Special considerations for therapeutic choice of non–vitamin K antagonist oral anticoagulants for Japanese patients with nonvalvular atrial fibrillation

Nonvalvular atrial fibrillation (AF ) is a risk factor for stroke in elderly patients. Although warfarin has been used to prevent AF ‐associated stroke for more than 50 years, non–vitamin K antagonist oral anticoagulants (NOACs ) including dabigatran, rivaroxaban, apixaban, and edoxaban recently have been developed to overcome the disadvantages of warfarin. Based on the results of NOAC clinical trials, Savelieva and Camm made recommendations regarding selection of NOACs in patients with nonvalvular AF . Recent accumulating evidence indicates that NOACs work differently in Asian and non‐Asian individuals. In this review, we discuss the results of the large, randomized, phase 3 international clinical trials on NOACs , the subanalyses of Asians, and a Japanese phase 3 clinical trial of rivaroxaban to discriminate Japanese patient–specific characteristics with regard to their responses to NOACs and make recommendations. Our analysis revealed that rivaroxaban decreased the incidence of gastrointestinal (GI ) bleeding compared with warfarin in Japanese patients. The efficacy results showed that rivaroxaban significantly decreased the incidence of ischemic stroke (hazard ratio: 0.40, 95% confidence interval: 0.17‐0.96) compared with warfarin. The lower incidence of GI bleeding and ischemic stroke may be specific to Japanese patients. Based on the present and previous results, the following recommendations regarding the selection of NOACs are added in the Camm chart for Japanese patients: edoxaban for patients with a high risk of bleeding and those with a previous stroke; and rivaroxaban for patients with a high risk of ischemic stroke and a low bleeding risk, and those with previous GI bleeding.     

Angiogenesis and vascular malformations： Antiangiogenic drugs for treatment of gastrointestinal bleeding

Treatment of gastrointestinal bleeding in patients with angiodysplasias and Osler＇s disease （hereditary hemorrhagic teleangiectasia） is clinically challenging. Frequently, vascular malformations occur as multiple disseminated lesions, making local treatment an unfavorable choice or impossible. After local therapy, lesions often recur at other sites of the intestine. However, as there are few therapeutic alternatives, repeated endoscopic coagulations or surgical resections are still performed to prevent recurrent bleeding. Hormonal therapy has been employed for more than 50 years but has recently been shown to be ineffective. Therefore, new therapeutic strategies are required. Understanding of the pathophysiology of angiogenesis and vascular malformations has recently substantially increased. Currently, multiple inhibitors of angiogenesis are under development for treatment of malignant diseases. Experimental and clinical data suggest that antiangiogenic substances, which were originally developed for treatment of malignant diseases, may also represent long-awaited specific drugs for the treatment of vascular malformations. However, antiangiogenics display significantly different actions and side-effects. Although antiangiogenics like thalidomide seem to inhibit gastrointestinal bleeding, other substances like bevacizumab can cause mucosal bleeding. Therefore differential and cautious evaluation of this therapeutic strategy is necessary.     

Gastroduodenal Vascular Ectasia in Patients with Liver Cirrhosis

The purpose of this study was to determine the incidence of hemorrhage due to vascular ectasia of the upper gastrointestinal tract in patients with liver cirrhosis and to assess the prevalence in cirrhotic patients without clinically overt gastrointestinal bleeding. Out of 96 cirrhotic patients with upper gastrointestinal bleeding, vascular ectasia was diagnosed in 6 patients (6.3%) as the cause of bleeding. These 6 patients had numerous spotty or confluent erythemas consisting of ectatic and tortuous capillaries throughout the antrutn and 4 patients required blood transfusion before diagnostic en-doscopy. Several sessions of endoscopic electrocoagulation resulted in eradication of almost all the abnormal vascular lesions and marked improvement of their anemia without further transfusion. The procedure was well tolerated and no resultant complications were encountered. Among 206 cirrhotic patients without clinically overt gastrointestinal bleeding 25 patients (12.1%) were diagnosed with vascular ectasia. The hemoglobin level was significantly lower in patients with vascular ectasia than those without vascular ectasia but the other features did not differ between the two groups. Vascular ectasia is an important cause of upper gastrointestinal bleeding and anemia in patients with liver cirrhosis. Endoscopic electrocoagulation may be a safe and effective treatment for controlling blood loss from gastroduodenal vascular ectasia in this subset of patients. (Dig Endosc 1999; 11: 241–245)     

