Gastrointestinal Bleeding and Anticoagulant or Antiplatelet Drugs: Systematic Search for Clinical Practice Guidelines

Gastrointestinal (GI) bleeding is a frequently encountered and very serious problem in emergency room patients who are currently being treated with anticoagulant or antiplatelet medications. There is, however, a lack of clinical practice guidelines about how to respond to these situations. The goal of this study was to find published articles that contain specific information about how to safely adjust anticoagulant and antiplatelet therapy when GI bleeding occurs.The investigators initiated a global search on the PubMed and Google websites for published information about GI bleeding in the presence of anticoagulant or antiplatelet therapy. After eliminating duplicate entries, the medical articles that remained were screened to narrow the sets of articles to those that met specific criteria. Articles that most closely matched study criteria were analyzed in detail and compared to determine how many actual guidelines exist and are useful.We could provide only minimal information about appropriate therapeutic strategies because no articles provided sufficient specific advice about how to respond to situations involving acute GI bleeding and concurrent use of anticoagulant or antiplatelet drugs. Only 4 articles provided enough detail to be of any use in an emergency situation.Clinical practice guidelines and also clinical trials for GI hemorrhaging should be expanded to state in which situations the use of anticoagulant or antiplatelet drugs should be suspended and the medications should later be resumed, and they should state the level of risk for any particular action.     

Stroke Prevention,Evaluation of Bleeding Risk,and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines

In recent years the management of atrial fibrillation patients has progressively and substantially changed because of the introduction of new treatments and the availability of new data regarding the epidemiology and clinical management of these patients. In the past 2 years alone, there have been 7 new guidelines or guideline updates that have been published, which have introduced new recommendations and significantly revised previously published ones. Two updates for Canadian guidelines were published in 2016 and 2018, whereas guidelines from the European Society of Cardiology in 2016, Asia Pacific Heart Rhythm Society were published in 2017, National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand, American College of Chest Physicians, and Korean Heart Rhythm Society have been published in 2018. In this narrative review we provide a comparison of these contemporary international guidelines, with particular attention on the evaluation of thromboembolic and bleeding risks and management of oral anticoagulant therapy. From the analysis of contemporary guidelines on the management of atrial fibrillation, a general agreement is evident about the baseline evaluation of thromboembolic and bleeding risk, as well as a preference for the use of non-vitamin K antagonist oral anticoagulants. Also, regarding the concomitant use of oral anticoagulant and antiplatelet drugs in patients with acute coronary syndromes, undergoing elective percutaneous coronary intervention, catheter ablation, and cardioversion procedures, all of the guidelines agree on the general principles and are supported by evidence. More data are still needed to better substantiate recommendations for specific atrial fibrillation subpopulations. The need for an integrated approach and holistic management is highlighted in the more recently published guidelines.     

上消化道大出血的分析研究

本文论述了上消化道大出血病因、诊断方法、止血措施等,重点阐述了三腔二囊管压迫止血、内镜下止血、经静脉肝内门体静脉分流术等止血的措施和方法,为消化道大出血临床实践提供了一定的理论指导.     

Non-variceal Gastrointestinal Bleeding in Patients with Liver Cirrhosis: A Review

Background

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

Aim

To review NVGI bleeding in cirrhosis.

Methods

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords “portal hypertensive gastropathy,” “gastric vascular ectasia,” “peptic ulcer,” “Dieulafoy’s,” “Mallory–Weiss syndrome,” “portal hypertensive enteropathy,” “portal hypertensive colopathy,” “hemorrhoids,” and “cirrhosis.”

Results

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy’s lesion, Mallory–Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

Conclusions

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.     

Review Article: Gastrointestinal Bleeding Risk with Direct Oral Anticoagulants

Cardiovascular Drugs and Therapy - Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared...     

Scintigraphic Detection of Gastrointestinal Bleeding: A Review of Current Methods

Recent experience with radionuclide imaging has provided the clinician with several techniques to noninvasively detect and locate sources of gastrointestinal hemorrhage. These tests can be rapidly performed and often in an ICU setting. One method used Tc-99m sulfur colloid which, in an animal model, has been shown to detect acute bleeding at rates as low as 0.1 ml/min. However, because the tracer remains in the blood for a short period of time, it may be suboptimal for identifying patients with intermittent bleeding. Tc-99m red cells is a tracer that remains within the blood and permits detection of both acute and intermittent bleeding. With tagged red cells, sites of bleeding from both the upper and lower gastrointestinal tract can be found. Both of these techniques can provide important information in the patient with suspected active gastrointestinal bleeding and aid the clinician in more effective management including the use of invasive diagnostic and therapeutic techniques.     

Diagnosis and Treatment of Acute Lower Gastrointestinal Bleeding

Diagnostic sigmoidoscopy and barium enema examinations (n = 214) or colonoscopy (n = 52) were performed for acute lower gastrointestinal (GI) bleeding. The cause of bleeding was detected in 76% (203 of 266) of the primary examinations, and the cause remained unclear after subsequent examinations in 17% of the cases. Hemorrhoids were the cause of bleeding in 28% (56 of 203) of the cases, colonic diverticular disease in 19% (39 of 203), adenomatous polyps in 11% (23 of 203), and colorectal cancer in 10% (20 of 203). The sources of bleeding did not differ significantly by sex. An anorectal site of bleeding was most often detected in patients less than 50 years of age (p < 0.0001) and a left colonic site in those more than 70 years (p < 0.0001). Hemorrhoids significantly more often caused rectal bleeding among the youngest patients (p < 0.0001) and colonic diverticular disease among the oldest patients (p < 0.0001) and colonic diverticular disease among the oldest patients (p < 0.0001) than among the others. Of the 266 patients, 19% have been operated on for the bleeding lesion. The mortality related to lower GI bleeding was 4% (11 of 266). The mean age of the patients who died was higher than that of those who survived (p < 0.05).     

