2 ratio for all patients was found to be significantly lowercompared to controls, 8 vs 28 respectively, P = 0.001, 95%CI: -27.55 to -7.12.CONCLUSIONOur novel pilot study suggests common alterations in Ang-1 and Ang-2 levelsacross several GI vascular disorders. Differences in Ang-1/Ang-2 ratios amongvascular disorders compared to controls suggest disease-specific modulation.