Impact of fecal occult blood on obscure gastrointestinal bleeding:Observational study

AIM: To elucidate the association between small bowel diseases(SBDs) and positive fecal occult blood test(FOBT) in patients with obscure gastrointestinal bleeding(OGIB).METHODS: Between February 2008 and August 2013, 202 patients with OGIB who performed both capsule endoscopy(CE) and FOBT were enrolled(mean age; 63.6 ± 14.0 years, 118 males, 96 previous overt bleeding, 106 with occult bleeding). All patients underwent immunochemical FOBTs twice prior to CE. Three experienced endoscopists independently reviewed CE videos. All reviews and consensus meeting were conducted without any information on FOBT results. The prevalence of SBDs was compared between patients with positive and negative FOBT.RESULTS: CE revealed SBDs in 72 patients(36%). FOBT was positive in 100 patients(50%) and negative in 102(50%). The prevalence of SBDs was significantly higher in patients with positive FOBT than those with negative FOBT(46% vs 25%, P = 0.002). In particular, among patients with occult OGIB, the prevalence of SBDs was higher in positive FOBT group than negative FOBT group(45% vs 18%, P = 0.002). On the other hand, among patients with previous overt OGIB, there was no significant difference in the prevalence of SBDs between positive and negative FOBT group(47% vs 33%, P = 0.18). In disease specific analysis among patients with occult OGIB, the prevalence of ulcer and tumor were higher in positive FOBT group than negative FOBT group. In multivariate analysis, only positive FOBT was a predictive factors of SBDs in patients with OGIB(OR = 2.5, 95%CI: 1.4-4.6, P = 0.003). Furthermore, the trend was evidentam on g patients with occult OGIB who underwent FOBT on the same day or a day before CE. The prevalence of SBDs in positive vs negative FOBT group were 54% vs 13% in patients with occult OGIB who underwent FOBT on the same day or the day before CE(P = 0.001), while there was no significant difference between positive and negative FOBT group in those who underwent FOBT two or more days before CE(43% vs 25%, P = 0.20).CONCLUSION: The present study suggests that positive FOBT may be useful for predicting SBDs in patients with occult OGIB. Positive FOBT indicates higher likelihood of ulcers or tumors in patients with occult OGIB. Undergoing CE within a day after FOBT achieved a higher diagnostic yield for patients with occult OGIB.     

Single-center experience of 309 consecutive patients with obscure gastrointestinal bleeding

AIM: To investigate the diagnostic yield of capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding (OGIB), and to determine whether the yield was affected by different bleeding status.METHODS: Three hundred and nine consecutive patients (all with recent negative gastric and colonic endoscopy results) were investigated with CE; 49 cases with massive bleeding and 260 cases with chronic recurrent overt bleeding. Data regarding OGIB were obtained by retrospective chart review and review of an internal database of CE findings.RESULTS: Visualization of the entire small intestine was achieved in 81.88% (253/309) of cases. Clinically positive findings occurred in 53.72% (166/309) of cases. The positivity of the massive bleeding group was slightly higher than that of the chronic recurrent overt bleeding group but there was no significant difference (59.18% vs 52.69%, P > 0.05) between the two groups. Small intestinal tumors were the most common finding in the entire cohort, these accounted for 30% of clinically significant lesions. In the chronic recurrent overt bleeding group angioectasia incidence reached more than 29%, while in the massive bleeding group, small intestinal tumors were the most common finding at an incidence of over 51%. Increasing patient age was associated with positive diagnostic yield of CE and the findings of OGIB were different according to age range. Four cases were compromised due to the capsule remaining in the stomach during the entire test, and another patient underwent emergency surgery for massive bleeding. Therefore, the complication rate was 1.3%. CONCLUSION: In this study CE was proven to be a safe, comfortable, and effective procedure, with a high rate of accuracy for diagnosing OGIB.     

New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics

Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.     

The natural history of occult or angiodysplastic gastrointestinal bleeding in von Willebrand disease

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.     

Epidemiology of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.     

Capsule endoscopy findings in patients with occult or overt bleeding older than 80 years

