Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention.

METHODS

A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data.

RESULTS

On logistic regression analysis, A hemoglobin drop of > 20 g/L was the only variable that predicted endoscopic intervention (p = 0.030). Tachycardia, hypotension, or presence of anticoagulation were not significantly associated with endoscopic intervention (p > 0.05).

CONCLUSIONS

A hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.

A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results.

METHODS

The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling.

RESULTS

Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (- 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03-2.93).

CONCLUSION

TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.

The diagnostic yield of urgent colonoscopy in acute lower gastrointestinal bleeding

BACKGROUND AND AIMS

Lower Gastrointestinal Bleeding (LGIB) is one of the leading causes of ER visits. Colonoscopy is indicated in all patients with LGIB, yet the time frame for performing colonoscopy remains unclear. Whether or not urgent endoscopic evaluation improves outcomes of LGIB has been questioned. We therefore aimed to examine the success of urgent colonoscopy in identifying the source of LGIB.

PATIENTS AND METHODS

A retrospective study was conducted in which timing of colonoscopy was divided into urgent (performed within the first 24 hours of presentation) and delayed (performed following 24 hours of hospitalization). Data on clinical presentation, investigations and endoscopic findings was collected. Risk ratios were calculated and regression analysis was used to examine associations and identify predictors of endoscopic success.

RESULT

A total of 183 patients underwent colonoscopies. 55.4% of colonoscopies were performed within 24 hours of presentation. A source of LGIB was identified in 55.7% of first attempt colonoscopies. Endoscopic intervention was required in 10.9% of cases and rebleeding occurred in 24.6%, of which 6.5% required hospital re-admission. 2.7% required emergency colectomy and the calculated mortality rate was 1%. Risk ratios comparing urgent to delayed colonoscopy for source of LGIB identification, colectomy and mortality were 1.01, 4.8 and 1.2, respectively. Age and timing of colonoscopy appeared to be predictive of colectomy on regression analysis.

CONCLUSIONS

Urgent colonoscopy for LGIB did not improve the rate of identification of the source of bleeding, colectomy rate or mortality rate and was predictive of the need for emergency colectomy.

Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre

BACKGROUND AND STUDY AIMS

Lower gastrointestinal bleeding originates from a site distal to the ligament of Treitz. It can present as an acute life-threatening or chronicbleeding. It is common among older patients and those with comorbidity. The common causes are diverticular disease, angiodysplasias, neoplasms, colitis, ischaemia and anorectal disorders. The aim of this study is to determine the prevalence and causes of acute lower gastrointestinal bleeding among Sudanese patients.

PATIENTS AND METHODS

In a period of 2 years we studied 301 patients with fresh rectal bleeding out of 5625 patients with gastrointestinal bleeding in Ibn Sina Specialized Hospital, Khartoum, Sudan, This is a cross sectional observational hospital based study. All patients with fresh rectal bleeding within 24 h were included and consented.

RESULT

Lower gastrointestinal bleeding constituted 5.37% of total cases of gastrointestinal bleeding. The mean age of patients was 55.43 ± 17.779, male: female ratio was 2:1. The most common cause (if upper gastrointestinal bleeding is excluded) was diverticular disease 39.6% (n = 61) followed by piles 24.1% (n = 35), colonic tumours 12.34% (n = 19), ulcerative colitis 5.19% (n = 8), Crohn's 5.19% (n = 8), colonic polyps 3,89% (n = 6), angiodysplesia 4.5% (n = 7), colonic ulcer 2.59% (n = 4), ischaemic colitis 1.3%, nonspecific colitis 1.3% (n = 2), and small bowel source in 1.3% (n = 2). The majority of those patients with diverticular disease were male and with first presentation. The commonest cause in those patients younger than 20 years was polyps, and in those between 21 and 40 was piles followed by inflammatory bowel disease, and in those between 41 and 60 years old was piles followed by diverticular disease and tumours, and in those above 60 years was diverticular disease followed by piles and tumours. The correlation between positive colonoscopy finding and diabetes and the use of nonsteroidal anti-inflammatory drugs were statistically significant. The one-month mortality rate was 2.3% CONCLUSION: Acute lower gastrointestinal bleeding is common among elderly patients and the commonest cause is diverticular disease. Colonoscopy plays an important role in the diagnosis. Most patients respond to conservative therapy.