Obscure digestive bleeding

Obscure digestive bleeding is defined as recurrent bleeding for which no definite source has been identified by routine endoscopic or barium studies. Mucosal vascular abnormality or 'angioectasia' is the most common course of obscure bleeding, especially in elderly patients. Small bowel tumours are more frequent in patients younger than 50 years. However, missed or underestimated upper and lower gastrointestinal lesions at the initial endoscopic investigation may be the source of a so-called obscure intestinal bleeding.The various radiological procedures, including enteroclysis, visceral angiography and CT scan as well as radioisotope bleeding scans have limitations in the case of obscure gastrointestinal bleeding. Recent developments in magnetic resonance imaging are promising. The different methods of enteroscopy have a similar diagnostic yield, reaching approximately 40-65%. Endoscopic cauterization of small bowel angioectasias seems to be efficacious but randomized trials are needed. Efficacy of hormonal therapy is very controversial.The extent of diagnostic and therapeutic strategies must be based on a number of factors including the patient's parameters, bleeding characteristics and also the result of previous work-up.     

Risk factors for the development of bacterial infections in hospitalized patients with cirrhosis

OBJECTIVE: Bacterial infection is a frequent and severe complication of cirrhosis. Cirrhotic patients admitted for gastrointestinal bleeding are at high risk of such a complication and have been targeted in trials of antibiotic prophylaxis. However, it has not been shown that these patients are at a higher risk than cirrhotic patients hospitalized for other reasons. This prospective study was performed to assess the risk of bacterial infection in unselected hospitalized cirrhotic patients and to evaluate possible risk factors for this complication. METHODS: One hundred-forty hospitalized cirrhotic patients without clinical evidence of infection at the time of initial presentation were followed-up prospectively for manifestations of infection. RESULTS: Twenty-eight (20%) patients developed an infection during their hospitalization. Infections without a specific site (39%) and spontaneous bacterial peritonitis (32%) were the most common diagnoses. Univariate analysis showed that patients who developed an infection were more likely to have a low serum albumin level, to be admitted for gastrointestinal bleeding, to stay in the intensive care unit, and to undergo therapeutic endoscopy. Logistic regression identified admission for gastrointestinal bleeding (odds ratio (OR) = 4.3, 95% confidence interval (CI) = 1.7-10.9) and a low serum albumin (OR = 1.3, 95% CI = 1.03-1.22) as the only two variables independently associated with the development of an infection. CONCLUSION: The present study indicates that patients with severe cirrhosis who are admitted for gastrointestinal bleeding have a higher risk of developing a bacterial infection during their hospitalization than other cirrhotic patients.     

The Endoscopic Detection and Treatment of Vascular Ectasia in the Gastrointestinal Tract —A One Year Experience at Karolinska Hospital—

Abstract: Vascular ectasia of the upper and lower gastrointestinal tract (GIT) is occasionally seen at diagnostic endoscopy. The therapeutic relevance of these lesions are not always immediately clear. The aim of this study was to review a single institution's experience in the endoscopic diagnosis and treatment of GIT vascular ectasia. In order to identify and determine the characteristics and clinical course of patients with vascular ectasia, records of all adult patients undergoing upper or lower GIT endoscopy between September 1996 and August 1997 were reviewed. During the study period 2547 gastroscopies and 1759 colonoscopies were performed. Eighteen patients (0.7%) were diagnosed with vascular ectasia of the upper GIT and 23 patients (1.6%) the lower GIT. Mean age was 72.7 years and the majority of patients were male. A large percentage of patients had coexisting systemic disease. Anemia without overt GIT bleeding was the presenting clinical sign in 67% of upper GIT and 43% of lower GIT vascular ectasia. Fourteen patients received endoscopic treatment for upper GIT and 18 for lower GIT vascular ectasia. Endoscopic treatment was effective in 12 (86%) and 14 patients (78%) with upper and lower GIT vascular ectasia, respectively. Follow-up ranged from 2 to 12 months. There was only one death in each group, both due to systemic diseases unrelated to vascular ectasia. Vascular ectasia of the GIT is a not infequent cause of upper and lower gastrointestinal bleeding and might be occult. Patients are usually elderly with coexisting systemic disease. Multi-modality endoscopic management is the first line of treatment for this condition and seems both effective and safe.     