Background: Overt and occult bleeding are the main indications for a wireless capsule endoscopy (WCE) study of the small bowel. Most published studies omit patients aged over 80. Aim: To determine whether WCE is feasible in patients with overt or occult bleeding over age 80 and to define the spectrum of small bowel pathologies in this age group. Patients and Methods: In a retrospective non‐randomized tertiary care study, 60 patients at least 80 years or older (aged group) and 120 matched patients aged <80 years (younger group) with overt or occult bleeding (including iron deficiency anaemia) and no significant gastroscopic or colonoscopic findings underwent WCE. Results: Of the 180 patients, 46 (77%) patients in the aged group and 97 (81%) in the younger group successfully completed small bowel study (P = 0.51). There was no difference in gastric transit time and small bowel passing time between the two groups. More patients in the aged group (48 cases, 80%) than the younger group (56 cases, 47%) presented with small bowel angiodysplasias (P < 0.0001). Nevertheless, there was no difference between the two groups concerning ulcerative and neoplastic lesions. No patient presented with capsule impaction, but more patients in the aged group (35 cases, 58%) than in the younger group (10 cases, 8%) found the study difficult and tiresome (P < 0.001). Preparation validation was poor in 34% of small bowel lumen in the aged group and 19% in the younger group (P = 0.03). Conclusion: WCE is feasible, although rather tiresome, in patients over the age of 80. Though the vast majority of patients older than 80 presented with angiodysplasias, there were no differences between the aged and younger groups in the presence of ulcerative lesions and polyps or tumors.     

A prospective study of same day bi-directional endoscopy in the evaluation of patients with occult gastrointestinal bleeding

Objective. Previous studies show conflicting results in the diagnostic yield of oesophagogastroduodenoscopy (OGD) and colonoscopy (bi-directional) in identifying potential bleeding sources (PBS) in patients investigated for occult gastrointestinal bleeding (OGIB). The aims of this study were to evaluate the diagnostic yield of bi-directional endoscopy in patients presenting with OGIB and to assess the factors predictive of a positive yield. Material and methods. Patients with OGIB referred to the gastroenterology unit were prospectively included in the study. Colonoscopy was immediately followed by OGD. Predetermined criteria for the diagnosis of a PBS were used. Potential clinical factors predictive of positive yield were assessed. Results. Of the 219 patients (mean age 65 years, 34% M), 110 (50%) had at least one PBS. Colonoscopy revealed 87 PBS in 73 patients (33%), the most common being adenoma. OGD detected 49 PBS in 48 patients (22%), gastric ulcer being the most common. Of the patients with PBS at OGD, 23% also had a PBS at colonoscopy, including 3 patients with colonic cancers. Patients presenting with either a positive faecal occult blood test (FOBT) or iron-deficiency anaemia (IDA) only had a significantly lower yield for PBS than patients with combined positive FOBT and IDA. The percentages of patients with a PBS increased substantially with age. Conclusions. A PBS was found in only 50% of the patients. Colonoscopy had a slightly higher diagnostic yield, and as expected, resulted in a significantly higher cancer detection rate than OGD. In older patients, colonoscopy should be done irrespective of the findings at OGD. Gastrointestinal-specific symptoms and the use of ASA/NSAIDs were not predictive in finding or localizing PBS.     

阑尾黏膜血管增生致下消化道出血并文献复习

阑尾来源的下消化道出血（LGIB）临床罕见，虽然目前存在较多诊断方法，但结肠镜仍被认为是首选。本文报告一例首次结肠镜检查阴性，依次行胃镜及胶囊内镜检查无阳性发现，再次行结肠镜检查发现阑尾腔内活动性出血导致便血的病例。患者行腹腔镜阑尾切除术后恢复良好。病理证实阑尾黏膜血管增生病变并出血。最后，对相关文献进行了复习。     

内镜治疗在急性非静脉曲张上消化道出血中的应用

急性非静脉曲张上消化道出血是临床常见的急危重症。内镜技术在急性非静脉曲张上消化道出血的治疗中有重要价值。近年此领域有了持续的新进展。本文即就内镜治疗对急性非静脉曲张上消化道出血的适宜治疗患者、治疗时机以及治疗方法和策略等方面给予简述。     

Acute upper gastrointestinal bleeding in octogenarians： Clinical outcome and factors related to mortality

AIM： To evaluate the aetiology, clinical outcome and factors related to mortality of acute upper gastrointestinal bleeding （AUGIB） in octogenarians.
METHODS： We reviewed the records of all patients over 65 years old who were hospitalised with AUGIB in two hospitals from January 2006 to December of 2006. Patients were divided into two groups： Group A （65-80 years old） and Group B （〉 80 years old）. RESULTS： Four hundred and sixteen patients over 65 years of age were hospitalized because of AUGIB. Group A included 269 patients and Group B 147 patients. Co-morbidity was more common in octogenarians （P = 0.04）. The main cause of bleeding was peptic ulcer in both groups. Rebleeding and emergency surgery were uncommon in octogenarians and not different from those in younger patients. In-hospital complications were more common in octogenarians （P = 0.05） and more patients died in the group of octogenarians compared to the younger age group （P = 0.02）. Inability to perform endoscopic examination （P = 0.002）, presence of high risk for rebleeding stigmata （P = 0.004）, urea on admission （P = 0.036）, rebleeding （P = 0.004） and presence of severe co-morbidity （P 〈 0.0001） were related to mortality. In multivariate analysis, only the presence of severe co-morbidity was independently related to mortality （P = 0.032）.
CONCLUSION： While rebleeding and emergency surgery rates are relatively low in octogenarians with AUGIB, the presence of severe co-morbidity is the main factor of adverse outcome.     

