bluuebunny/crossref_metadata_2025 huggingface dataset:
576 Comparing Electronic Consults versus Outpatient Referrals to Gastroenterology: Impact on Timespan to and Completion Rates of Recommended Procedures
Authors: Lindholm Christopher , Ramkissoon Resham , Cohen Emily , Anderson Joseph
Published: October 2019

INTRODUCTION:

Electronic consults (econsults) are a valuable tool embedded in the electronic medical record. There have been a number of studies regarding econsults, however most are descriptive studies. There are currently few studies describing the impact of econsults on clinical practice. In this retrospective study we examined how econsults to gastroenterology compared to “standard consults” submitted via primary care practitioners (PCP) impacted 1) time to recommended procedure and 2) completion rate of recommended procedures.

METHODS:

A retrospective chart review of econsults and outpatient referrals made to the gastroenterology department at the Veteran's Affairs Medical Center in Vermont was performed from 2012 to 2014. Charts were analyzed and patient demographic information including age, gender, comorbidities (hypertension, coronary artery disease, diabetes mellitus) was collected. With regards to econsults and standard consults, the following information was collected: date of econsult/referral, referring PCP credentials, nature of question (clinical versus administrative), disease process in question, completion of econsult or referral, timespan to answer econsult, timespan to initial clinic visit for referrals, whether or not a procedure (EGD or colonoscopy) was recommended, whether or not recommended procedure was completed and time to completed procedure. Data collection and analyses were done in accordance with local IRB. Chi square and t-test were performed, and logistic regression model used to predict factors associated with time to procedure.

RESULTS:

Overall 253 econsults and 171 outpatient referrals were included in our study with 253 (100%) and 98 (57.3%) completed respectively. Sixty-four procedures were recommended via econsults and 53 procedures were recommended via referrals with 36 (56.2%) and 30 (56.6%) (P = 0.89) completed respectively. Of the completed consults, 25.3% of econsults versus 54.1% (P < 0.0001) of standard consults had a recommended procedure. The mean timespan to procedures was 82 days for econsults and 87.3 days (P = 0.21) for referrals.

CONCLUSION:

Gastroenterologists were more likely to recommend a procedure after a face to face encounter with patients compared to econsults. There was no difference found between rates of completed procedures or the timespan to completion for econsults versus standard outpatient referrals.
577 Randomized Controlled Trial (RCT) of Over-the-Scope Clip (OTSC) as Initial Endoscopic Treatment of Severe Non-Variceal Upper Gastrointestinal Bleeding (NVUGIB)
Authors: Jensen Dennis M. , Kovacs Thomas , Ghassemi Kevin , Kaneshiro Marc , Gornbein Jeffrey
Published: October 2019

INTRODUCTION:

Recurrent GI bleeding from peptic ulcers (PUB's) & Dieulafoy's lesions is common in high risk patients. In our recent RCT, patients treated with Standard Hemostasis- RX (e.g. hemoclips &/or multipolar probe with epinephrine pre-injection) for severe NVUGIB had a 30 day rebleed rate of 26.3 % (Gastro 2017;152:1310). OTSC obliterates arterial flow underneath stigmata of hemorrhage (SRH) of PUB's more effectively than Standard RX & residual blood flow correlates with rebleed risk (DDW 2019). No one has reported an RCT of OTSC as primary, initial treatment compared to current Standard RX. Therefore, we performed this RCT.

METHODS:

The RCT was conducted at 2 academic medical centers after IRB approvals & Clinicaltrials.gov registration (NCT03065465). After informed consent for emergency endoscopy (EGD), patients & their caregivers (general GI, ICU & primary care) were blinded as to EGD Rx & the latter MD's made all management decisions about medical treatment, RBC transfusions, or ordering repeat EGD or angiography (IR) for rebleeding. Patients who met clinical & EGD criteria for PUB's or UGI Dieulafoy's lesions (with major SRH or spots with arterial blood flow) were randomized in a 1:1 allocation to either Standard RX (as described in above RCT) or OTSC. All patients received high dose PPI's after randomization & were followed prospectively for 30 days. Clinical outcomes data were collected on standard forms, de-identified, entered onto computer files, managed with SAS, & analyzed by a biostatistician (JG).

RESULTS:

49 RCT patients were well matched in demographics, risk factors, lesion type & SRH (Table 1). In contrast, the proportion of patients with 30 day rebleeding was significantly higher with Standard RX - 28% (7/25) - compared to OTSC Rx – 4.2% (1/24) - P = 0.0285 by Chi square (P = 0.022 by log rank test – See Figure 1). The OTSC rebleed rate was 85% lower than Standard group (Relative Risk 0.149 with 95% confidence intervals of 0.006, 0.863). The number needed to treat (NNT) was 4.2. See Table 2 for other outcomes.

