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Connell NT, Caicedo J, Nieto N, Chatterjee S, Hait A, Gupta AK, Bullano M, Schultz BG. Real-world healthcare costs and resource utilization in patients with von Willebrand disease and angiodysplasia. Expert Rev Pharmacoecon Outcomes Res 2023:1-9. [PMID: 37183836 DOI: 10.1080/14737167.2023.2211270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To describe the economic burden among VWD patients with angiodysplasia compared to VWD patients without angiodysplasia and the general population. METHODS This was a retrospective analysis using the Merative MarketScan Commercial and Medicare Databases® (January 2011-September 2020). Selected patients had ≥1 medical claim for VWD or low VWF, ≥1 medical claim for AGD, and ≥3 GI-related bleeding episodes within a year. HCRU and all-cause costs were compared with the VWD (only) and the general cohorts. RESULTS The mean total all-cause costs were $150,101 among patients with VWD and angiodysplasia (n = 34), higher compared to $48,249 among matched VWD patients without angiodysplasia (n = 136) and $31,029 among matched individuals of the general population [n = 136; p-value < 0.0001]. The differences in costs between groups were primarily due to inpatient care. During the 12-month follow-up, VWD patients with symptomatic (n = 35), asymptomatic (n = 81), and suspected (n = 378) angiodysplasia had an average of 4.1, 0.6, and 3.8 gastrointestinal (GI) bleeds, respectively. Desmopressin, VWF concentrates, and aminocaproic acid were the most frequent treatments used. The most frequent procedures to treat GI-related bleeding and underlying lesions were blood transfusion and laser therapy. CONCLUSIONS Despite recent therapeutic advances, there is room for considerable reduction of the disease burden in patients with VWD and angiodysplasia.
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Affiliation(s)
- N T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J Caicedo
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - N Nieto
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | | | - A Hait
- Complete HEOR Solutions, North Wales, PA, USA
| | - A K Gupta
- Complete HEOR Solutions, North Wales, PA, USA
| | - M Bullano
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - B G Schultz
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
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Efficacy of pharmacologic treatment for treating gastrointestinal angiodysplasias-related bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2022; 34:1021-1030. [PMID: 35913758 DOI: 10.1097/meg.0000000000002414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION We evaluated the efficacy of pharmacologic treatments for patients with overt or occult bleeding due to gastrointestinal angiodysplasias (GIADs). METHODS A systematic computer-aided literature search across Medline, Cochrane, Scopus and Embase databases was performed. Studies evaluating pharmacologic treatments for patients presenting with GIADs-related overt or occult bleeding were included. Post-treatment rebleeding was the primary outcome. Need for red blood cells (RBC) transfusion, post-treatment hemoglobin levels and adverse events rate comprised secondary outcomes. Results are presented as odds ratio (OR), mean difference (MD) or pooled rates (%) with 95% confidence intervals (95%CI). RESULTS Four types of pharmacologic treatment were identified (25 studies): somatostatin analogs, hormonal therapy, thalidomide and angiogenesis inhibitors. Pharmacologic treatment of any kind led to significantly reduced bleeding episodes [OR (95% CI), 0.08 (0.04-0.18)]. No pharmacologic treatment was superior to others ( P = 0.46). Overall, pooled rebleeding rate post-treatment was 34% (26-43%). Similarly, significantly fewer patients required RBC transfusion during the post-treatment period [0.03 (0.03-0.07)], with no differences among various treatments ( P = 0.83), yielding an overall pooled transfusion rate of 33% (19-46%). Administration of pharmacological treatment led to significant improvement in terms of hemoglobin levels [MD (95% CI), 3.21 g/dL (2.42-3.99)]. The pooled rate of adverse events was 32% (22-42%). CONCLUSION In patients with GIADs administration of any pharmacologic treatment significantly decreases rebleeding episodes and transfusions leading to higher hemoglobin values. One-third of them experience at least one adverse event related to the treatment.
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Khan A, Gupta K, Chowdry M, Sharma S, Maheshwari S, Patel C, Naseem K, Pervez H, Bilal M, Ali Khan M, Singh S. Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA. Eur J Gastroenterol Hepatol 2022; 34:11-17. [PMID: 33405425 DOI: 10.1097/meg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. AIM The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. METHODS We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. RESULTS A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. CONCLUSION Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.
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Affiliation(s)
- Ahmad Khan
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Kamesh Gupta
- Department of Medicine, UMass Medical Center, Springfield, Massachusetts
| | - Monica Chowdry
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Sachit Sharma
- Department of Medicine, The Toledo Hospital, Toledo, Ohio
| | | | - Chirag Patel
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Khadija Naseem
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Hira Pervez
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Bilal
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Muhammad Ali Khan
- Division of Gastroenterology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Belov DV, Garbuzenko DV, Lukin OP, Anufrieva SS. Heyde’s syndrome as a rare cause of gastrointestinal bleeding in aortic stenosis patients. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- D. V. Belov
- Federal Center for Cardiovascular Surgery; South Ural State Medical University
| | | | - O. P. Lukin
- Federal Center for Cardiovascular Surgery; South Ural State Medical University
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Li S, Oshea B, Sun S. Special considerations in the management of lower GI bleed by interventional radiology. J Interv Med 2019; 2:101-105. [PMID: 34805880 PMCID: PMC8562260 DOI: 10.1016/j.jimed.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Despite the rapid development of diagnostic and therapeutic modalities and techniques to manage LGIB patients from interventional radiology's standpoint, a successful localization of the bleeding site that leads to an effective embolotherapy remains a significant technical challenge. The interventional radiologist's decisions when managing patients with LGIB may significantly impact the clinical outcomes; therefore, management should be made based on careful and thorough considerations of factors such as etiology, locations, patient's comorbidities, and potential post-procedure complications, among others. The purpose of this paper is to review the management of LGIB by interventional radiology, focusing on a few challenging and common clinical situations that require special consideration by interventional radiologists.