Protein C deficiency related obscure gastrointestinal bleeding treated by enteroscopy and anticoagulant therapy

Obscure gastrointestinal bleeding is an uncommonly encountered and difficult-to-treat clinical problem in gastroenterology,but advancements in endoscopic and radiologic imaging modalities allow for greater accuracyin diagnosing obscure gastrointestinal bleeding.Ectopic varices account for less than 5% of all variceal bleeding cases,and jejunal variceal bleeding due to extrahepatic portal hypertension is rare.We present a 47-year-old man suffering from obscure gastrointestinal bleeding.Computed tomography of the abdomen revealed multiple vascular tufts around the proximal jejunum but no evidence of cirrhosis,and a visible hypodense filling defect suggestive of thrombus was visible in the superior mesenteric vein.Enteroscopy revealed several serpiginous varices in the proximal jejunum.Serologic data disclosed protein C deficiency(33.6%).The patient was successfully treated by therapeutic balloonassisted enteroscopy and long-term anticoagulant therapy,which is normally contraindicated in patients with gastrointestinal bleeding.Diagnostic modalities for obscure gastrointestinal bleeding,such as capsule endoscopy,computed tomography enterography,magnetic resonance enterography,and enteroscopy,were also reviewed in this article.     

Video push enteroscopy in the investigation of small bowel disease: defining clinical indications and outcomes

Background: Push enteroscopy is a new technique for investigation of the small intestine. The clinical indications are still being defined. It also offers the potential for therapeutic intervention in suitable cases. Aims: To evaluate further the role of push enteroscopy in the diagnosis and treatment of patients with suspected or known small bowel disease. Methods: A prospective record was kept of all patients having enteroscopy at Royal Prince Alfred Hospital between March 1995 and July 1997. The procedure was performed 73 times in 68 patients. Indications and diagnoses were noted. The outcome in patients with obscure gastrointestinal bleeding or anaemia in whom a vascular lesion was treated with a heater probe was also determined. Results: Enteroscopy was performed in 23 patients for gastrointestinal bleeding of obscure origin. An active or possible bleeding source was found in 13 (57%). The commonest of these was jejunal angiodysplasia. In the 21 patients with chronic iron deficiency anaemia a lesion was found in ten (48%). The majority of these were in the stomach, as described by others. The diagnostic yield in the 16 patients having enteroscopy for known or suspected small bowel disease was 56%. One patient underwent balloon dilatation of a postoperative jejunal stricture. Eleven patients with obscure bleeding or anaemia had ablation of a vascular lesion with a heater probe. Transfusion requirements fell after this procedure, particularly in those with active bleeding at the time of the examination. In five of the 11 no further transfusions were required in over six months of follow-up. Conclusions: The most common indications for enteroscopy are obscure gastrointestinal bleeding, chronic anaemia and known or suspected small bowel disease. A positive result can be expected in over 50% of patients. The treatment of vascular lesions via the enteroscope has a significant impact of subsequent transfusion requirements. (Aust NZ J Med 1998; 28: 198–203.)     