CONCLUSION:

In patients with severe UGI bleeding from PUB's or Dieulafoy's lesions, primary endoscopic treatment with a large over the scope hemoclip resulted in significantly lower rates of rebleeding & severe complications, & fewer RBC transfusions than standard endoscopic hemostasis. Results appear to relate OTSC's superior ability to obliterate arterial blood flow underneath SRH & thereby reduce lesion rebleeding.
578 Resuming Anticoagulation Following Hospitalization for Gastrointestinal Bleeding Is Associated With Reduced Thromboembolic Events and Improved Mortality: Results From a Systematic Review and Meta-Analysis
Authors: Tapaskar Natalie , Pang Alice , Sengupta Neil
Published: October 2019

INTRODUCTION:

Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). There is limited data on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality.

METHODS:

We performed a systematic review and meta-analysis to determine the risk of recurrent GIB, thromboembolism and mortality after resuming anticoagulation following GIB. PubMed, Embase and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism and mortality following initial hospitalization for GIB.

RESULTS:

A total of 5,354 studies were reviewed of which 10 were included in the meta-analysis (Figure 1). There were 2,080 patients who resumed anticoagulation and 2,296 patients who stopped their anticoagulation post index GIB (Table 1). Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, P = 0.035, I2 = 55.5%) though recurrent GIB leading to death was rare (Figure 2). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, P = 0.001, I2 = 62.7%) and a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, P = 0.000, I2 = 14.2%) (Figure 2). Optimal timing of re-initiation of anticoagulation varied, but as early as 2 weeks from index GIB or hospital discharge may be ideal.

CONCLUSION:

While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality. Re-initiation of anticoagulation as early as 2 weeks post-GIB may be optimal.
582 CRP and BUN as Risk Factor for Complications in Patients With Upper Gastrointestinal Bleeding
Authors: Mariadi I. Ketut , Sudjana Karismayusa , Nyoman Wibawa I Dewa
Published: October 2019

INTRODUCTION:

Rebleeding and mortality were serious complications following upper gastrointestinal bleeding. We need to identify the risk factor of the complication for prevention and prompt treatment. This study aims to know the risk factor for rebleeding and mortality in patient with upper gastrointestinal bleeding.

METHODS:

A prospective analytic observational study was made in patients with upper gastrointestinal bleeding, who admitted to Sanglah General Hospital. Data of CRP and BUN was collected when the patients admitted to the hospital, and follow up was done in 6 weeks to see the complication. The data were analysed using the chi-square test.

RESULTS:

Sixty-eight patients admitted to the hospital with upper gastrointestinal bleeding were involved in this study. 2 patients loss of follow up, and the rest 66 patients were involved in the analysis. Range age of patients was 18-68 years old. Forty-six (69.7%) patients were male, and the rest 20 (30.3%) were female. Both variceal and nonvariceal upper gastrointestinal bleeding patients were involved in this study. Median of CRP was 4.61 (0.30-65.80) mg/L and CRP level >5 mg/L was defined as high risk for complication. Mean BUN 35.65 ± 34.45 mg/dL, and BUN >20 mg/dL was defined as high risk for complication. During follow up, 41 patients have a complication. Rebleeding occurred in 27 patient and mortality in 14 patients. The results of Chi-square test for CRP:X

2
= 16.0; P < 0.001; OR=9.67 (2.95-31.73); for BUN: X

2
= 6.70; P = 0.01; OR = 3.95 (1.36-11.43).

CONCLUSION:

Rebleeding and death is the major complication in a patient with upper gastrointestinal bleeding, both variceal and nonvariceal. It is crucial to identify the risk factor of complication to predict the outcome of the patients. In this study, we found CRP level > 5 mg/L and BUN level >20 mg/dL was a significant risk factor for rebleeding and mortality in patient with upper gastrointestinal bleeding. This result is supported by the previous study, that found the serum CRP was an independent risk factor for 30-day rebleeding in patients with acute nonvariceal upper gastrointestinal bleeding and study by Wu et al., observed BUN/Creatinine ratio of >30 was an independent risk factor for mortality. Identifying the risk factor for a bad outcome will guide us to manage and treat the patients. In conclusion, In this study CRP level >5 mg/L and BUN level >20 mg/dL was a significant risk factor for rebleeding and mortality in patient with upper gastrointestinal bleeding.
583 Rebleeding After Hemoclip versus Argon Plasma Coagulation Use for Bleeding Gastrointestinal Angiodysplasias in Patients Receiving Antithrombotics: A Retrospective Multi-Center Study
Authors: Ismail Bahaaeldeen , Alayoubi Mhd Suhaib , Abdelwadoud Moaz , Castro Fernando
Published: October 2019

INTRODUCTION:

Endoclips have been used for treating bleeding gastrointestinal angiodysplasias (GIAD), but the supporting evidence in the literature has been limited. We previously presented a retrospective study that showed a significantly lower rebleeding rate with clips compared to argon plasma photocoagulation (APC); however, the sample size was small particularly the number of patients receiving antithrombotics (ATs). Aim of the current study is to compare the rebleeding rate with the use of clips versus APC in patients with bleeding GIAD receiving ATs.

METHODS:

We retrospectively included adults with bleeding GIAD that received either APC, clips monotherapy or in combination, at any of the Cleveland Clinic hospitals between 1/1/2009 to 11/1/2016. Only patients who resumed ATs after the intervention were included. Charts were reviewed to collect baseline and outcome characteristics.