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Affiliation(s)
- Shihong Li
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
| | - Brendan Oshea
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
| | - Shiliang Sun
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
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Risk factors for incidentally detected and symptomatic angiodysplasias: a case-control study with the general population as reference. Eur J Gastroenterol Hepatol 2019; 31:458-462. [PMID: 30562184 DOI: 10.1097/meg.0000000000001335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is no literature on risk factors for incidentally found angiodysplasias. In clinical practice, endoscopists may defer treatment owing to uncertainty about a causal role of any found angiodysplasia and overt or occult bleeding. The objective is to identify risk factors that distinguish incidental angiodysplasias from angiodysplasias that are the cause of symptomatic bleeding. PARTICIPANTS AND METHODS A case-control study was conducted to compare angiodysplasia groups and a random sample from the general population. Patients with angiodysplasia were diagnosed between 2010 and 2015. Controls were from a 2005 population survey. Determinants were demographics, past medical history, lifestyle, medication and angiodysplasia characteristics. Multivariable logistic regression analyses were performed to identify independent risk factors. RESULTS A total of 270 (59% men, mean age 65 years) patients with angiodysplasia and 5594 (46% men, mean age 58 years) controls were included in this study. Independent risk factors for incidental angiodysplasias are male sex [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.02-2.6], thyroid dysfunction (OR: 4.1; 95% CI: 2.0-8.4), autoimmune disease (OR: 2.3; 95% CI: 1.2-4.1), chronic obstructive pulmonary disease (OR: 1.8; 95% CI: 1.0-3.2), and blood thinners (OR: 2.8; 95% CI: 1.6-4.8). Besides angiodysplasia characteristics, factors independently associated with symptomatic angiodysplasias are increased age (OR: 1.7/10 years age band; 95% CI: 1.3-2.5), valvular heart disease (OR: 10.4; 95% CI: 1.6-69.2), diabetes mellitus (OR: 2.6; 95% CI: 1.03-6.7) and hyperlipidemia (OR: 3.7; 95% CI: 1.1-12.1). CONCLUSION The risk factor profile for incidental angiodysplasias differs from symptomatic angiodysplasias and is more profound for the latter. This knowledge could help endoscopists in the decision-making process to treat an endoscopically detected angiodysplasia.
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Fok KY, Murugesan JR, Maher R, Engel A. Management of per rectal bleeding is resource intensive. ANZ J Surg 2019; 89:E113-E116. [PMID: 30887672 DOI: 10.1111/ans.15149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Haematochezia or per rectal (PR) bleeding is the most common presentation of lower gastrointestinal bleeding. This study analyses the hospital resources used in the management of patients with PR bleeding. METHODS A retrospective analysis was performed on patients who presented with PR bleeding from June 2012 to December 2013 to a single tertiary centre in Sydney, Australia. Age, gender, comorbidities, use of antiplatelet or anticoagulant medications, vital signs, and haematological data were recorded. The objective factors available on initial patient assessment were analysed for their relationship with the following outcomes: use of computed tomography mesenteric angiogram, formal angiography and embolization, transfusion of blood products, endoscopy, operative management and length of stay. RESULTS There were 523 confirmed presentations of PR bleeding. Four hundred and fifty-two of these presented directly to emergency department, while 71 were referred from another hospital. One in five patients had blood transfusion (19%), 13% had computed tomography mesenteric angiogram, 4% had embolization and 13% underwent diagnostic and/or therapeutic colonoscopy. Patients referred from other facilities were more comorbid (55% versus 30%), more likely to be on antiplatelet or anticoagulant (69% versus 33%) with a higher rate of embolization (28% versus 4%), more packed cell transfusions (2.1 versus 0.7 units) and longer length of stay (7.9 versus 5.7 days) but mortality was the same (1%). CONCLUSIONS The management of patients with PR bleeding is resource intensive. Better identification and allocation of resources in patients who present with PR bleeding may lead to better efficiency in managing this growing clinical problem.
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Affiliation(s)
- Kar Yin Fok
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jothi R Murugesan
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Richard Maher
- Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alexander Engel
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
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Abstract
Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.
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Affiliation(s)
- Grainne Holleran
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
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Mohee K, Aldalati O, Dworakowski R, Haboubi H. Aortic stenosis and anemia with an update on approaches to managing angiodysplasia in 2018. Cardiol J 2018; 27:72-77. [PMID: 30009379 DOI: 10.5603/cj.a2018.0068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/11/2018] [Indexed: 11/25/2022] Open
Abstract
Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.
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Affiliation(s)
- Kevin Mohee
- Department of Cardiology, ABMU Health Board, Morriston Hospital, Swansea, SA6 6NL Swansea, United Kingdom
| | | | - Rafal Dworakowski
- Kings College London, London, United Kingdom. .,Department of Cardiology, Medical University of Gdansk, Poland.