Tranexamic acid may be a useful pharmacotherapy for endoscopically resistant small bowel angiodysplasia

Small bowel angiodysplasia (SBAD) is reported to account for nearly 50% of cases of small bowel bleeding. When SBAD occurs frequently, it is difficult to treat all the angiodysplasias endoscopically, and gastrointestinal bleeding often recurs. Hormone therapy, somatostatin analogs, thalidomide and vascular endothelial growth factor (VEGF)-neutralizing antibodies have been reported to reduce gastrointestinal angiodysplasia (GIAD) bleeding. However, there is no strong evidence to recommend them. Also, there are no guidelines for their use. Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disease caused by abnormalities in VEGF, resulting in multiple GIADs. A treatment guideline has been created for GIAD in HHT, and the use of tranexamic acid, an antifibrinolytic agent, is the first recommendation pharmacotherapy for GIAD with gastrointestinal bleeding that is difficult to treat endoscopically. It has been reported that fibrinolysis is accelerated in GIAD patients who are not HHT, similar to HHT patients. The use of tranexamic acid for gastric antral vascular ectasia in GIAD has been reported to be useful. However, there are very few reports of its use for SBAD. There are concerns with tranexamic acid use regarding the development of thrombosis/embolism, but there are few reports of such side effects. Future clinical trials including tranexamic acid for SBAD are desired.     

结肠血管发育不良的肠镜诊治与随访研究

目的探讨结肠血管发育不良（AD）的临床特点以及肠镜下高频电治疗的安全性、疗效。方法分析结肠AD的临床和肠镜特点，对结肠AD无症状者、合并出血者和出血后肠镜治疗者进行了3年随访以了解结肠AD自发出血的风险和治疗的效果：结果10200例结肠镜检查患者中共检出结肠AD126例，总检出率为1．24%，无症状组血管畸形检出率为0．89％；出血组2．62％；非出血组0．82％。1014例无症状者检出9例结肠AD患者，3年随访期问均未出血。结肠AD合并出血者3年内大多数患者会自发再出血，11例行肠镜电凝治疗无并发症且能显著减少1年内再出血率（18％ vs 54％，P〈0．05）：结论结肠AD患病率低，无症状人群中的结肠AD患病率较低且自然转归良好，结肠AD合并出血者多数3年内易自发再出血，肠镜电凝治疗1年内疗效显著.     

Giant Heterotopic Pancreas Presenting with Massive Upper Gastrointestinal Bleeding

Heterotopic pancreas, or pancreatic rest, refers to extra-pancreatic tissue without an obvious vascular or anatomic connection with the pancreas. Although the frequency of heterotopic pancreatic tissue in autopsy series has been reported as high as 14%, clinical manifestations are rare [2]. Although common in the upper gastrointestinal tract, heterotopic pancreatic tissue rarely causes gastrointestinal bleeding. In a large case series following patients with heterotopic pancreatic tissue, only 7 of 212 patients had any evidence of bleeding [3]. We present a patient who presented with massive hematochezia found to have a giant heterotopic pancreas in the duodenum.     

Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: A systematic review

BACKGROUNDAnemia is considered a public health issue and is often caused by iron deficiency. Iron-deficiency anemia (IDA) often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women, and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%. However, few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.AIMTo review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.METHODSFive gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites. MEDLINE (via PubMed) searches combined medical subject headings (MeSH) terms and the keywords “gastrointestinal bleeding” with “iron-deficiency anemia” and “diagnosis” or “treatment” or “management” or “prognosis” or “prevalence” or “safety” or “iron” or “transfusion” or “quality of life”, or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding; retrieved studies were published in English between January 2003 and April 2019. Worldwide professional association websites were searched for clinical practice guidelines. Reference lists from guidelines were reviewed to identify additional relevant articles. The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.RESULTSFrom 494 Literature citations found during the initial literature search, 17 original articles, one meta-analysis, and 13 clinical practice guidelines were analyzed. Based on the published evidence and clinical experience, the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding: (1) Evaluation of hemoglobin and iron status; (2) Laboratory testing; (3) Target treatment population identification; (4) Indications for erythrocyte transfusion; (5) Treatment targets for erythrocyte transfusion; (6) Indications for intravenous iron; (7) Dosages; (8) Monitoring; (9) Indications for intravenous ferric carboxymaltose treatment; and (10) Treatment targets and monitoring of patients. The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding, which should be implemented during the hospital stay and follow-up visits after patient discharge.CONCLUSIONThese recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.     