Recurrence and mortality among patients hospitalized for acute lower gastrointestinal bleeding

BACKGROUND & AIMS

The long-term recurrence of lower gastrointestinal bleeding (LGIB) and associated mortality have not been studied extensively. We investigated rates of recurrence of LGIB, mortality, and associated risk factors.

METHODS

In a retrospective study, we analyzed data from 342 patients hospitalized for overt LGIB at the National Center for Global Health and Medicine in Japan from December 2004 through June 2013. All patients underwent colonoscopy. We assessed Charlson comorbidity index scores and the use of nonsteroidal anti-inflammatory drugs, low-dose aspirin, other antiplatelet drugs, or warfarin. Rebleeding, the total number of rebleeding episodes, and mortality were measured. The Cox proportional hazards model was used to estimate hazard ratios (HRs).

RESULTS

Rebleeding occurred in 84 patients, at a mean follow-up time of 19 months. The cumulative percentages of patients with rebleeding at 1 and 5 years were 19% and 46%, respectively. During the follow-up period, 29 patients (39%) had secondary rebleeding and 18 patients (62%) had subsequent rebleeding. Multivariate analysis showed age 65 years and older (HR, 1.7; P = .04) and the use of nonsteroidal anti-inflammatory drugs (HR, 2.0; P < .01) and nonaspirin antiplatelet drugs (HR, 1.8; P < .05) as independent risk factors for rebleeding. Dual therapy had a higher risk than single therapy (adjusted HR, 1.8; P < .05). During the mean follow-up period of 28 months, 21 patients died (2 from bleeding). Cumulative mortality rates at 1 and 5 years were 4.2% and 13%, respectively. Mortality was associated significantly with age ≥65 years (P < .05), Charlson comorbidity index score, and warfarin use.

CONCLUSIONS

Based on a retrospective analysis of patients with LGIB, 46% of all patients have rebleeding, and the overall mortality rate is 13% within 5 years after hospitalization. Besides age ≥65 years, use of antithrombotic drugs increases the risk of bleeding recurrence and mortality among patients with LGIB.

Endoscopic hemostasis is rarely used for hematochezia: a population-based study from the Clinical Outcomes Research Initiative National Endoscopic Database

BACKGROUND

Data on the use of endoscopic hemostasis performed during colonoscopy for hematochezia are primarily derived from expert opinion and case series from tertiary care settings.

OBJECTIVES

To characterize patients with hematochezia who underwent in-patient colonoscopy and compare those who did and did not receive endoscopic hemostasis.

DESIGN

Retrospective analysis.

SETTING

Clinical Outcomes Research Initiative National Endoscopic Database, 2002 to 2008.

PATIENTS

Adults with hematochezia.

INTERVENTIONS

None.

MAIN OUTCOME MEASUREMENTS

Demographics, comorbidities, practice setting, adverse events, and colonoscopy procedural characteristics and findings.

RESULTS

We identified 3151 persons who underwent in-patient colonoscopy for hematochezia. Endoscopic hemostasis was performed in 144 patients (4.6%). Of those who received endoscopic hemostasis, the majority were male (60.3%), white (83.3%), and older (mean age 70.9 ± 12.3 years); had a low-risk American Society of Anesthesiologists classification (53.9%); and underwent colonoscopy in a community setting (67.4%). The hemostasis-receiving cohort was significantly more likely to be white (83.3% vs 71.0%, P = .02), have more comorbidities (classes 3 and 4, 46.2% vs 36.0%, P = .04), and have the cecum reached (95.8% vs 87.7%, P = .003). Those receiving hemostasis were significantly more likely to have an endoscopic diagnosis of arteriovenous malformations (32.6% vs 2.6%, P = .0001) or a solitary ulcer (8.3% vs 2.1%, P < .0001).