Gastrointestinal Bleeding After Continuous-flow Left Ventricular Device Implantation: Review of Pathophysiology and Management

Gastrointestinal bleeding is one of the most common complications in patients with continuous-flow left ventricular assist devices. Though the exact pathophysiology is still unclear, continuous-flow physiology, acquired Von Willebrand disease, and formation of arteriovenous malformations in the gastrointestinal tract are implicated. An individualized plan of endoscopic therapy and anticoagulation management is required when caring for these patients.     

Somatostatin Analogues in the Treatment of Recurrent Bleeding from Gastrointestinal Vascular Malformations: An Overview and Systematic Review of Prospective Observational Studies

Background  

Vascular malformation of the gastrointestinal tract is an uncommon cause for gastrointestinal bleeding. Traditionally, gastroenterologists prefer to use endoscopic modalities like argon plasma coagulation and electrocoagulation to treat accessible lesions. The role of somatostatin analogues (octreotide) in preventing recurrent bleeding in these patients is unclear. The use of pharmacological treatments would be useful especially in refractory bleeding, inaccessible lesions and in patients who are at high risk for invasive interventions.     

Gastrointestinal Bleeding in Aortic Stenosis

Gastrointestinal bleeding in aortic stenosis is an uncommon condition but when present it is often undiagnosed. The usual radiological proceedures fail to demonstrate the source of bleeding. Mesenteric angiography, however, will identify the lesion. The lesion is usually a vascular malformation located in the right colon. The angiodysplasia may also occur in other parts of the gastrointestinal tract. We have encountered five patients with aortic stenosis who had multiple massive hemorrhages of the lower gastrointestinal tract who defied diagnosis by the conventional methods. Mesenteric angiography, however, disclosed the orgin of the bleeding. In four patients vascular malformations were found in the right colon and one in the jejunum. Right hemicolectomy and partial jejunectomy resulted in a cure in all.     

Management of Gastrointestinal Bleeding in Children

Opinion statement Gastrointestinal bleeding in infants and children is a potentially life-threatening problem that is encountered by virtually all practicing pediatric gastroenterologists. Youngsters with a normal hematocrit, hemodynamic stability, and a history consistent with an acute, self-limited illness most frequently need only close observation; others require more in-depth assessment and intervention. Meticulous attention to the patient’s cardiopulmonary status and knowledge of appropriate pediatric resuscitation schemes form the cornerstones on which more specific therapeutic interventions are based. Many treatment techniques and approaches have been extrapolated for pediatric use from adult studies; the regimen implemented for a child should be individualized and based on factors such as patient size, underlying condition, and operator expertise. Although the physician treating pediatric gastrointestinal hemorrhage requires more than a modicum of patience and determination, this must be tempered with a ready willingness to seek consultation from surgical colleagues to ensure optimal outcomes. Knowledge of acid-suppressive and vasoactive medications is essential, as is familiarity with at least one injection technique and one thermocoagulation technique for hemostasis. Endoscopic sclerotherapy and variceal band ligation are equally efficacious in achieving control of acute variceal bleeding, but band ligation is emerging as the technique best suited for prophylaxis. Beta blockade appears to have a smaller and less well-defined role in pediatric variceal prophylaxis compared with that in adults, but random controlled trials are necessary to confirm this impression.     

Treatment Decision for Potential Bleeders in Obscure Gastrointestinal Bleeding During Double-Balloon Enteroscopy

Double-balloon enteroscopy (DBE) is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. The aim is to describe how outcomes differ with patient setting (with DBE diagnosis and intervention, with DBE diagnosis but without intervention, and without DBE diagnosis), and thus demonstrate the value of endoscopic intervention when encountering potential bleeder during DBE. From November 2003 to January 2008, 90 patients with obscure gastrointestinal bleeding presented with DBE at our tertiary referral center. A total of 113 DBE procedures were carried out. Overall diagnostic yield was 75.6% (68/90). Endoscopic intervention was performed in 58 (85.3%) of the 68 patients with potential bleeder. The 90 patients were divided into three settings: with endoscopic diagnosis and intervention (n = 58), with endoscopic diagnosis but without intervention (n = 10), and without endoscopic diagnosis (n = 22). Rebleeding rates for the three groups were 22.4%, 60%, and 22.7%, respectively. For the 35 patients diagnosed with vascular lesions, the rebleeding rates in patients with and without endoscopic intervention, were 38.5% (10/26) and 66.7% (6/9), respectively. One (0.9%) severe adverse event occurred during the 113 procedures, and the patient died. DBE is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. DBE involves relatively safe procedures and has an acceptable complication rate. When potential bleeders are encountered during the procedure, especially for vascular lesions, therapeutic intervention should be attempted, since the intervention-related complication rate is acceptable, and such intervention can reduce the rebleeding rate and enhance the cost-effectiveness of DBE.