Somatostatin analogs in the medical management of occult bleeding of the lower digestive tract

Effect of postoperative utilization of somatostatin on clinical outcome after definitive surgery for duodenal fistula

PURPOSE

To evaluate the effect of postoperative utilization of somatostatin after definitive surgery for duodenal fistula (DF) in preventing a recurrence.

METHODS

Patients with definitive surgery for DF between January 2010 and December 2021 were categorized based on the utilization of somatostatin or not after the surgery. Patients in the Somatostatin group were matched to those in the Non-somatostatin group using propensity scores matching (PSM), so as to evaluate the effect of postoperative use of somatostatin by comparing the two groups.

RESULTS

A total of 154 patients were divided into the in the Somatostatin group (84) and the Non-somatostatin group (70). Forty-three patients (27.9%) exhibited a recurrent fistula, with which the postoperative use of somatostatin was not associated (19 [22.6%] in the Somatostatin group and 24 (34.3%) in the Non-somatostatin group; unadjusted OR 0.56; 95% CI 0.28-1.14; P = 0.11). However, the postoperative usage of somatostatin served as a protective factor for developing into high-output recurrent fistula (eight (13.3%) in the Somatostatin group and 15 (25%) in the Non-somatostatin group; adjusted OR 0.39; 95% CI 0.15-0.93; P = 0.04). After PSM, the recurrent fistula occurred in 29.2% subjects (35/120). The postoperative usage of somatostatin was not associated with recurrent fistula (13 in PSM Somatostatin group vs. 22 in PSM Non-somatostatin group; unadjusted OR 0.48; 95% CI 0.21-1.07; P = 0.07), while its postoperative usage decreased the incidence of recurrent high-output fistula (5/60 in the PSM Somatostatin group, compared with 13/60 in the PSM Non-somatostatin group; adjusted OR 0.30; 95% CI 0.09-0.95).

CONCLUSION

Postoperative use of somatostatin could effectively reduce the incidence of recurrent high-output fistula, without association with overall incidence of postoperative recurrent fistula.

Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE)

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.

Systemic Octreotide Therapy in Prevention of Gastrointestinal Bleeds Related to Arteriovenous Malformations and Obscure Etiology in Atrial Fibrillation

OBJECTIVES

The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding.

BACKGROUND

AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs.

METHODS

In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6 months' follow-up.

RESULTS

After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA₂DS₂-VASc score 3 ± 1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36 (78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and 1 required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p < 0.001).

CONCLUSIONS

Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief from bleeding.