RESULTS:

178 patients were included, 92 received APC, 28 received clips monotherapy and 58 received clips combined with a second modality. At baseline, the clips group had more single GIADs, more actively bleeding lesions on index endoscopy and a tendency towards more overt bleeding. Baseline characteristics were otherwise similar [Table 1]. Median follow up duration was 18.5 months [IQR 9.9-27.3]. Rebleeding was significantly lower in the clips group (34.9% compared to 51.1% for APC, P = 0.03). The probability of remaining free of rebleeding was also higher in the clips group compared to APC (P = 0.037) [Figure 1a] but not significantly different when patients were classified into 3 groups [Figure 1b]. On a multivariate hazards regression model [Table 2], receiving clips combined with a second modality was predictive of lower rebleeding (HR 0.46 (0.25-0.84)). Other significant factors were having a smaller sized GIAD and having higher hemoglobin nadir at the initial bleed.

CONCLUSION:

Clips were associated with a lower probability of rebleeding in patients with GIADs receiving ATs compared to APC. After accounting for potential confounders, using clips in combination with a second modality remained significant, suggesting a role for combined intervention in patients that will resume ATs after endoscopic therapy.
585 Risks of Recurrent Bleeding in Patients Hospitalized With Gastrointestinal Bleeding While on Warfarin vs Direct Oral Anticoagulants
Authors: Tapaskar Natalie , Ham Sandra A. , Sengupta Neil
Published: October 2019

INTRODUCTION:

There is limited data on the management of anticoagulation following hospitalization for gastrointestinal bleeding (GIB) and the subsequent risks of recurrent GIB and thromboembolism in patients who are on warfarin compared to direct oral anticoagulants (DOACs).

METHODS:

We conducted a retrospective analysis of medical claims data from the IBM®MarketScan® Research Databases from January 1, 2008 through December 31, 2017. We collected data on adults with atrial fibrillation treated with warfarin or DOACs and subsequently hospitalized for GIB. Post discharge readmissions for recurrent GIB and thromboembolism within 180 days of initial discharge were reviewed. Univariable and multivariable cox regression were used to determine risks of recurrent GIB and thromboembolism.

RESULTS:

There were 2,991 patients hospitalized for GIB while on anticoagulants (warfarin, n = 1872; rivaroxaban, n = 676; dabigatran, n = 293; apixaban, n = 250). Differences between warfarin and DOAC users are reported in Table 1. Twenty-nine percent (n = 869) of warfarin users had warfarin resumed following discharge with a median time to resumption of 27 days (IQR 10-63), compared to 16% percent (n = 485) of DOAC users who had DOAC resumed (median time to resumption of 32 days (IQR 16-69). Discharge on warfarin was associated with the highest risk of recurrent GIB (HR 1.69, 95% CI 1.23-2.31) whereas discharge on dabigatran (HR 0.13, 95% CI 0.02-0.90) and apixaban (HR 0.38, 95% CI 0.14-1.01) had the lowest risk of recurrent GIB (Table 2). In a multivariable model adjusting for demographics, comorbidities, in-hospital management, source of bleeding, and post-discharge anticoagulant resumption, resumption of warfarin was associated with an increased risk of recurrent GIB (HR 1.53, 95% CI 1.07-2.18) compared to resumption of DOAC (HR 0.85, 95% CI 0.51-1.42). Variables associated with thromboembolism on multivariable regression included preceding venous thromboembolism (HR 2.42, 95% CI 1.66-3.51) and history of left ventricular assist device (HR 7.84, 95% CI 3.20-19.2). Survival analysis showed a significant association between type of anticoagulant on discharge and risk of recurrent GIB (log-rank, P = 0.001) (Figure 1).

CONCLUSION:

Resumption of warfarin following hospitalization for gastrointestinal bleeding was associated with an increased risk of recurrent GIB when compared to DOACs.
586 Investigation of Gastrointestinal Bleeding Among Left Ventricular Assist Device Recipients
Authors: Kalinowski Michael , Kothari Shana , Kobeszko Matthew , Josephson Greta , Cotts William , Pauwaa Sunil , Tatooles Antone , Elkhatib Imad , Silva Rogelio
Published: October 2019

INTRODUCTION:

Left ventricular assist device (LVAD) therapy is a form of mechanical support for patients with advanced heart failure as either a bridge to heart transplant or destination therapy. The association between gastrointestinal bleeding (GIB) and LVAD recipients is well established. There has been reported literature comparing demographics and clinical associations between patients with and without GIB. The aim of this study was to further investigate these characteristics, identify associations with GIB, and further understand endoscopic management of GIB among LVAD recipients.

METHODS:

This was a single-center retrospective study analyzing randomly selected patients from a population of 425 Heartmate (HMII) and 193 Heartware recipients from 2007 to 2018. Chart review was performed and data pertaining to demographics, LVAD therapy intention and settings, endoscopic reports, home medications, and echocardiogram reports was collected. Univariate analysis was performed.