双联抗血小板治疗并高危消化道出血的临床用药

急性冠脉综合征（ACS）及经皮冠状动脉介入术（PCI）后患者应用双联抗血小板（阿司匹林＋氯吡格雷）要优于单一抗血小板药物治疗。但随着阿司匹林及氯毗格雷为代表的抗血小板药物在冠状动脉疾病中的广泛应用,与该类药物相关的胃肠道损伤亦随之备受关注。     

Effect of cimetidine on marathon-associated gastrointestinal symptoms and bleeding

Occult gastrointestinal bleeding occurs in 8–30% of marathon runners. We hypothesized that cimetidine would decrease bleeding by reducing acid-mediated injury and conducted a blinded, placebo-controlled prospective trial to determine the impact of cimetidine on gastrointestinal symptoms and bleeding during a marathon. Thirty participants in the 1989 Marine Corps or New York City marathons completed pre- and postrace: (1) a questionnaire evaluating demographic, medication usage, training history, and gastrointestinal symptoms; (2) three consecutive stool Hemoccult (HO) cards; and (3) a stool Hemoquant (HQ). Fourteen runners (CR) took 800 mg of cimetidine by mouth 2 hr before the start and 16 runners (PR) took placebo. Three subjects were HO+ prerace and were not analyzed. Three subjects failed to take drug as directed and were analyzed as PR. Five of 14 PR and two of 13 CR were HO+ postrace (P>0.05). Prerace HQ values (PR: 1.49 ±0.6 and CR: 0.60±0.1 mg hemoglobin/g stool) were not significantly different from postrace HQ values (PR:0.73±0.2 and CR:0.86±0.2 mg Hgb/g stool). Despite postrace HO+ conversion, no individual postrace HQ became abnormal. The frequency of gastrointestinal symptoms was similar for CR and PR, as well as HO- and HO+ individuals. Cimetidine did not significantly affect occult gastrointestinal bleeding as measured by HO or HQ results. This suggests that marathon-associated gastrointestinal symptoms and bleeding may be due to lesions other than acid-mediated disease or hemorrhagic gastritis.This work was presented in part at the 1990 Digestive Disease Week Annual Scientific Meeting, American Gastroenterological Association, San Antonio, Texas, May 16, 1990, and published in abstract form in Gastroenterology 98:A91, 1990.Work supported by: US Naval Medical Research and Development Command, Grant NN0007589 WR 00016.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, the Department of Defense, or the Uniformed Services University of the Health Sciences.     

Upper gastrointestinal bleeding in the setting of excessive warfarin anticoagulation: Risk factors,and clinical outcome

AimGastrointestinal tract is the most common source of severe bleeding following excessive warfarin anticoagulation (EWA). We aimed to describe the risk factors and outcome associated with upper gastrointestinal bleeding (UGIB) in patients admitted with EWA.MethodsDemographics, clinical, laboratory and endoscopic findings of patients admitted with EWA from 2003 to 2015 were reviewed. Hospital mortality, blood product utilization and hospital length of stay were recorded. Regression analyses were performed for prediction of GI bleeding and mortality in patients with EWA.ResultsMedical records of 157 women and 121 men were reviewed. From 41 patients presented with UGIB, 31 (75.6%) underwent esophagogastroduodenoscopy. Preexisting peptic ulceration (32.2%) was the most common source of bleeding in these patients. Hospital mortality was 9.8% in patients with UGIB which was similar to those without. In average, patients with UGIB required 2 units more packed red blood cells and fresh frozen plasma. Older age (P = 0.045) and previous history of peptic ulcer disease (P < 0.001) were the predictors of UGIB in patients with EWA.ConclusionPresence of past or current peptic disorders was the strongest predictor of UGIB in patients with EWA. Despite comparable hospital mortality, these patients required more transfusion of blood products.     