Crohn's disease of the upper gastrointestinal tract

Although Crohn's disease (CD) is generally found in the ileum and/or colon, since the 1960s it has become evident that this chronic inflammatory disorder of unknown aetiology can affect the whole gastrointestinal tract from mouth to anus. In 0.5–13% of patients with ileocolonic CD the disease occurs in the upper gastrointestinal tract as well (i.e., from mouth through jejunum). With the radiological double-contrast technique, however, early signs of upper gastrointestinal CD may be detected in 20–40% of patients with ileocolitis. On the other hand, histologically evaluated biopsies from the lower oesophagus, body of the stomach, gastric antrum and the duodenal bulb of patients with Crohn's disease from whom the upper gastrointestinal tract is normal, according to X-ray or endoscopy may reveal lesions, which are considered to be pathologically diagnostic. Jejunal involvement occurs in 4–10% of patients with ileitis, ileocolitis or colitis. In early studies biopsies of apparently normal buccal mucosa from patients with Crohn's disease showed a significant correlation between the activity of the disease, as defined by the Crohn's Disease Activity Index, and the number of plasma cells containing IgM, suggesting a generalized activated humoral defence system during relapse. A diagnosis of Crohn's disease of the upper gastrointestinal tract can be achieved by combining recognition of clinical, roentgenographic, and endoscopic features. Provided that other causes of granulomatous involvement of the gastrointestinal tract can be excluded, non-caseating granulomas are generally accepted as the histological proof of Crohn's disease. When Crohn's disease does involve the upper gastrointestinal tract, there is nearly always concomitant disease in the small bowel or colon. Compared to patients with an ileocolonic localization, patients with Crohn's disease in the upper gastrointestinal tract more frequently have colic-like abdominal pain and/or cramps, nausea and anorexia as presenting symptoms and are younger at onset of the disease. Medical therapeutic principles are the same as for Crohn's disease elsewhere in the gastrointestinal tract. Absolute indications for surgical treatment are massive bleeding, progressive stenosis, and extensive fistula formation.     

Multiple angiodysplasia of the small intestine. A diagnostic and therapeutic challenge

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.     

Rate and predictive factors of rebleeding with obscure-overt gastrointestinal bleeding.

BACKGROUND/AIMS: Little information is available on the rate and predictive factors of rebleeding of unknown cause, which is very important in deciding further investigations on obscure-overt gastrointestinal bleeding. The aim of this study was to evaluate the rebleeding rate and related factors in obscure-overt gastrointestinal bleeding patients who revealed normal gastroscopic and colonoscopic findings. METHODS: A total of 69 patients with negative first-line gastroscopy and colonoscopy were enrolled in this study as obscure-overt gastrointestinal bleeding cases. The relationships between rebleeding and clinical characteristics were analyzed retrospectively. RESULTS: The causes of obscure-overt gastrointestinal bleeding were confirmed in 30 cases among the 69 cases. Small bowel tumors (14 cases) were the most common cause, followed by vascular lesions (6 cases). The mean follow-up period was 28 months and rebleeding was noticed in 19 patients (27.5%). Among these rebleeding patients, 14 cases (73.7%) occurred within 6 months. The past experience of previous bleeding was significantly related with rebleeding (p=0.0009). CONCLUSIONS: Close observation and detailed investigations are needed for obscure-overt gastrointestinal bleeding patients with bleeding history, especially during 6 months follow-up.     

Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57–100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13–52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.     

A sampling of Canadian practice in managing nonvariceal upper gastrointestinal bleeding before recent guideline publication: is there room for improvement?