RESULTS:

A total of 188 HMII and 134 Heartware patients were included in this study. Patients that developed GIB tended to be older (56.4 vs. 61.7 years; P = 0.0002). No differences were found in race and gender. Patients that developed a GIB had a higher baseline Cr (1.2 vs. 1.4; P = 0.0284) and lower baseline Hg (10 vs. 11; <0.001). A supratherapeutic INR was associated with GIB (14.7% vs. 26.7%; P = 0.0075). Patients prescribed angiotensin II receptor blockers had less occurrence of GIB (Table 1). Melena was the most common presenting sign. Bleeding lesions were most frequent in the small bowel (42.6%). Of all bleeding lesions identified, 73% were found with EGD and 80.4% were found with push enteroscopy. Arteriovenous malformations were the predominant etiology (Table 2).

CONCLUSION:

This is one of the largest single-center studies of GIB among patients with LVADs. Small bowel gastric arteriovenous malformations were the most common etiology. The majority of upper GI bleeds were within reach of a push enteroscope (proximal small bowel), which had an incremental diagnostic yield over EGD. There was a protective association with reduced occurrence of GIB among patients taking angiotensin II receptor blockers. The use of proton pump inhibitors showed no association in GIB occurrence and may be overused in this population. Further development of the association between angiotensin II receptor blockers and GIB effect in LVADs are warranted. Multivariate analyses to validate these associations are in progress.
590 Gastrointestinal Bleeding in Veterans on Oral Anticoagulants
Authors: Wayde Melinda , Hussain We'am , Loesch Erin B. , Markert Ronald , Agrawal Sangeeta
Published: October 2019

INTRODUCTION:

Oral anticoagulants play an integral role in the prevention and treatment of cerebral and systemic thromboembolism. Traditionally, this has been managed with vitamin K antagonists, primarily warfarin. Over time, however, the use of direct oral anticoagulants (DOACs) have gained popularity. Unsurprisingly, the initiation of a medication that decreases the blood's ability to clot increases the risk of bleeding. The aim of this study was to examine the incidence of gastrointestinal bleeding (GIB) in patients enrolled in an anticoagulation clinic at a Veterans Affairs (VA) medical center.

METHODS:

The VA's Computerized Patient Record System was used to create a list of patients seen in the VA anticoagulation (AC) clinic from 10/2010 to 9/2016. A sample of 1997 patients was randomly selected using a web-based program. Based on the formulary at the VA, only warfarin, rivaroxaban, dabigatran, and apixaban were examined. Demographics, indications for anticoagulation, and relevant comorbidities and concomitant medications were recorded.

RESULTS:

Despite increasing use of DOACs since their introduction in 2011, results of the analysis indicate warfarin was still the most commonly prescribed anticoagulant in our population with 1270/1997 (64%). Rivaroxaban was taken by 28%, apixaban by 13%, and dabigatran by 10%. GIB was seen in 31/1270 patients (1.55%). In those taking warfarin, 28/1270 (2.3%) had GIB (P < 0.001). GIB was seen in 3/552 patients taking rivaroxaban (0.5%, P = 0.024). GIB was seen in 5/256 patients taking apixaban (2%), but this did not reach statistical significance. GIB was seen in 1/198 patients taking dabigatran (0.5%), but this did not reach statistical significance. Factors associated with increased risk of GI bleeding included chronic kidney disease and diabetes mellitus. Patients not on proton pump inhibitors, clopidogrel, and nonsteroidal anti-inflammatory medications had an increased risk of GIB.

CONCLUSION:

Given similar efficacy of DOACs to warfarin shown in prior studies, the choice of oral anticoagulant rests largely on the safety profile. In a population of patients seen in the VA AC clinic, the most commonly prescribed anticoagulant was warfarin. The risk of GI bleeding was highest in these patients, similar to findings in previous studies. The lowest risk was seen with dabigatran. A data set with more GIB patients would allow multiple logistic regression analysis of the medications and comorbidities identified as risk factors.
593 Impact of Computed Tomography Angiography-First Approach on Length of Stay and Time to Definitive Therapy in Patients Presenting for Lower GI Bleed
Authors: Ekekezie Chiazotam , Vecchio Eric , Argueta Erick , Jimoh Lanre , Carter Valerie , Reinert Steven E. , Monteiro Joao Filipe G. , Grand David , Rich Harlan
Published: October 2019

INTRODUCTION:

The initial study of choice in patients who present to the emergency department (ED) for lower gastrointestinal bleeding (LGIB) is a topic of debate. It is unclear how patient outcomes are affected if computed tomography angiography (CTA) of the abdomen and pelvis is a preliminary study. A major teaching hospital implemented a CTA-first protocol in patients presenting for LGIB in December of 2014. Our goal was to determine how this policy impacted outcomes like hospital length of stay (LOS), time to definitive intervention, number of colonoscopies or embolizations performed, and yield or impression of colonoscopy.

METHODS:

Electronic medical records were queried for patients presenting for acute LGIB from January 2011 to December 2016. We gathered healthcare and demographic information in patients older than 18. SAS© software was used to perform student's t-tests, chi-square and multivariable linear regression analysis of the data.