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Nardone G, Compare D, Martino A, Rocco A. Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis 2018; 50:542-548. [PMID: 29610020 DOI: 10.1016/j.dld.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
Angioectasias (AD) belong to benign vascular malformations of the gastrointestinal tract and are responsible for about 4-7% of upper non variceal bleeding, 30-40% of small bowel occult bleeding and 3-40% of colonic bleeding episodes. Gastrointestinal haemorrhage secondary to AD represents an important diagnostic and therapeutic problem that negatively impacts on the quality of life of patients and heath care costs. Endoscopic interventions are the mainstay in both diagnosis and treatment of vascular malformations. However, in a substantial percentage of the cases, age of the patients, comorbidities, clinical severity of anaemia and blood loss as well as size, site and number of lesions prevent this therapeutic approach. Hormonal therapy, thalidomide and somatostatin analogues have been investigated for their potential role as rescue therapies in controlling AD bleeding although, thus far, no recommendations have been provided on their use in this clinical setting. In order to implement appropriate prescription of pharmacological agents to manage gastrointestinal bleeding due to ADs, the Italian Society of Gastroenterology (SIGE) nominated a panel of experts who reviewed the available clinical literature and produced practical clinical recommendations.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alberto Martino
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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Benamouzig R, Benallaoua M, Saurin JC, Boubaya M, Cellier C, Laugier R, Vincent M, Boustière C, Gincul R, Samaha E, Grandval P, Aparicio T, Airinei G, Bejou B, Bon C, Raynaud JJ, Levy V, Sautereau D. Efficacy and safety of pasireotide-LAR for the treatment of refractory bleeding due to gastrointestinal angiodysplasias: results of the ANGIOPAS multicenter phase II noncomparative prospective double-blinded randomized study. Therap Adv Gastroenterol 2018; 11:1756283X18756260. [PMID: 29479375 PMCID: PMC5818089 DOI: 10.1177/1756283x18756260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/31/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding. METHODS A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg (n = 10) or placebo (n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment. RESULTS The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0-26) and 11.5 pRBC units in the placebo group (range 0-23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes. CONCLUSION This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.
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Affiliation(s)
| | | | | | | | | | - René Laugier
- Gastroenterology Unit, Timone Hospital, Marseille, France
| | | | | | - Rodica Gincul
- Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Elia Samaha
- Gastroenterology Unit, Georges-Pompidou Hospital, Paris, France
| | | | | | | | - Bakhtiar Bejou
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | - Cyriaque Bon
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | | | - Vincent Levy
- Clinical Research Unit, Avicenne Hospital, Bobigny, France
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12
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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13
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Abstract
BACKGROUND Small bowel angiodysplasias (SBA) account for 50% of obscure gastrointestinal bleeding. Lesions bleed recurrently and current treatments are relatively ineffective at reducing re-bleeding. Little is known about the natural history of SBA which is needed to guide treatment decisions and counsel patients on prognosis. AIM The aim of this study is to describe the natural history of a cohort of patients with SBA. METHODS Patients with SBA were identified retrospectively and clinical and outcome information were collected. Logistic regression analysis was performed to identify factors associated with re-bleeding. RESULTS SBAs were found in 86 patients of which 54% (n = 47) were female, and the average age was 71.6 years. The majority (69%) had multiple lesions, mean of 2.76/patient, and 65% were located in the jejunum. Follow-up was available in 65% (n = 56). There was a significant increase in haemoglobin level from 10.05g/dL to 11.94g/dL, p < 0.001 after mean follow up of 31.9 (6-62) months. Re-bleeding events occurred in 80% (n = 45), with an average of 2.91/person. The mean interval between diagnosis and the first re-bleeding event was 10.7 months. Of the group overall, 70% (n = 40) required transfusions during follow up, and 67% required hospitalisation due to re-bleeding. About 50% received a directed treatment, including argon plasma coagulation, somatostatin analogues, or surgical resection. A total of 3.5% (n = 2) died as a direct consequence of bleeding from SBAs. Multiple lesions (p = 0.048) and valvular heart disease (p = 0.034) were predictive of re-bleeding. CONCLUSION Our results show the significant impact of SBA on patients' morbidity, with high rates of re-bleeding, persistent anaemia and a mortality rate of 3.5%, despite the use of currently available medical and endoscopic therapies.
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Affiliation(s)
- Grainne Holleran
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Barry Hall
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Lina Zgaga
- b Department of Public Health and Primary Care , Trinity College Dublin , Ireland
| | - Niall Breslin
- c Department of Gastroenterology , Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
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14
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Grooteman KV, van Geenen EJM, Drenth JPH. Multicentre, open-label, randomised, parallel-group, superiority study to compare the efficacy of octreotide therapy 40 mg monthly versus standard of care in patients with refractory anaemia due to gastrointestinal bleeding from small bowel angiodysplasias: a protocol of the OCEAN trial. BMJ Open 2016; 6:e011442. [PMID: 27619827 PMCID: PMC5030574 DOI: 10.1136/bmjopen-2016-011442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Gastrointestinal angiodysplasias are an important cause of difficult-to-manage bleeding, especially in older patients. Endoscopic coagulation of angiodysplasias is the mainstay of treatment, but may be difficult for small bowel angiodysplasias because of the inability to reach them for endoscopic intervention. Some patients are red blood cell (RBC) transfusion dependent due to frequent rebleeding despite endoscopic treatment. In small cohort studies, octreotide appears to decrease the number of bleeding episodes in patients with RBC transfusion dependency due to gastrointestinal angiodysplasias. This trial will assess the efficacy of octreotide in decreasing the need for RBC transfusions and parenteral iron in patients with anaemia due to gastrointestinal bleeding of small bowel angiodysplasias despite endoscopic intervention. STUDY DESIGN Randomised controlled, superiority, open-label multicentre trial. PARTICIPANTS 62 patients will be included with refractory anaemia due to small bowel angiodysplasias, who are RBC transfusion or iron infusion dependent despite endoscopic intervention and oral iron supplementation. INTERVENTION Patients will be randomly assigned (1:1) to standard care or 40 mg long-acting octreotide once every 4 weeks for 52 weeks, in addition to standard care. The follow-up period is 8 weeks. MAIN OUTCOME MEASURES The primary outcome is the difference in the number of blood and iron infusions between the year prior to inclusion and the treatment period of 1 year. Important secondary outcomes are the per cent change in the number of rebleeds from baseline to end point, adverse events and quality of life. ETHICS AND DISSEMINATION The trial received ethical approval from the Central Committee on Research Involving Human Subjects and from the local accredited Medical Research Ethics Committee of the region Arnhem-Nijmegen, the Netherlands (reference number: 2014-1433). Results will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER NCT02384122; Pre-results.