LIMITATIONS

Retrospective database analysis.

CONCLUSIONS

Less than 5% of persons presenting with hematochezia and undergoing inpatient colonoscopy received endoscopic hemostasis. These findings differ from published tertiary care setting data. These data provide new insights into in-patient colonoscopy performed primarily in a community practice setting for patients with hematochezia.

Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study

BACKGROUND

The role of urgent colonoscopy in lower GI bleeding (LGIB) remains controversial. Population-based studies on LGIB outcomes are lacking.

OBJECTIVE

To investigate the impact of the timing of colonoscopy on outcomes of patients with LGIB.

DESIGN

Cross-sectional study.

SETTING

Nationwide Inpatient Sample 2010.

PATIENTS

International Classification of Diseases, Ninth Revision, Clinical Modification codes identified patients with LGIB who underwent colonoscopy.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality, length of stay, and hospitalization costs in patients who underwent early (≤24 hours) or delayed (>24 hours) colonoscopy.

RESULTS

A total of 58,296 discharges with LGIB were identified; 22,720 had a colonoscopy performed during the hospitalization. A total of 9156 patients had colonoscopy performed within 24 hours (early colonoscopy), and 13,564 had colonoscopy performed after 24 hours (delayed colonoscopy). There was no difference in mortality in patients with LGIB who had early versus delayed colonoscopy (0.3% vs 0.4%, P = .24). However, patients who underwent early colonoscopy had a shorter length of hospital stay (2.9 vs 4.6 days, P < .001), decreased need for blood transfusion (44.6% vs 53.8%, P < .001), and lower hospitalization costs ($22,142 vs $28,749, P < .001). On multivariate analysis, timing of colonoscopy did not affect mortality (adjusted odds ratio 1.5; 95% confidence interval, 0.7-2.7). On multivariate analysis, delayed colonoscopy was associated with an increase in the length of hospital stay by 1.6 days and an increase in hospitalization costs of $7187.

LIMITATIONS

Administrative dataset.

CONCLUSIONS

Early colonoscopy within 24 hours is associated with decreased length of hospital stay and hospitalization costs in patients with LGIB.

Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients

PURPOSE

To assess the safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding (LGIB) and to determine the prognostic factors that affect clinical outcome.

MATERIALS AND METHODS

All patients diagnosed with LGIB by angiography at a single institution from April 2006 to January 2013 were included in a retrospective study. The rates of technical success, early recurrent bleeding, major complications, clinical success, and in-hospital mortality for transcatheter arterial embolization were determined. The influence of possible prognostic factors on the outcome was analyzed.

RESULTS

A total of 112 patients were included (36 with small-bowel LGIB, 36 with colon LGIB, and 40 with rectal LGIB). N-butyl cyanoacrylate (NBCA) was the embolic agent for 84 patients (75.0%), whereas gelatin sponge pledgets (n = 20), microcoils (n = 2), polyvinyl alcohol particles with adjunctive gelatin sponge pledgets (n = 1), and blood clots (n = 1) were used in the other patients. The technical success rate was 96.4%. For the entire group, the rates of early recurrent bleeding, major complications, clinical success, and in-hospital mortality were 17.4%, 4.6%, 74.5%, and 25.0%, respectively. These were 15.2%, 4.8%, 75.3%, and 26.2%, respectively, in the NBCA group. Hematologic malignancy, immobilization status, and coagulopathy were significant prognostic factors for clinical outcomes.

CONCLUSIONS

Transcatheter arterial embolization is a safe and effective treatment for LGIB. NBCA could be used as a primary embolic agent for this procedure.