RESULTS:

Five-hundred seventy-four encounters were analyzed, 297 before CTA-first policy (B-CTA) and 277 after CTA-first (A-CTA) policy implementation. The groups were without significant differences in sex, race, age, admission day of the week, hemoglobin or creatinine on presentation (Table 1). There were significant differences in heart rate and systolic blood pressure on presentation (Table 1). LOS in the B-CTA group was 5.8 days compared to 5.1 days in the A-CTA group (P > 0.05; Table 2). In those hospitalized for more than two weeks, interestingly, LOS did seem shorter overall A-CTA (P < 0.01; Figure 2). More CTAs were performed after policy implementation (Table 2). Multivariate analyses showed a 77% reduction in the number of colonoscopies (P < 0.0001) and a 47% decrease in early (those within 24h of admission) colonoscopies (P = 0.0082) (Table 3). Time to colonoscopy was not significantly reduced B-CTA versus A-CTA (Table 2). Colonoscopy impressions detailing the source of bleeding pre- and post-policy implementation were similar (Figure 1). There was no significant change in the number of or time to embolizations (Table 2).

CONCLUSION:

The CTA-first protocol was intended to facilitate effective triage of patients, targeted definitive therapy, and decreased overall LOS. Our findings suggest that for patients presenting for LGIB, this approach did not significantly improve LOS unless admitted for more than 2 weeks. Moreover, it is questionable that it facilitated more targeted intervention with embolization or colonoscopy.
595 The Glasgow-Blatchford Score: Pitfalls and Cost of Generalization
Authors: Contreras Alberto , Robles Alejandro , Mendoza-Ladd Antonio
Published: October 2019

INTRODUCTION:

Non-variceal acute upper gastrointestinal bleeding (NVAUGIB) is one of the most common causes of hospitalization worldwide. The Glasgow-Blatchford Score (GBS) was developed to identify subjects who would benefit from hemostatic endoscopic intervention (HEI), in this and other types of GIB. According to the literature, a GBS score <2 identifies with up to 99% accuracy subjects who do not need emergent HEI. Experience at our center suggests that the average GBS of our patients with NVAUGIB is consistently >2 and yet our rate of HEI is low. Therefore, the primary aim of this study was to accurately determine the rate of significant HEI in subjects with NVAUGIB with GBS >2. The secondary aim was to determine the cost of esophagogastroduodenoscopy (EGD) in patients in whom no significant HEI was performed.

METHODS:

Medical records of subjects admitted for NVAUGIB who underwent EGD from January 2015 – December 2017 were reviewed. NVAUGIB was defined as the presence of any of the following: hematemesis, hematochezia, coffee ground emesis, + FOBT, melena, drop in Hgb >2 g/dl and absence of varices on EGD. The GBS was calculated on the day of EGD on all subjects. Data obtained was compared using a Kolmogorov-Smirnov Test of Normality first to ensure normal distribution, then an independent T-test was used to evaluate for significance. EGD cost was obtained from the hospital administration.

RESULTS:

A total of 586 subjects underwent EGD for the evaluation of NVAUGIB, and their demographic characteristics are listed in Table 1. The mean GBS for subjects with ≤2 and >2 were 1 and 8.8 respectively. Of those with a GBS >2 (503/586), only 16.9% (85/503) underwent a HEI. On the other hand, only 1% (1/83) of those with GBS ≤2 (83/586), underwent HEI. Overall, subjects who received HEI (86) had higher GBS compared to those who didn't (9.29, SD 3.51) vs. (7.42, SD 4.06) (P ≤ 0.05). A total of 418 EGDs without HEI were performed in subjects with GBS >2. The cost of a diagnostic EGD at our institution is approximately $2,866.00. Therefore, the cost of these procedures was approximately $1,200,000.00.

CONCLUSION:

In our population, a GBS cutoff of >2 did not identify patients requiring HEI accurately as previously reported in the literature. The cost of performing non-therapeutic endoscopic evaluation in these subjects is alarming. Further research regarding the generalizability of the GBS is needed at this time.
600 Impact of Anti Coagulation and Anti Platelet Treatment on 30-Days Readmission Rate of Patients With Gastrointestinal Bleeding in Tertiary Care Setting of Northern Pennsylvania
Authors: Kirshan Ravi Shri Jai , Yang Tsujung , Ravi Priyanika , Ahuja Satish Kumar , Makhejani Kailash , Ahuja Keerat Rai , Essrani Rajesh
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding remains the major complication of blood thinners such as anti platelet agents and anticoagulants leading to frequent hospitalization. It requires involvement of multi disciplinary approach for its management. Despite the hard efforts, patient readmission remains a major concern. Our study aims to highlight the impact of these agents on 30 day readmission.