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Affiliation(s)
- K V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Nelson KK, Lipka S, Davis-Yadley AH, Rodriguez AC, Doraiswamy V, Rabbanifard R, Kumar A, Brady PG. Timing of single balloon enteroscopy: significant or not? Endosc Int Open 2016; 4:E761-6. [PMID: 27556093 PMCID: PMC4993889 DOI: 10.1055/s-0042-108189] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 04/20/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The development of balloon assisted enteroscopy (BAE) has revolutionized diagnostic and therapeutic modalities for small-bowel disorders. Although the role of emergent esophagogastroduodenoscopy and colonoscopy for upper and lower gastrointestinal bleeding is well defined, there is scarce data with regard to emergent BAE for gastrointestinal bleeding. STUDY We performed a retrospective cohort study including 110 hospitalized patients with obscure gastrointestinal bleeding who underwent single balloon enteroscopy (SBE) between January 2010 and August 2013. Patients were divided into two groups based on procedures performed emergently (within 24 hours) versus non-emergently (greater than 24 hours). Data on patient demographics, hemodynamic characteristics, type of obscure bleed, lesions identified, location of lesions, endoscopic intervention performed, need for further surgical or radiological intervention, diagnostic and therapeutic yield, and adverse events were compared between groups. Independent samples t test and Fisher's exact test were used to assess the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and 95 % confidence intervals (CI), and for binary as odds ratio and 95 %CI. RESULTS Although patients in the group where enteroscopy was performed within 24 hours had a significantly higher incidence of radiological intervention (10.0 % vs. 0.0 %, P = 0.019), the diagnostic and therapeutic yields between the two groups were not significantly different. Additionally, there were no statistically significant differences between the groups for overt and occult bleeding, transfusion requirements, type and location of lesions, endoscopic intervention performed, or adverse events. Hospital stay was shorter in the patients who had SBE within 24 hours of admission (6.2 vs. 11.3 days, P < 0.001). CONCLUSIONS Although the diagnostic and therapeutic yields of SBE were not significantly different between patients having the procedure within 24 hours and those having it later, the early SBE group required more interventional radiology procedures. While endoscopists may not necessarily have to perform emergent assessment within 24 hours in patients with obscure gastrointestinal bleeding (OGIB) for greater diagnostic or therapeutic yield, early intervention may allow for earlier stabilization and thus shorter hospital stays. Prospective studies further evaluating these findings are indicated.
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Affiliation(s)
- Kirbylee K. Nelson
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA,Corresponding author Kirbylee K. Nelson, MD Department of Internal MedicineUniversity of South Florida Morsani College of Medicine12901 Bruce B. Downs BlvdTampaFL 33612USA+1-813-259-0697
| | - Seth Lipka
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ashley H. Davis-Yadley
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Andrea C. Rodriguez
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | - Roshanak Rabbanifard
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ambuj Kumar
- Department of Evidence Based Medicine and Outcomes Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Patrick G. Brady
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Fujishiro M, Iguchi M, Kakushima N, Kato M, Sakata Y, Hoteya S, Kataoka M, Shimaoka S, Yahagi N, Fujimoto K. Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding. Dig Endosc 2016; 28:363-378. [PMID: 26900095 DOI: 10.1111/den.12639] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 01/10/2023]
Abstract
Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.
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Affiliation(s)
| | | | | | - Motohiko Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shu Hoteya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Lee J, Hwang SW, Kim J, Kang J, Kang GH, Park KJ, Im JP, Kim JS. Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding. Clin Endosc 2016; 49:91-6. [PMID: 26855931 PMCID: PMC4743715 DOI: 10.5946/ce.2016.49.1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/16/2015] [Accepted: 07/03/2015] [Indexed: 12/29/2022] Open
Abstract
Angiodysplasia (AD) is increasingly being recognized as a major cause of gastrointestinal bleeding. Morphologically flat lesions are common types of AD, whereas the polypoid types are rare. We report a case of multiple polypoid AD in the small bowel causing severe anemia and requiring surgical treatment. A 60-year-old male patient visited our hospital with dyspnea and hematochezia. He had a history of myocardial infarction and was taking both aspirin and clopidogrel. Capsule endoscopy, enteroscopy, computed tomography, and angiography revealed multifocal vascular lesions with a polypoid shape in the jejunum. Surgical resection was performed because endoscopic treatment was considered impossible with the number and the location of lesions. The risk of recurrent bleeding related to the use of antiplatelet agents also contributed to the decision to perform surgery. AD was histologically diagnosed from the surgical specimen. He resumed taking both aspirin and clopidogrel after surgery. He fully recovered and has been doing well during the several months of follow-up.
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Affiliation(s)
- Jooyoung Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihye Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Gyeong Hoon Kang
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.
METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.
RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.
CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
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Compagna R, Serra R, Sivero L, Quarto G, Vigliotti G, Bianco T, Rocca A, Amato M, Danzi M, Furino E, Milone M, Amato B. Tailored treatment of intestinal angiodysplasia in elderly. Open Med (Wars) 2015; 10:538-542. [PMID: 28352751 PMCID: PMC5368880 DOI: 10.1515/med-2015-0091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 11/04/2015] [Indexed: 01/10/2023] Open
Abstract
Background Angiodysplasia of the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and severe anemia in elderly. Different treatments exist for this kind of pathology. Methods The aim of this work was to study 40 patients treated for intestinal angiodysplasia with two different kind of endoscopic treatments: argon plasma coagulation (APC) and bipolar electrocoagulation (BEC). Results Age of patients was similar in both groups (76,2 ± 10.8 years vs 74,8 ± 8,7 years, P = 0,005). Angiodysplasia treated were located in small bowel, right colon, left colon, transverse colon and cecum. We analysed number of treatment, recurrence, hospital discharge, needs of blood transfusions before and after endoscopic treatment. Number of treatment was the same in both groups (1,2 ± 0,2 vs 1,1 ± 0,1, P < 0,001). We had more recurrence in patients treated with BEC (4/20 vs 2/20, P < 0,001). Hospital discharge was comparable in both groups (5,3 ± 3,1 days vs 5,4 ± 2,8 years, P < 0.001) Conclusions Treatment of angiodysplasia in elderly is not easy. Different kinds of treatment could be adopted. APC and BEC are both safe and effective. The choice of a treatment should consider several factors: age, comorbidity, source of bleeding. In conclusion we think that treatment of bleeding for angiodysplasia in elder population should be a tailored treatment.
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Affiliation(s)
- Rita Compagna
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy ; Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy .; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy ; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Luigi Sivero
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Gennaro Quarto
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Gabriele Vigliotti
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Tommaso Bianco
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Aldo Rocca
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Michele Danzi
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Ermenegildo Furino
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Via S. Pansini,5 - 80131 Napoli, Italy . Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro. Catanzaro, Italy ; Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy
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20
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Holleran G, Hall B, Breslin N, McNamara D. Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial. United European Gastroenterol J 2015; 4:70-6. [PMID: 26966525 DOI: 10.1177/2050640614559121] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/12/2014] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Small bowel angiodysplasias account for over 50% of causes of small bowel bleeding and carry a worse prognosis than lesions located elsewhere in the gastrointestinal tract. Re-bleeding rates are high even after first-line endoscopic therapy and are associated with high levels of morbidity for affected patients. Small trials of long-acting somatostatin analogues have shown promising results but have not yet been assessed in patients with refractory small bowel disease. AIM The purpose of this study was to assess the effect of long-acting somatostatin analogues in reducing re-bleeding rates and transfusion requirements, and improving haemoglobin levels in patients with refractory small bowel angiodysplasia. METHODS Patients with refractory small bowel angiodysplasia were treated with 20 mg of long-acting octreotide for a minimum of three months. Response was assessed according to: rates of re-bleeding, haemoglobin levels, transfusion requirements, and side effects. RESULTS A total of 24 patients were initially treated and 20 received at least three doses. Rates of complete, partial and non-response were 70%, 20% and 10% respectively. Average haemoglobin rates increased from 9.19 g/dl to 11.35 g/dl (p = 0.0027, 95% confidence interval (CI) -3.5 to -1.1) in the group overall and 70% remained transfusion-free after a mean treatment duration of 8.8 months. The rate of adverse events was higher than previously reported at 30%. CONCLUSION Long-acting somatostatin analogues offer a therapeutic advantage in a significant proportion of patients with small bowel angiodysplasia. With careful patient selection and close observation, a long-acting somatostatin analogue should be considered in all patients with persistent anaemia attributable to refractory disease in conjunction with other standard treatments.
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Affiliation(s)
- Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Barry Hall
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Niall Breslin
- Department of Gastroenterology, Tallaght Hospital, Dublin, Ireland
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
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21
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Yamada A, Niikura R, Kobayashi Y, Suzuki H, Yoshida S, Watabe H, Yamaji Y, Hirata Y, Koike K. Risk factors for small bowel angioectasia: The impact of visceral fat accumulation. World J Gastroenterol 2015; 21:7242-7247. [PMID: 26109811 PMCID: PMC4476886 DOI: 10.3748/wjg.v21.i23.7242] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 01/25/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate visceral fat accumulation in association with the risk of small bowel angioectasia.
METHODS: We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding (OGIB) from January 2009 to September 2013. The visceral fat area (VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records. Logistic regression analysis was used to evaluate associations.
RESULTS: Capsule endoscopy revealed small bowel angioectasia in 18/198 (9.1%) patients with OGIB. Compared to patients without small bowel angioectasia, those with small bowel angioectasia had a significantly higher VFA (96 ± 76.0 cm2vs 63.4 ± 51.5 cm2, P = 0.016) and a higher prevalence of liver cirrhosis (61% vs 22%, P < 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia (22% vs 9%, P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio (OR) for each 10-cm2 increment = 1.1; [95% confidence interval (CI): 1.02-1.19; P = 0.021] and liver cirrhosis (OR = 6.1, 95%CI: 2.2-18.5; P < 0.001) were significant risk factors for small bowel angioectasia.
CONCLUSION: VFA is positively associated with the prevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.
