A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding

INTRODUCTION

Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients.

METHODS

We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB.

RESULTS

We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05-5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29-12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization.

DISCUSSION

Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.

A Rare Case of Waldenstrom Macroglobulinemia of the Rectosigmoid Colon

Waldenstrom macroglobulinemia is an uncommon mature B-cell lymphoma characterized by monoclonal immunoglobulin M protein in peripheral blood and lymphoplasmacytic cells in bone marrow and/or extramedullary sites. The gastrointestinal tract is a rare site of involvement. The diagnosis is based on clinicopathologic findings, although somatic mutations, such as MYD88, can aid in the diagnosis. We present a patient with irregular stools diagnosed with Waldenstrom macroglobulinemia involving the rectosigmoid colon by histopathology and immunohistochemistry on colonic biopsies, immunoglobulin M protein in serum, clonal plasma cells in bone marrow, and MYD88 mutation in colonic and bone marrow specimens.

Increased Risk of Progression to Gastric Adenocarcinoma in Patients with Non-dysplastic Gastric Intestinal Metaplasia Versus a Control Population

AIM

In previous studies, the 5-year progression rate of gastric intestinal metaplasia to gastric adenocarcinoma has varied substantially. We investigated the incidence rate of dysplasia and gastric adenocarcinoma and the rate of progression among a cohort of patients with non-dysplastic gastric intestinal metaplasia.

METHODS

This is a single-center, single-cohort retrospective study. Patients who had undergone an EGD with biopsies from 01/01/1993 to 12/31/2013 were included. The primary outcome of interest was the composite of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma. Time to progression and risk factor subgroup analyses were performed.

RESULTS

A total of 1628 subjects were screened, of whom 358 met the inclusion criteria. A total of 21 first-time events were recorded. The annual incidence rate of low-grade dysplasia was 2.1 (95% CI 1.3-3.5) cases per 1000 person-years, 0.5 (95% 0.2-1.3) per 1000 person-years for high-grade dysplasia, and 0.8 (95% CI 0.3-1.6) cases per 1000 person-years for gastric adenocarcinoma. The historical control group had an annual adenocarcinoma incidence rate of 0.07 per 1000 person-years. The event rate in Asians was also noted to be significantly higher between years 0-8 as compared with patients of non-Asian race, and extensive intestinal metaplasia was an independent risk factor (HR = 4.06 (95% CI 1.45-11.34), p = 0.007).

CONCLUSIONS

Patients with non-dysplastic gastric intestinal metaplasia may progress to dysplasia and gastric adenocarcinoma. The incidence rate of gastric adenocarcinoma is higher than that of the historical control population (0.07 per 1000 person-years). The presence of extensive intestinal metaplasia was a risk factor for progression of disease. Triennial EGD may be warranted in patients with non-dysplastic gastric intestinal metaplasia.

An update on the management of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) are a rare and heterogeneous group of neoplasia and differ in their clinical presentation, behavior, and prognosis based on both histological features and cancer stage at the time of diagnosis. Although small-sized tumors can be surgically resected, locally advanced and metastatic tumors confer a poor prognosis. In addition, only limited treatment options are available to the latter group of patients with PNETs, such as hormonal analogs, cytotoxic agents, and targeted therapy. In selected patients, liver-directed therapies are also used. As expected, clinicians taking care of these patients are challenged to develop an effective and comprehensive treatment strategy for their patients amid a wide variety of treatment modalities. Targeted therapy for PNETs is limited to sunitinib and everolimus. Presently, a number of clinical studies are ongoing to assess the efficacy of newer targeted agents alone and in combination with previous agents for the treatment of advanced PNETs. The authors reviewed the current treatment and also discussed the emerging agents and emphasized the need to identify biomarkers.

Pretreatment with methylprednisolone to prevent ERCP-induced pancreatitis: a randomized, multicenter, placebo-controlled clinical trial

OBJECTIVE

Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP). Uncontrolled data suggest a lower incidence of pancreatitis in patients with a history of iodine sensitivity when given pretreatment with corticosteroids. We conducted a clinical trial to assess the efficacy of a commonly prescribed corticosteroid, methylprednisolone, to prevent ERCP-induced pancreatitis.

METHODS

Patients were entered into a randomized, multicenter, double-blind, placebo-controlled study of intravenous methylprednisolone (125 mg) versus a saline placebo immediately before the ERCP. All patients were evaluated for early and late complications.

RESULTS

Two hundred eighty-six patients were randomized. Thirty-one randomized patients were excluded for technical reasons at the time of ERCP. Overall, the incidence of pancreatitis was 16 of 129 (12.4%, 95% CI: 6.7-18.1%) in the methylprednisolone group and 11 of 126 (8.7%, 95% CI: 4.4-15.1%) in the placebo group, which was not significantly different (p = 0.34). Although there was a higher rate of sphincterotomy performed in the methylprednisolone group compared to the control group (31.8% vs 16.8%, p = 0.005), the incidence of pancreatitis was not different when patients undergoing sphincterotomy were analyzed separately (13.6% in the methylprednisolone group and 9.6% in the placebo group,p = 0.50). There was no significant difference between the two groups for those with ERCP-induced pancreatitis in hospital length of stay (p = 0.22), days of parenteral analgesia (p = 0.09), or days of parenteral nutrition (p = 0.15).

CONCLUSION

Intravenous methylprednisolone is not beneficial in preventing ERCP-induced pancreatitis.

Pemoline-induced autoimmune hepatitis

We present a case of pemoline-induced autoimmune hepatitis in a 46-yr-old woman who received the drug for management of her multiple sclerosis. The autoimmune nature of the hepatitis is based on elevation of her anti-nuclear antibodies, anti-thyroid antibodies, IgA, and IgM globulins. These features of autoimmunity disappeared with normalization of her liver-associated enzymes and have remained negative for at least 6 months after completion of prednisone therapy.