胶囊内镜对不明原因消化道出血诊断的相关影响因素探讨

目的 分析在不同情况下胶囊内镜(CE)对于不明原因消化道出血(OGIB)患者的小肠疾病检出率,以探讨CE检查时机、OGIB出血类型、出血量等因素对于OGIB诊断率的影响.方法 收集北京军区总医院2005年7月-2012年5月209例因OGIB行CE检查患者的临床资料进行分析,将全部入选者分为显性出血组与隐性出血组及轻、中、重出血组;根据患者出血时间与胶囊内镜检查间隔时间将各组患者分别分为3组(A组:72 h内检查组;B组:2周内检查组;C组:2周后检查组).对各组小肠疾病检出情况进行记录并对各组间小肠疾病检出率进行比较.结果 显性出血组中小肠病变检出率58.0％,隐性出血组中小肠病变检出率37.9％,两组比较差异有统计学意义.轻、中、重出血3组小肠疾病检出率分别为30.6％、57.4％、61.3％.显性出血组中A组患者与B组患者小肠疾病检出率差异无统计学意义,A组及B组患者小肠疾病检出率明显高于C组患者.隐性出血组中B组小肠疾病检出率高于A组及C组患者.结论 CE对于OGIB的小肠疾病检出率与显性出血、出血量及CE检查时间等因素相关.对于显性出血患者来说,出血2周内行CE检查小肠疾病检出率明显高于出血2周后进行CE检查;选择显性出血时及中、重度出血患者可获得较高CE小肠疾病检出率.OGIB最常见病因为小肠血管发育异常.     

Hemospray for treatment of acute bleeding due to upper gastrointestinal tumours

BackgroundHemospray is a new endoscopic haemostatic powder that can be used in the management of upper gastrointestinal bleedings.AimsTo assess the efficacy and safety of Hemospray as monotherapy for the treatment of acute upper gastrointestinal bleeding due to cancer.MethodsThe endoscopy databases of 3 Italian Endoscopic Units were reviewed retrospectively and 15 patients (8 males; mean age 74 years) were included in this study.ResultsImmediate haemostasis was achieved in 93% of cases. Among the successful cases, 3 re-bled, one case treated with Hemospray and injection had a good outcome, while 2 cases died both re-treated with Hemospray, injection and thermal therapy. No complications related to Hemospray occurred. Finally, 80% of patients had a good clinical outcome at 30 days and 50% at six months.ConclusionHemospray may be considered an effective and safe method for the endoscopic management of acute neoplastic upper gastrointestinal bleedings.     

Clinical study of a new fecal occult blood test using a combination assay of hemoglobin and transferrin

The applicability of a new immunological fecal occult blood test in which hemoglobin (Hb) and transferrin (Tf) are simultaneously assayed was evaluated. The mean absorbance and standard deviation (510/630 nm) obtained by this test was 0.840±0.805 in 51 fecal samples from patients with colon cancer, 0.248±0.305 in 95 samples from patients with colon polyps, and 0.104±0.053 in 110 samples from control patients; these values differed significantly (P<0.005). Hb and Tf concentrations were separately determined in the same fecal sampels, and qualitative evaluation was performed with a cutoff value of 5.1μg/g feces for Hb and 0.4μg/g feces for Tf. Hb or Tf was positive in 41 of the 51 samples in the colon cancer group, 33 of the 95 in the colon polyp group, and 3 of the 110 in the control group. Qualitative analysis of the values obtained by the combination assay of Hb and Tf with a cutoff value of 0.200 revealed positive rates of 41/51 in the colon cancer gorup, 33/95 in the colon polyp group, and 4/110 in the control group. These results sugest the usefulness of a combination assay of Hb and Tf as a fecal occult blood test.     

Time trends and outcome of gastrointestinal bleeding in the Veneto Region: A retrospective population based study from 2001 to 2010

BackgroundGastrointestinal bleeding is the most frequent emergency for gastroenterologists. Despite advances in management, an improvement in mortality is still not evident.AimDetermining time trends of gastrointestinal bleeding hospitalization and outcomes from 2001 to 2010 in the Veneto Region (Italy).Patients and methodsData of patients admitted with gastrointestinal bleeding from Veneto regional discharge records were retrospectively evaluated. Chi-squared and multivariate logistic regression model were used.ResultsOverall, 44,343 patients (mean age 64.2 ± 8.6 years) with gastrointestinal bleeding were analysed: 23,450 (52.9%) had upper, 13,800 (31.1%) lower, and 7093 (16%) undefined gastrointestinal bleeding. Admission rate decreased from 108.0 per 100,000 in 2001 to 80.7 in 2010, mainly owing to a decrease in upper gastrointestinal bleeding (64.4 to 35.9 per 100,000, p < 0.05). Reductions in hospital fatality rate (from 5.3% to 3%, p < 0.05), length of hospital stay (from 9.3 to 8.7 days, p < 0.05), and need for surgery (from 5.6% to 5%, p < 0.05) were observed. Surgery (OR: 2.97, 95% CI: 2.59–3.41) and undefined gastrointestinal bleeding (OR: 2.89, 95% CI: 2.62–3.19) were found to be risk factors for mortality.ConclusionsPatient admissions for gastrointestinal bleeding decreased significantly over the years, owing to a decrease in upper gastrointestinal bleeding. Improved outcomes could be related to regional dedicated clinical gastroenterological management.