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22
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Makris M, Federici AB, Mannucci PM, Bolton-Maggs PHB, Yee TT, Abshire T, Berntorp E. The natural history of occult or angiodysplastic gastrointestinal bleeding in von Willebrand disease. Haemophilia 2014; 21:338-342. [PMID: 25381842 DOI: 10.1111/hae.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 01/15/2023]
Abstract
Recurrent gastrointestinal bleeding is one of the most challenging complications encountered in the management of patients with von Willebrand disease (VWD). The commonest cause is angiodysplasia, but often no cause is identified due to the difficulty in making the diagnosis. The optimal treatment to prevent recurrences remains unknown. We performed a retrospective study of VWD patients with occult or angiodysplastic bleeding within the setting of the von Willebrand Disease Prophylaxis Network (VWD PN) to describe diagnostic and treatment strategies. Centres participating in the VWD PN recruited subjects under their care with a history of congenital VWD and gastrointestinal (GI) bleeding due to angiodysplasia, or cases in which the cause was not identified despite investigation. Patients with acquired von Willebrand syndrome or those for whom the GI bleeding was due to another cause were excluded. Forty-eight patients from 18 centres in 10 countries were recruited. Seven individuals had a family history of GI bleeding and all VWD types except 2N were represented. Angiodysplasia was confirmed in 38%, with video capsule endoscopy and GI tract endoscopies being the most common methods of making the diagnosis. Recurrent GI bleeding in VWD is associated with significant morbidity and required hospital admission on up to 30 occasions. Patients were treated with multiple pharmacological agents with prophylactic von Willebrand factor concentrate being the most efficient in preventing recurrence of the GI bleeding. The diagnosis and treatment of recurrent GI bleeding in congenital VWD remains challenging and is associated with significant morbidity. Prophylactic treatment with von Willebrand factor concentrate was the most effective method of preventing recurrent bleeding but its efficacy remains to be confirmed in a prospective study.
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Affiliation(s)
- M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK; Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
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23
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Jacques J, Legros R, Chaussade S, Sautereau D. Endoscopic haemostasis: an overview of procedures and clinical scenarios. Dig Liver Dis 2014; 46:766-76. [PMID: 25022337 DOI: 10.1016/j.dld.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023]
Abstract
Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.
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Affiliation(s)
- Jérémie Jacques
- Gastroenterology Department, University Hospital of Limoges, Limoges, France.
| | - Romain Legros
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
| | | | - Denis Sautereau
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
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24
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Nardone G, Compare D, Scarpignato C, Rocco A. Long acting release-octreotide as "rescue" therapy to control angiodysplasia bleeding: A retrospective study of 98 cases. Dig Liver Dis 2014; 46:688-94. [PMID: 24893688 DOI: 10.1016/j.dld.2014.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/25/2014] [Accepted: 04/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients. AIM To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding. METHODS 98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1mg tid for 28 days and, then from day 14, long acting release-octreotide 20mg monthly, for 6 months. RESULTS The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy. CONCLUSION Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology, Division of Gastroenterology, Department of Clinical Sciences, University of Parma, Parma, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
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25
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Marion Y, Lebreton G, Le Pennec V, Hourna E, Viennot S, Alves A. The management of lower gastrointestinal bleeding. J Visc Surg 2014; 151:191-201. [PMID: 24768401 DOI: 10.1016/j.jviscsurg.2014.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2-4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient.
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Affiliation(s)
- Y Marion
- Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France.
| | - G Lebreton
- Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - V Le Pennec
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - E Hourna
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - S Viennot
- Service de gastro-entérologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - A Alves
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
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Medical management of patients with continuous-flow left ventricular assist devices. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:283. [PMID: 24398802 DOI: 10.1007/s11936-013-0283-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT The prevalence of patients living with advanced heart failure continues to rise. For a subset of these patients, continuous-flow left ventricular assist devices (LVADs) are a life-saving therapy. Given the efficacy and durability of contemporary LVAD devices, their use has increased exponentially in recent years. The medical management of patients with an LVAD is an area of expertise for advanced heart failure clinicians, but a general understanding of the initial approach to, and stabilization of, LVAD patients is an important skillset for many health care providers. The rapidly changing field of the medical management of LVAD patients is largely based on clinical experience and limited published data. In this manuscript, we integrate the available published data on the medical management of LVAD patients with the growing clinical experience.
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Fabbiocchi F, Pirondini M, Trabattoni D, Ferrari C, Bartorelli AL, De Franchis R, Kaplan AV, Jayne JE. How should I treat a patient with life-threatening gastrointestinal bleeding early after coronary drug-eluting stent implantation? EUROINTERVENTION 2013; 9:880-4. [PMID: 23838321 DOI: 10.4244/eijv9i7a143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND A 68-year-old man was referred for stable angina pectoris and a large apical perfusion defect on stress myocardial scintigraphy. Medical history included chronic oral anticoagulation with warfarin due to longstanding atrial fibrillation, type 2 diabetes mellitus, hypertension, and dyslipidaemia. INVESTIGATION Coronary angiography. DIAGNOSIS Severe stenosis of the mid left anterior descending coronary artery. TREATMENT Percutaneous coronary intervention with implantation of drug-eluting stent.
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Affiliation(s)
- Franco Fabbiocchi
- Department of Clinical Sciences and Community Health, Cardiovascular Section, Centro Cardiologico Monzino, IRCCS University of Milan, Milan, Italy
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Thachil J, Hay CRM, Campbell S. Tamoxifen for recurrent bleeds due to angiodysplasia in von Willebrand's disease. Haemophilia 2013; 19:e313-5. [PMID: 23731407 DOI: 10.1111/hae.12196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2013] [Indexed: 12/21/2022]
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Recurrent jejunal bleeding due to angiodysplasia in a Bernard–Soulier patient. Blood Coagul Fibrinolysis 2013; 24:428-9. [DOI: 10.1097/mbc.0b013e328358e8fd] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Masrur M, Gheza F, Raimondi P, D'Ugo S, Calatayud D, Giulianotti PC. Robot-assisted subtotal pancreas-preserving duodenectomy. JSLS 2013; 16:654-9. [PMID: 23484581 PMCID: PMC3558909 DOI: 10.4293/108680812x13517013316591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Angiodysplasia of the duodenum is a rare disorder, often requiring surgical resection. Technical difficulties have made the use of the minimally invasive approach uncommon. Herein, we present a subtotal pancreas-preserving duodenectomy using robotic assistance. METHODS The patient is a 60-y-old female with a long medical history including chronic gastrointestinal bleeding due to angiodysplasia with intermittent melena, and requiring multiples blood transfusions. A capsule endoscopy and double-balloon upper endoscopy showed angiectasis, which appeared to be limited to the third and fourth portion of the duodenum and the proximal loops of the jejunum. Despite multiple endoscopic cauterizations, the patient continued to require blood transfusion for several years. The patient underwent a robot-assisted subtotal pancreas-preserving duodenectomy. RESULTS The operation lasted 420 min with minimal blood loss. The postoperative course was uneventful. The pathology report showed multiple small bowel mucosal and submucosal distorted and dilated vasculature, consistent with angiodysplasia. At 2-mo follow-up, the patient was totally asymptomatic. A barium swallow study showed contrast passed antegrade through the duodenojejunostomy with no evidence of obstruction, stricture, or leakage. CONCLUSION The use of robotic assistance to perform a subtotal pancreas-preserving duodenectomy for the treatment of benign duodenal disease, such as angiodysplasia, is feasible and safe. The technical advantages include a high degree of freedom offered by the robotic instruments, as well as enhanced visualization, which allows for precise microdissection and microsuture, thereby preserving the benefits of minimally invasive surgery. The use of robotic technology allows for a wider range of indications for minimally invasive surgery.