METHODS:

Patients admitted with Gastrointestinal bleeding were extracted using ICD 10 codes K 92.0, K 92.1, and K 92.2. Essential baseline characteristics including age, race, Primary Diagnosis, Readmission Diagnosis, Patients not on blood thinners, Patients on anti platelet, Patients on anti coagulants, Patients on combined medications, Atrial fibrillation, Deep Vein Thrombosis, Pulmonary embolism, Metallic Heart Valve, History of Stroke, 30-day mortality, causes of re admissions were identified by reviewing the electronic medical record of individual patients. Patients were stratified into 4 groups as Patients not on blood thinners (group A), taking Anti platelet (group B), Anticoagulant (group C) and combined anti platelet with anticoagulant (group D). Statistical analysis was performed using SPSS version 25.

RESULTS:

Total of 1296 patients was admitted in the last decade from 2009-2018 with the diagnosis of Gastrointestinal bleeding. Mean age of patients was 70.31± 15.38 (Mean ± SD), the majority were Males (50.2%) and Caucasians (97.1%). Patients had following associated comorbidities such as Deep venous thrombosis (9.0%), Pulmonary Embolism (5.8%), Atrial Fibrillation (33.4%), History of Stroke/TIA (16.4%) and Metallic Heart Valve(5.8%).Majority of Patients were not on any agent (41.7%) followed by Anti platelet (29.6%), Combined (16.5%) and Anti coagulation (12.2%). The 30-days Readmission rate was higher among patients on Combined agents followed by Anticoagulant group, No agent group and Anti platelet agent (29.0% vs. 19% vs. 17.7 vs. 16.4%, respectively, OR: 1.89 CI 1.20-2.73 P-value = 0.01, whereas 30-days mortality was not significantly different among patients in different agents P-value= 0.70.

CONCLUSION:

This study reveals a very significant finding that odds of 30-day readmission approximately double for patients who are on combined anti platelet and anticoagulant therapy when compared with other groups, whereas 30-day mortality remains unchanged.
602 Angiography Versus Colonoscopy in Diverticular Hemorrhage
Authors: Lipcsey Megan , Moore Matthew , Stein Daniel J. , Feuerstein Joseph
Published: October 2019

INTRODUCTION:

Diverticular hemorrhage is the most common cause of lower gastrointestinal hemorrhage. Determining the source of bleeding is difficult and therapeutic intervention rates are variable. Many centers perform angiography for patients with more severe bleeding since it does not require bowel preparation and can be rapidly performed; however it has never been directly compared to colonoscopy and may not be available. Using the national inpatient sample, we compared outcomes for patients with diverticular bleeding undergoing angiography to colonoscopy.

METHODS:

This national inpatient sample (NIS) from 2016 was queried for cases of diverticular hemorrhage based on ICD-10. Outcomes were compared for colonoscopy alone to angiography including mortality and rate of post-procedure transfusion. Angiography use was compared by hospital type to deduce if there was an availability bias in usage pattern. Survey-adjusted logistic regression was used to examine mortality and predictors of angiography use. Adjustment was made for the Elixhauser mortality score (a validated measure of comorbidities) and other confounders as below.

RESULTS:

63,620 patients were admitted for diverticular hemorrhage in 2016. 2,795 (4.4%) underwent angiography and 40,380 (63.5%) underwent colonoscopy. 62.3% of angiography patients had a colonoscopy (98.6% prior to the angiogram). Angiography was more common in patients at academic (5.1%) and urban non-teaching (4.0%) compared with rural (0.5%) hospitals. Mortality was 2.3% in patients undergoing angiography versus 0.8% in patients undergoing colonoscopy alone. In the multivariable regression, requiring angiography was associated with a 3.2 times the odds of mortality (95% CI 1.7-6.0) adjusting for age, transfusion requirement and Elixhauser. Adjusting for age, Elixhauser and transfer status, freedom from transfusion (OR = 0.34, 95% CI 0.28-0.40) and rural hospital location (OR = 0.13, 95% CI 0.06-0.28 compared to urban teaching) were strongly associated with angiography.

CONCLUSION:

In a national cohort of patients managed for diverticular bleeding, angiography was performed in under 5% compared with nearly 64% who had colonoscopy. However, it was associated with a higher rate of mortality though not transfusion. This persisted after controlling for confounders. Far fewer patients underwent angiography at small community hospitals, raising concern about the availability of this resource in the community setting.
607 Underutilization of Digital Rectal Exam in the Evaluation of Patients With Gastrointestinal Bleed in the Ambulatory Setting: Analysis of the National Ambulatory Medical Care Survey
Authors: Mossad David , Wu Benita , Agrawal Sangeeta
Published: October 2019

INTRODUCTION:

Digital rectal exam (DRE) is a critical component in evaluating gastrointestinal (GI) bleeds in the ambulatory setting. It is important in dictating medical management and decision making.1 Ideal patient outcomes, in such an acute setting, require selection of appropriate interventions and therapies. The purpose of this study was to evaluate the overall frequency in which this test is performed in patients presenting with GI bleed in the ambulatory setting.

