Protons pump inhibitor treatment and lower gastrointestinal bleeding: Balancing risks and benefits

Proton pump inhibitors(PPIs) represent a milestone in the treatment of acid-related diseases, and are the mainstay in preventing upper gastrointestinal bleeding in high-risk patients treated with nonsteroidal antiinflammatory drugs(NSAIDs) or low-dose aspirin. However, this beneficial effect does not extend to the lower gastrointestinal tract. PPIs do not prevent NSAID or aspirin-associated lower gastrointestinal bleeding(LGB). PPIs may increase both small bowel injury related to NSAIDs and low-dose aspirin treatment and the risk of LGB. Recent studies suggested that altering intestinal microbiota by PPIs may be involved in the pathogenesis of NSAID-enteropathy. An increase in LGB hospitalization rates may occur more frequently in older patients with more comorbidities and are associated with high hospital resource utilization, longer hospitalization, and increased mortality. Preventive strategies for NSAID and aspirin-associated gastrointestinal bleeding should be directed toward preventing both upper and lower gastrointestinal damage. Future research should be directed toward identifying patients at low-risk for gastrointestinal events associated with the use of NSAIDs or aspirin to avoid inappropriate PPI prescribing. Alternatively, the efficacy of new pharmacologic strategies should be evaluated in high-risk groups, with the aim of reducing the risk of both upper and lower gastrointestinal bleeding in these patients.

Lower gastrointestinal bleeding: Association with Sevelamer use

Stercoral ulceration results from impaction of hard fecal mass on the colonic wall and is a relatively unknown cause of lower gastrointestinal bleeding. In this report, we describe a case of lower gastrointestinal bleeding due to stercoral ulceration resulting from Sevelamer, a drug which is commonly associated with constipation.

Accelerated Infliximab Induction for Severe Lower Gastrointestinal Bleeding in a Young Patient with Crohn’s Disease:A Case Report

BACKGROUND Severe lower gastrointestinal bleeding(SLGIB)is a rare complication of Crohn's disease(CD).The treatment of these patients is a clinical challenge.Monoclonal anti-TNFαantibody(IFX)can induce relatively fast mucosal healing.It has been reported for the treatment of SLGIB,but there are few reports on accelerated IFX induction in CD patients with SLGIB.CASE SUMMARY A 16-year-old boy with a history of recurrent oral ulcers for nearly 1 year presented to the Gastroenterology Department of our hospital complaining of recurrent periumbilical pain for more than 1 mo and having bloody stool 4 times within 2 wk.Colonoscopy showed multiple areas of inflammation of the colon and a sigmoid colon ulcer with active bleeding.Hemostasis was immediately performed under endoscopy.The physical examination of the patient showed scattered small ulcers in the lower lip of the mouth and small cracks in the perianal area.Combined with his medical history,physical examination,laboratory examinations with high C-reactive protein(CRP),platelet count(PLT),erythrocyte sedimentation rate(ESR)and fecal calprotectin levels,imaging examinations and pathology,a diagnosis of CD was taken into consideration.According to the pediatric CD activity index 47.5,methylprednisolone(40 mg QD)was given intravenously.The abdominal pain disappeared,and CRP,PLT,and ESR levels decreased significantly after the treatment.Unfortunately,he had a large amount of bloody stool again after 1 wk of methylprednisolone treatment,and his hemoglobin level decreased quickly.Although infliximab(IFX)(5 mg/kg)was given as a combination therapy regimen,he still had bloody stool with his hemoglobin level decreasing from 112 g/L to 80 g/L in a short time,so-called SLGIB.With informed consent,accelerated IFX(5 mg/kg)induction was given 7 days after initial presentation.The bleeding then stopped.Eight weeks after the treatment,repeat colonoscopy showed mucosal healing;thus far,no recurrent bleeding has occurred,and the patient is symptom-free.CONCLUSION This case highlights the importance of accelerated IFX induction in SLGIB secondary to CD,especially after steroid hormone treatment.

Disparities in colonoscopy utilization for lower gastrointestinal bleeding in rural vs urban settings in the United States