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Affiliation(s)
- Mario Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois, Chicago, IL 60612, USA.
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Holleran G, Hall B, Hussey M, McNamara D. Small bowel angiodysplasia and novel disease associations: a cohort study. Scand J Gastroenterol 2013; 48:433-8. [PMID: 23356721 DOI: 10.3109/00365521.2012.763178] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Gastrointestinal angiodysplasias recurrently bleed, accounting for 3-5% of obscure gastrointestinal bleeding. The advent of small bowel capsule endoscopy (SBCE) has led to an increased recognition of small bowel angiodysplasias (SBAs) but little is known about their etiology. Previous small cohorts and case reports suggest an equal gender incidence and associations with cardiovascular disease, renal impairment, and coagulopathies. METHODS Patients with SBA were identified from our SBCE database. A control group, in whom gastrointestinal bleeding had been excluded, was also identified. Information on patient demographics, past medical/surgical/social history and medications was prospectively obtained. RESULTS A total of 82 patients and 95 controls were identified. Data was available from 81% (n = 66) of SBA patients. The mean age of patients and controls was 66.9 years (35-90) and 69.2 years (54-77), and 60% (n = 40) and 58% (n = 55) were females, respectively. There was a higher rate of all comorbidities in the SBA group 92% (61/66) versus controls 76% (72/95) p < 0.002. Significant associations were found with: hypertension (odds ratio [OR] 2.8), ischemic heart disease (OR 4.25), arrhythmias (OR 4.36), valvular heart disease (OR 18), congestive heart failure (OR 4.22), chronic kidney disease (CKD) (OR 8.4), chronic respiratory conditions (OR 2.0), and previous venous thromboembolism (VTE) (OR 6.4). Anticoagulant use was higher in patients with SBA, 50% (n = 33) versus 27% (n = 26) of controls, p < 0.002, specifically warfarin and asasantin retard. CONCLUSIONS SBA occurs in elderly patients with cardiovascular disease and CKD, as previously suggested. This study identifies a previously unrecognised risk in females, patients with chronic respiratory conditions and VTE, and the use of warfarin and asasantin retard. These associations should raise awareness of possible underlying SBA in risk patients with anemia.
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Affiliation(s)
- Grainne Holleran
- Department of Clinical Medicine, Adelaide and Meath Hospital, Trinity College Dublin, Dublin, Ireland.
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The use of small bowel capsule endoscopy in iron deficiency anaemia: low impact on outcome in the medium term despite high diagnostic yield. Eur J Gastroenterol Hepatol 2013. [PMID: 23183118 DOI: 10.1097/meg.0b013e32835b7d3a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Small bowel capsule endoscopy (SBCE) is a useful diagnostic modality in small bowel disorders. Iron deficiency anaemia (IDA) is one of the most common indications for SBCE. However, there are limited data on the diagnostic yield for IDA alone, and little is known about the clinical impact and long-term outcome of patients following SBCE. AIM To determine the diagnostic yield of SBCE in IDA and to examine outcome. MATERIALS AND METHODS A retrospective review of a tertiary referral centre's database over a 21-month time period was carried out. Information on follow-up and management was obtained through chart review. RESULTS In all, 309 SBCEs were identified, 30% (n=93) for anaemia and in 70% (n=65), follow-up data were available. The small bowel diagnostic yield for IDA was 53% (n=35), including angiodysplasia 49% (n=17), nonspecific inflammation 34% (n=12), active bleeding 11% (n=4) and Crohn's disease 6% (n=2). In addition, 16% (n=10) had abnormalities (gastritis, gastric antral vascular ectasia, duodenitis) outside the small bowel. In all, 42% (n=27) were persistently anaemic after a mean follow-up of 9.3 months. Of these, 52% (n=14) and 48% (n=13) had positive and negative SBCEs, respectively. In total, SBCE led to a change in treatment in 28 patients (44%), of whom 17 (61%) remained anaemic. CONCLUSION This study shows a high overall diagnostic yield for SBCE in IDA 71% (n=45). Despite the majority, 53% (n=24), of patients with positive tests receiving specific treatment, 61% (n=17) remained anaemic in the long term. SBCE results were not predictive of long-term outcome even when stratified for a change in management.