BACKGROUND: There are few recent published consensus guidelines regarding nonvariceal upper gastrointestinal bleeding. In 2003, the Canadian Association of Gastroenterology sponsored a set of 20 recommendations. AIM: To compare current Canadian clinical practice patterns with these most recent guidelines. METHODS: Data obtained from the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), complemented by a questionnaire sent out to the 18 participating RUGBE sites, were used to compare present practice with all 20 guidelines. RESULTS: Only three RUGBE sites had an explicit written protocol for nonvariceal upper gastrointestinal bleeding, and only 40% of the sites had support staff available after hours. The Blatchford prognostic scale was not used routinely, and only one site used the Rockall score for risk stratification. Most patients classified as low-risk according to the literature had endoscopy within 24 h and a median length of stay of two days compared with high-risk patients who underwent endoscopy approximately 4 h earlier, had a median length of stay of 4.3 days and displayed a higher mortality. Nineteen per cent of all patients had a routine second-look endoscopy. Proton pump inhibitors were frequently used in the acute setting. Thirteen per cent of all patients rebled and only 34% of these received a second endoscopy. One-half of all patients were tested for Helicobacter pylori while in hospital, mostly by histology, and one-third of those who tested positive received H pylori eradication during their hospitalization. CONCLUSION: Compared with recommendations put forward in the new guidelines, clinical practice before guideline publication was variable. The future level of guideline adherence and patient outcome data should be quantified and monitored as the guidelines are disseminated.     

Actualización en hemorragia gastrointestinal de origen no varicoso

This article summarizes the main studies in the field of non-variceal gastrointestinal bleeding reported in the last American Congress of Gastroenterology (Digestive Disease Week) in 2013. Some of these studies have provided new knowledge and expertise in areas of uncertainty. In this context and among other findings, it has been reported that the administration of a proton pump inhibitor (PPI) prior to endoscopy or the early performance of endoscopy–within 6 hours of admission in patients with upper gastrointestinal bleeding (UGIB) (or colonoscopy within 24 hours in patients with lower gastrointestinal bleeding)–does not improve the prognosis of the event. It has also been reported that oral administration of a PPI after endoscopic hemostasis may produce a similar outcome to that of intravenously administered PPI in patients with upper gastrointestinal bleeding (UGIB). In the field of endoscopic therapy, the use of radiofrequency ablation for antral vascular ectasia is of interest. Regarding UGIB and nonsteroidal antiinflammatory drugs (NSAIDs), new data confirm the risk of cardiovascular events by stopping treatment with acetylsalicylic acid (ASA) after an episode of UGIB, the increased risk of UGIB when associating gastrotoxic drugs, and the need to identify both the gastrointestinal and cardiovascular risks of each NSAID and coxib when prescribing these agents. Finally, there is evidence that both environmental and genetic factors are involved in individual susceptibility to gastrointestinal bleeding.     

Effect of endoscopic treatment of gastric antral vascular extasia associated with chronic liver disease

Background : Gastric antral vascular ectasia (GAVE), as a cause of upper gastrointestinal bleeding, has been treated surgically, endoscopically and pharmacologically for the past 20 years. Methods : We analyzed the clinical effect of endoscopic treatment for 12 cases of GAVE diagnosed at Osaka National Hospital between January 1993 and October 1998. Results : Eight of the 12 cases were treated endoscopically due to marked anemia and histories of gastrointestinal bleeding. All had chronic liver disease (CLD). Mean age was 69 years on diagnosis. Male to female ratio was 1 : 1. Gastric antral vascular ectasia was a cause of 3.9% of bleeding associated with CLD. The modes of endoscopic treatment of the eight cases were laser photocoagulation (1), electrocautery (3), and heater probe thermocoagulation (4). The initial treatment required an average of 5.1 sessions over a period of 43 days. Initial hemostasis was successful in all cases. Treatments for recurrent bleeding were necessary in six cases within 9.2 months, and endoscopic coagulation was again effective in two cases. Corticosteroids were effective in two of three cases resistant to endoscopic therapy. Mean follow‐up period after initial treatment was 2.8 years. The mean total number of therapeutic endoscopy sessions was 9.6. Conclusion : Endoscopic treatments and/or corticosteroids have yielded sufficient results in the hemorrhage of GAVE. Factors affecting the recurrence of GAVE need to be analyzed in CLD patients.     

Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration. METHODS: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up. RESULTS: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). CONCLUSIONS: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.