BACKGROUND Lower gastrointestinal bleeds(LGIB)is a very common inpatient condition in the United States.Gastrointestinal bleeds have a variety of presentations,from minor bleeding to severe hemorrhage and shock.Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB,there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings.AIM To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals.METHODS This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality.It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016.This study does not differentiate between acute and chronic LGIB and both are included in this study.The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds;the secondary outcome measures were in-hospital mortality,length of stay,and costs involved in those receiving colonoscopy for LGIB.Statistical analyses were all performed using STATA software.Logistic regression was used to analyze the utilization of colonoscopy and mortality,and a generalized linear model was used to analyze the length of stay and cost.RESULTS Our study found that 37.9%of LGIB patients at rural hospitals compared to approximately 45.1%at urban hospitals received colonoscopy,(OR=0.730,95%CI:0.705-0.7,P>0.0001).After controlling for covariates,colonoscopies were found to have a protective association with lower inhospital mortality[OR=0.498,95%CI:0.446-0.557,P<0.0001],but a longer length of stay by 0.72 d(95%CI:0.677-0.759 d,P<0.0001)and approximately$2199 in increased costs.CONCLUSION Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals,patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality.In both settings,benefit came at a cost of extended stay,and higher total costs.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

BACKGROUND Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding.Contrast extravasation is a prerequisite for successful embolization.Provocative angiography is helpful in the detection of elusive bleeding.AIM We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies,as well as the role of norepinephrine(NE)in unmasking bleeding.METHODS We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years.All patients had a positive shock index and needed intensive care.RESULTS In three of four patients,angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.CONCLUSION We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization.However,this statement must be confirmed in prospective studies.

Endoscopic hemostasis makes the difference:Angiographic treatment in patients with lower gastrointestinal bleeding

BACKGROUND The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment.However,a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability,and endoscopy does not achieve adequate hemostasis.Interventional radiology supplemented with catheter angiography(CA)and transarterial embolization have gained importance in recent times.AIM To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding(LGIB).METHODS We compared two groups of patients in a retrospective analysis.One group had been treated for more than 10 years with CA for LGIB(n=41).The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry(n=92).The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment.RESULTS Patients in the CA group had a higher shock index,a higher Glasgow-Blatchford bleeding score(GBS),lower serum hemoglobin levels,and more rarely achieved hemostasis in primary endoscopy.These patients needed more transfusions,had longer hospital stays,and had to undergo subsequent surgery more frequently(P<0.001).CONCLUSION Endoscopic hemostasis proved to be the crucial difference between the two patient groups.Primary endoscopic hemostasis,along with GBS and the number of transfusions,would permit a stratification of risks.After prospective confirmation of the present findings,the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Cecum Dieulafoy＇s Lesion Presenting with Recurrent Lower Gastrointestinal Bleeding： Case Report

Introduction： Gastrointestinal Dieulafoy＇s lesion is a rare entity, of unknown etiology, and corresponds to an arterial malformation at the submucosal space that can be a source of life-threatening hemorrhage. We report a case of a Cecum Dieulafoy＇s bleeding lesion that was managed endoscopically with a favorable outcome. Case report： Female, 70-year-old, diagnosed with type 2 diabetes, hypothyroidism, and chronic heart failure associated with rheumatic mitral stenosis, submitted to biological valve replacement in 2006 and with permanent atrial fibrillation using vitamin K antagonist anticoagulant for thrombosis prophylaxis. Her background includes a stroke in 2004 without any permanent disability. In 2016, the patient experienced voluptuous and painless lower gastrointestinal bleeding with severe acute anemia, requiring hospital admission, fluid resuscitation and blood transfusion. Urgent colonoscopy revealed a small reddish vascular malformation at the cecum with oozing active bleeding, about 3 mm in size. Initially argon plasma coagulation was performed with satisfactory and immediate hemostasis. One week later, she recurred with hematochezia. The lesion at the cecum was reassessed and it was possible to notice a large caliber vessel surrounded by a normal appearance mucosa, compatible with Dieulafoy＇s lesion and it was treated with an endoscopic clip placement with a good long-term response. Conclusion： Endoscopy is the method of choice for diagnosis of Dieulafuy＇s lesion and may provide efficient treatment with mechanical hemostasis such as endoclip placement with a high success rate.

Appendiceal bleeding caused by vascular malformation: A case report

BACKGROUND Acute lower gastrointestinal bleeding(LGIB)is a common occurrence in clinical practice.However,appendiceal bleeding is an extremely rare condition that can easily be overlooked and misdiagnosed.The preoperative detection of appen-diceal bleeding often poses challenges due to the lack of related guidelines and consensus,resulting in controversial treatment approaches.CASE SUMMARY We presented a case of a 33-year-old female who complained of hematochezia that had lasted for 1 d.Colonoscopy revealed continuous bleeding in the appen-diceal orifice.A laparoscopic appendectomy was performed immediately,and a pulsating blood vessel was observed in the mesangium of the appendix,accor-dingly,active bleeding into the appendicular lumen was considered.Pathological examination revealed numerous hyperplastic vessels in the appendiceal mucosa and dilated capillary vessels.CONCLUSION The preoperative detection of appendiceal bleeding is often challenging,colo-noscopy is extremely important,bowel preparation is not routinely recommend-ed for patients with acute LGIB or only low-dose bowel preparation is recom-mended.Laparoscopic appendectomy is the most appropriate treatment for appendiceal bleeding.

Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology

There are many causes of gastrointestinal bleeding(GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the "Gastro-Ped Bleed Team" of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition(SIGENP) carried out a systematic search on MEDLINE via Pub Med(http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: "upper GIB" and "pediatric" [all fields]; "lower GIB" and "pediatric" [all fields]; "obscure GIB" and "pediatric" [all fields]; "GIB" and "endoscopy" [all fields]; "GIB" and "therapy" [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, casecontrol studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.

Inverted Meckel's diverticulum as a cause of occult lower gastrointestinal hemorrhage

Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly,but rarely it can present with hemorrhage.Over the last few years inverted Meckel's diverticulum has been reported in the literature with increasing frequency as an occult source of lower gastrointestinal hemorrhage.Here,we report a case of a 54-year-old male,who was referred for surgical evaluation with persistent anemia and occult blood per rectum after a work up which failed to localize the source over 12 mo,including upper and capsule endoscopy,colonoscopy,enteroclysis,Meckel scan,and tagged nuclear red blood cell scan.An abdominal computed tomography scan showed a possible mid-ileal intussusception and intraluminal mass.During the abdominal exploration,inverted Meckel's diverticulum was diagnosed and resected.We review the literature,discuss the forms in which the disease presents,the diagnostic modalities utilized,pathological findings,and treatment.Although less than 40 cases have been reported in the English literature from 1978 to 2005,19 cases have been reported in the last 6 years alone(2006-2012) due to improved diagnostic modalities.Successful diagnosis and treatment of this disease requires a high index of clinical suspicion,which is becoming increasingly relevant to general gastroenterologists.

Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage

Gastrointestinal stromal tumor is rare, which arises from the mesenchymal tissues in the gastrointestinal tract, and it is extremely rare in the appendix. Only a few cases have been found in this location to date. Although the annual incidence of lower gastrointestinal bleeding has been increasing, bleeding related to the appendix is quite rare. We herein present a very rare case of gastrointestinal stromal tumor incidentally found by appendiceal hemorrhage.

Bladder urothelial carcinoma extending to rectal mucosa and presenting with rectal bleeding

An 87-year-old-man with prostate-cancer-stage-T1cGleason-6 treated with radiotherapy in 1996, recurrent prostate cancer treated with leuprolide hormonal therapy in 2009, and bladder-urothelial-carcinoma in situ treated with Bacillus-Calmette-Guerin and adriamycin in 2010, presented in 2015 with painless, bright red blood per rectum coating stools daily for 5 mo. Rectal examination revealed bright red blood per rectum; and a hard, fixed, 2.5 cm × 2.5 cm mass at the normal prostate location. The hemoglobin was 7.6 g/d L(iron saturation = 8.4%,indicating iron-deficiency-anemia). AbdominopelvicCT-angiography revealed focal wall thickening at the bladder neck; a mass containing an air cavity replacing the normal prostate; and adjacent rectal invasion. Colonoscopy demonstrated an ulcerated, oozing, multinodular, friable, 2.5 cm × 2.5 cm mass in anterior rectal wall, at the usual prostate location. Histologic and immunohistochemical analysis of colonoscopic biopsies of the mass revealed poorly-differentiatedcarcinoma of urothelial origin. At visceral angiography, the right-superior-rectal-artery was embolized to achieve hemostasis. The patient subsequently developed multiple new metastases and expired 13 mo postembolization. Comprehensive literature review revealed 16 previously reported cases of rectal involvement from bladder urothelial carcinoma, including 11 cases from direct extension and 5 cases from metastases. Patient age averaged 63.7 ± 9.6 years(all patients male). Rectal involvement was diagnosed on average 13.5 ± 11.8 mo after initial diagnosis of bladder urothelial carcinoma. Symptoms included constipation/gastrointestinal obstruction-6, weight loss-5, diarrhea-3, anorexia-3, pencil thin stools-3, tenesmus-2, anorectal pain-2, and other-5. Rectal examination in 9 patients revealed annular rectal constriction-6, and rectal mass-3. The current patient had the novel presentation of daily bright red blood per rectum coating the stools simulating hemorrhoidal bleeding; the novel mechanism of direct bladder urothelial carcinoma extension into rectal mucosa via the prostate; and the novel aforementioned colonoscopic findings underlying the clinical presentation.