METHODS:

The National Ambulatory Medical Care Survey (NAMCS) was searched using International Classification of Diseases - Ninth Revision (ICD-9) diagnosis codes for patients seen in the office for GI bleed for the years 2011-2015. Patients were separated into two groups: those who underwent DRE and those who did not. Data was analyzed based on ethnicity, gender, race, and age. Statistical comparisons were made using Statistical Package for the Social Sciences (SPSS) with chi-square and student T tests with a significance level of 0.05.

RESULTS:

A total of 265 ambulatory care patients with GI hemorrhage were identified. Only 38 patients (14%) underwent DRE. Between gender groups, there was no difference in DRE performed (13.3% of males vs 15.4% of females, P = 0.727). Race had no significant impact on DRE rates when Asians, Whites and African Americans were compared (P = 0.487). There was no difference in DRE rates in Hispanic versus Non- Hispanic ethnicity groups (P = 0.087). Age was also found to be noncontributory to DRE performance (mean age of 54.3 for DRE vs 50.4 for no DRE, P = 0.349).

CONCLUSION:

With 14% of patients undergoing appropriate examination for GI hemorrhage, this study shows underutilization of DRE in the ambulatory setting. In this study, factors such as age, race, ethnicity and gender had no impact on DRE performance rates. GI bleeds can pose significant implications in morbidity and mortality and appropriate decision making is crucial for good patient outcomes. Evaluation of potential bleeds via DRE can impact clinical decision making and medical management in the form of admissions, endoscopic procedures and medical therapies. Proper physical examination in the setting of GI bleed should be emphasized in the ambulatory setting.
612 Impact of a Pharmacist-Managed Protocol Limiting Continuous Infusion of Proton Pump Inhibitor Use in Patients With an Upper Gastrointestinal Bleed
Authors: Lauren Schwaner , Thomas Drew , Kaila Vishal , Faust Andrew , Feldman Mark
Published: October 2019

INTRODUCTION:

In patients with an upper gastrointestinal bleed, previous reports have shown that there is no difference among clinically significant endpoints when prescribed a continuous infusion of pantoprazole versus intermittent bolus administration. Our study evaluates the impact of a pharmacist-managed protocol aimed at reducing continuous infusion proton pump inhibitor use in upper gastrointestinal bleeds.

METHODS:

We performed a retrospective analysis of patients receiving intravenous pantoprazole for suspected upper gastrointestinal bleeding before and after the implementation of a pharmacist managed protocol. Prior to implementation, patients were continued on pantoprazole continuous infusions (8 mg/hr) at the physician's discretion. After implementation, all hemodynamically stable patients were allowed one dose of pantoprazole as a continuous infusion (8 mg/hr for 10 hours) and then were transitioned by the pharmacist to intermittent 40 mg IV injections twice daily. The primary endpoint assessed was the incidence of upper gastrointestinal re-bleeding within 7 days of treatment. Secondary endpoints included the number of pantoprazole continuous infusions and IV push injections, number of blood transfusions, number of endoscopic interventions, length of hospital stay, and mortality.

RESULTS:

After screening 702 patients, 222 patients met inclusion criteria (115 in the pre-protocol group and 107 in the post-protocol group). The re-bleeding rate at day 7 was 7% in the pre-protocol group, compared to 4% in the post-protocol group (P = 0.17). As expected, use of the protocol reduced the median number of continuous infusions per patient [4 (IQR 2-4) vs 2 (IQR 1-3); P < 0.001] and increased the median number of IV push injections [2 (IQR 2-4) vs 4 (IQR 2-7); P < 0.001] in the pre- and post-protocol groups, respectively. There were no significant differences between the pre- and post-intervention groups regarding blood transfusions (65% vs. 63%; P = 0.78), endoscopic interventions (79% vs. 79%; P = 1.0), hospital length of stay [4 days (IQR 3-8) vs. 4 days (IQR 2-8); P = 0.521], or hospital mortality (5% vs. 2%; P = 0.28) (See Tables 1 and 2).

CONCLUSION:

Implementation of this pharmacy-managed protocol, allowing automatic transition from pantoprazole continuous infusions to intermittent injections in hemodynamically stable patients with an upper gastrointestinal bleed, had no detrimental effect on the incidence of re-bleeding within 7 days.
614 Bidirectional Endoscopy in Premenopausal Women With Asymptomatic-Iron Deficiency Anemia (A-IDA)
Authors: Schopis Michael , Guerson Gil Arcelia , Ziv Yonatan , Seu Rie , Yeat Nai Chien , Muench Samuel , Nair Singh , Aroniadis Olga , Brandt Lawrence
Published: October 2019

INTRODUCTION:

GI investigation of premenopausal women with A-IDA is a controversial subject with some societal guidelines recommending initially only celiac or Helicobacter pylori (HP) screening instead of upper (U) and lower (L) GI endoscopy. The aim of this study was to determine the relative frequencies of associated GI sources of A-IDA in premenopausal women who underwent bidirectional endoscopy (BDE).