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Bon C, Aparicio T, Vincent M, Mavros M, Bejou B, Raynaud JJ, Zampeli E, Airinei G, Sautereau D, Benamouzig R, Michopoulos S. Long-acting somatostatin analogues decrease blood transfusion requirements in patients with refractory gastrointestinal bleeding associated with angiodysplasia. Aliment Pharmacol Ther 2012; 36:587-93. [PMID: 22831465 DOI: 10.1111/apt.12000] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 04/27/2012] [Accepted: 07/10/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) may be the cause of recurrent bleeding, despite endoscopic treatment. AIM To evaluate the effect of long-acting somatostatin analogues on blood transfusion requirements, in patients with refractory bleeding due to GIADs. METHODS Consecutive patients with recurrent bleeding from GIADs were enrolled. They received somatostatin analogue treatment for at least 6 months. The efficacy was evaluated in terms of blood transfusions, frequency of bleeding episodes and haemoglobin level during 6 months of treatment (Period During) compared to a 6-months' period before treatment (Period Before). RESULTS Fifteen patients were enrolled from 2007 to 2010. The median duration of somatostatin analogue treatment was 12 months (range: 6-36). The number of transfusions significantly decreased in Period During compared with Period Before [median number: 2 (0-14) vs. 10 (6-24); P < 0.001]. The percentage of patients who experienced a bleeding event was lower during somatostatin analogues treatment (20% vs. 73%; P = 0.01). The mean haemoglobin level was significantly higher when somatostatin analogues were offered [median: 10 g/dL (9-13) vs. 7 (5-8.5); P < 0.001]. None of the patients discontinued treatment due to side effects. CONCLUSIONS Long-acting somatostatin analogues treatment decreased transfusion needs in patients with refractory bleeding from gastrointestinal angiodysplasias. Bleeding episodes were limited and haemoglobin improved during treatment. Long-acting somatostatin analogues may represent an option for the management of patients with chronic bleeding due to gastrointestinal angiodysplasias.
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Affiliation(s)
- C Bon
- Department of Gastroenterology, Avicenne Hospital, APHP, Bobigny, France
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Gill MD, Bramble MG, Rees CJ, Lee TJW, Bradburn DM, Mills SJ. Comparison of screen-detected and interval colorectal cancers in the Bowel Cancer Screening Programme. Br J Cancer 2012; 107:417-21. [PMID: 22782347 PMCID: PMC3405230 DOI: 10.1038/bjc.2012.305] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood testing (FOBt) followed by colonoscopy after positive results. Colorectal cancers (CRCs) registered with the Northern Colorectal Cancer Audit Group database were cross-referenced with the BCSP database to analyse their screening history. Methods: The CRCs in the screening population between April 2007 and March 2010 were identified and classified into four groups: control (diagnosed before first screening invite), screen-detected, interval (diagnosed between screening rounds after a negative FOBt), and non-uptake (declined screening). Patient demographics, tumour characteristics and survival were compared between groups. Results: In all, 511 out of 1336 (38.2%) CRCs were controls; 825 (61.8%) were in individuals invited for screening of which 322 (39.0%) were screen detected, 311 (37.7%) were in the non-uptake group, and 192 (23.3%) were interval cancers. Compared with the control and interval cancer group, the screen-detected group had a higher proportion of men (P=0.002, P=0.003 respectively), left colon tumours (P=0.007, P=0.003), and superior survival (both P<0.001). There was no difference in demographics, tumour location/stage, or survival between control and interval groups. Conclusion: The FOBt is better at detecting cancers in the left colon and in men. The significant numbers of interval cancers weren’t found to have an improved outcome compared with the non-screened population.
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Affiliation(s)
- M D Gill
- Northern Colorectal Cancer Audit Group, Northumbria Health Care Trust, Northumberland, UK.
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Severe gastro-intestinal angiodysplasia in context of Heyde's syndrome durably cured after aortic valve replacement. Presse Med 2012; 41:763-6. [DOI: 10.1016/j.lpm.2011.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Revised: 10/05/2011] [Accepted: 10/10/2011] [Indexed: 02/07/2023] Open
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Albert JG. Interventional balloon-enteroscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:42-50. [PMID: 22586550 DOI: 10.4161/jig.20134] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 12/16/2011] [Accepted: 12/18/2011] [Indexed: 12/20/2022]
Abstract
Balloon assisted enteroscopy (BE) expands greatly the therapeutic options in interventional endoscopy; bleeding sites, strictures, polyps, and other small bowel lesions are increasingly been treated by use of BE in the last 10 years. Treatment options for small bowel bleeding include Argon plasma coagulation (APC), injection therapy, and application of TTS metal clips, and thereby bleeding is stopped in most cases. Dilating symptomatic strictures, resecting polyps as seen in Peutz-Jeghers syndrome (PJS), and removing foreign bodies, BE carries most endoscopic treatment techniques to the small bowel. Another new indication field for BE are interventions at the biliary system in patients with surgically modified anatomy such as Roux-Y anastomosis. This review offers a full overview on indications of BE and refers to the practical use of the method for all endoscopic interventions.
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Affiliation(s)
- Jörg G Albert
- Department of Medicine I, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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Abstract
Angiodysplasia of the gastrointestinal tract is common in the population 60 years of age and older and may be the cause of acute and/or chronic bleeding. Colonic angiodysplastic lesions are presumed to be degenerative in nature, secondary to either intermittent obstruction of the submucosal veins or hypoxemia. The pathogenesis of upper intestinal angiodysplasia is most likely related to a degenerative process. The clinical presentation varies from an incidental finding in an otherwise asymptomatic person to occult bleeding or an acute massive hemorrhage. Endoscopy and angiography are useful diagnostic modalities. Management options include surgery, endoscopic obliteration, or angiographic embolization of an identified bleeding angiodysplastic lesion(s). In a subset of patients who have angiodysplasia associated with Osler-Rendu-Weber disease or chronic renal failure, hormonal therapy with estrogen-progesterone may be efficacious.
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