Current state of practice for colonic diverticular bleeding in 37 hospitals in Japan:A multicenter questionnaire study

AIMTo clarify the current state of practice for colonic diverticular bleeding(CDB)in Japan.METHODSWe conducted multicenter questionnaire surveys of the practice for CDB including clinical settings(8 questions),diagnoses(8 questions),treatments(7 questions),and outcomes(4 questions)in 37 hospitals across Japan.The answers were compared between hospitals with high and low number of inpatient beds to investigate which factor influenced the answers.RESULTSEndoscopists at all 37 hospitals answered the questions,and the mean number of endoscopists at these hospitals was 12.7.Of all the hospitals,computed tomography was performed before colonoscopy in 67%of the hospitals.The rate of bowel preparation was 46.0%.Early colonoscopy was performed within 24 h in 43.2%of the hospitals.Of the hospitals,83.8%performed clipping as first-line endoscopic therapy.More than half of the hospitals experienced less than 20%rebleeding events after endoscopic hemostasis.No significant difference was observed in the annual number of patients hospitalized for CDB between high-(&ge;700 beds)and low-volume hospitals.More emergency visits(P=0.012)and endoscopists(P=0.015),and less frequent participation of nursing staff in early colonoscopy(P=0.045)were observed in the high-volume hospitals.CONCLUSIONSome practices unique to Japan were found,such as performing computed tomography before colonoscopy,no bowel preparation,and clipping as first-line therapy.Although,the number of staff differed,the practices for CDB were common irrespective of hospital size.

Colonic Bleeding Due to Histoplasma and Mycobacterium Coinfection in Renal Transplant Patient

Introduction： Histoplasmosis is a rare infectious condition caused by the fungus Histoplasma capsulatum that can be presented from asymptomatic to severe forms. Tuberculosis, still an endemic infection in some developing countries, can also have variable clinical presentations. Both diseases involve the lungs mostly, but in immunocompromised patients, especially those with advanced HIV infection and transplant patients, disseminated forms are more frequently found. Gastrointestinal involvement is unusual, and digestive bleeding is an even rarer complication. Case presentation： We report the case of a 39-year-old female who was diagnosed with a Mycobacterium tuberculosis and Histoplasma capsulatum coinfection occurring 11 years after a living-donor-related renal transplant. The patient presented a severe gastrointestinal bleeding caused by an ulcer in the ascending colon. She improved after a combined treatment with tuberculostatic and fungicidal drugs. Conclusions： Simultaneous gastrointestinal involvement by histoplasmosis and tuberculosis, presenting as severe digestive bleeding, with minimal respiratory symptoms associated, make this an extremely rare case and a diagnostic challenge. Therefore, it is important to keep a high clinical suspicion of opportunistic infection, especially in immunocompromised patient who presents with LGB.

Rupture of abdominal aortic aneurysm into sigmoid colon:A case report

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day.

Spontaneous aortic pseudoaneurysm rupture into the sigmoid colon in Behcet's disease patient

Beh?et's disease(BD) is a multisystem autoimmune disorder characterized by recurrent orogenital ulcers,uveitis,and skin lesions. The vascular manifestations include thrombophlebitis,stenosis,occlusion,and pseudoaneurysm. BD infrequently precipitates aortic pseudoaneurysm rupture into the sigmoid mesocolon and lumen of the adjacent colon. Here we report an extremely rare case of spontaneous abdominal aortic pseudoaneurysm rupture via the sigmoid mesocolon into the lumen of the sigmoid colon in a 37-year-old patient with BD.

Early colonoscopy in patients with acute diverticular bleeding is associated with improvement in healthcare-resource utilization

Background:Diverticular bleeding(DB)is the most common cause of severe acute lower gastrointestinal bleeding(GIB)in developed countries.The role of early colonoscopy(<24 hours)continues to remain controversial and data on early colonoscopy in acute DB are scant.We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample.Methods:Data from the nationwide inpatient sample from 2012 to 2014 were used.The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection.We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding.Discharges with no primary or secondary diagnosis of diverticulosis with bleeding,diverticulitis with bleeding,patients who were less than 18 years old and those who did not undergo colonoscopy during the admission were excluded.The primary outcomes were length of stay(LOS)and total hospitalization costs.Results:A total of 88600 patients were included in our analysis,amongstwhom 45020(50.8%)had colonoscopy within 24hours of admission(early colonoscopy),while 43580(49.2%)patients had colonoscopy after 24hours of admission(late colonoscopy).LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy(3.7 vs 5.6days,P<0.0001).Total hospitalization costs were also significantly lower in patients with early colonoscopy($9317 vs$11767,P<0.0001).There was no difference inmortality between both groups(0.7 vs 0.8%).After adjusting for potential confounders,the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant.Conclusions:Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs.There was no significant difference inmortality observed.Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications.Further research is needed to identify which patients would benefit from early colonoscopy in DB.