METHODS:

We performed a retrospective chart review noting clinical characteristics of asymptomatic premenopausal women who had BDE performed within 6 months of IDA diagnosis between the yrs 2014-2019. Pts were excluded if they had GI tract surgery within 10 yrs, active pregnancy, active GI bleeding, an obvious site of non-GI blood loss or ferritin >100. McNemar's test was used to compare frequency of UGI and LGI lesions. Bivariate analyses of characteristics associated with UGI and LGI lesions were performed using t-test, Chi-squared test, or Fisher's exact test. Multivariate logistic regression models estimated odds ratios.

RESULTS:

Records of 98 premenopausal female pts were available for analysis (mean age 44 yrs; Table 1). BDE revealed lesions associated with IDA in 61 pts (62.2%) comprising 41 (41.8%) UGI lesions, 10 (10.2%) LGI lesions, and 7 (7.1%) both UGI and LGI lesions. In our cohort, UGI lesions were more common than LGI lesions [48 (49%) vs 17 (17%); P < 0.001]. Predictors of an UGI lesion included NSAIDS use [OR 3.60 (95% CI 1.36-10.25); P = 0.01] and HP infection [OR 5.4 (2.20-14.24); P < 0.001]. No significant predictors of LGI lesions were identified (Table 1). The most common UGI lesions were HP -associated gastritis (35.6%) and peptic ulcer disease (15.3%) (Figure 1a). The most common LGI lesions were large polyps (45%) and hemorrhoids (35%) (Figure 1b).

CONCLUSION:

Our results indicate 1) premenopausal women often have a GI-associated source of A-IDA; 2) premenopausal women with A-IDA are more likely to have an UGI than LGI source for blood loss; thus starting with UGI endoscopy may be prudent 3) H. pyloriinfection and NSAID use predict UGI lesions associated with A-IDA in premenopausal women.
616 Risk Factors and Outcomes in Critically Ill Patients Presenting With Gastrointestinal Bleeding Complicated by Myocardial Ischemia
Authors: Zakarya Mohamed , Krinsley James
Published: October 2019

INTRODUCTION:

Gastrointestinal Bleeding (GIB) is one of the most common conditions that lead to an admission to the intensive care unit (ICU). The aim of this study is to determine the risk factors, clinical predictors, and prognostic significance of myocardial ischemia associated with GIB.

METHODS:

We reviewed our ICU database and electronic medical record of all patients admitted to the ICU with GIB (including upper or lower GIB) between 10/1/05 and 9/30/18. Data aggregated include demographics, hemoglobin (HGB) and troponin (TROP) values, comorbidities and outcome parameters. Patients were categorized as having myocardial ischemia (“ISCH,” including ST elevation myocardial infarction, non-ST elevation myocardial infarction, or demand ischemia), or no ischemia (“NON”). We compared risk factors and clinical characteristics of both groups and created a multivariable logistic regression model to determine the independent association of ISCH with mortality.

RESULTS:

This investigation includes 403 patients with GIB. 155 of 403 (38.5%) had enzymatic and/or electrocardiographic evidence of ischemia. ISCH were older than NON (78 [66-86] vs. 68 [55-79]; P < 0.0001) with higher rates of cardiac risk factors, including diabetes mellitus (30.3% vs. 20.6%; P = 0.0367), class III or IV cardiac disease (25.8% vs. 5.2%; P < 0.0001), and prior myocardial infarction (20.0% vs. 10.1%; P = 0.0081). ISCH had higher severity of illness: APACHE (acute physiology and chronic health evaluation) III score (62 [50-77] vs. 47 [34-61]; P < 0.0001) and higher rates of mechanical ventilation (18.7% vs. 10.5%; P = 0.029). Minimum HGB values were similar (7.5 [2.0] vs. 7.7 [2.0]; P = 0.2) and maximum TROP were higher (0.21 [0.09-1.90] vs. 0.01 [0.01-0.03]; P < 0.0001). ISCH had longer ICU length of stay (1.7 [1.0-3.2] vs. 1.3 [0.8-2.0] days; P = 0.0001) and higher mortality (20.0% vs. 5.6%; P < 0.0001). Multivariable analysis demonstrated that ISCH was independently associated with higher mortality: Odds ratio (95% confidence interval) 3.23 (1.34-7.78; P = 0.0088).

CONCLUSION:

Myocardial ischemia occurs frequently in critically ill patients admitted to the ICU with GIB and is identified in this investigation as being an independent risk factor for mortality. Recognition of risk factors and comorbidities associated with cardiac disease in the setting of GIB can identify patients who are at increased risk of cardiovascular stress and could aid in targeting more aggressive treatment, potentially improving outcomes.
619 Efficacy of Hemospray in Non-Variceal Upper Gastrointestinal Bleeds: A Systematic Review and Meta-Analysis
Authors: Aziz Muhammad , Weissman Simcha , Mehta Tej I. , Hassan Shafae , Khan Zubair , Fatima Rawish , Alshati Ali , Malik Fahad , Tsirlin Yuriy , Hassan Ammar , Sciarra Michael , Nawras Ali , Rastogi Amit
Published: October 2019

INTRODUCTION:

Despite various accepted modalities of treatment, gastrointestinal bleeding (GIB) is a major cause of death in the United States. Recently, amongst other hemostatic powders, Hemospray (TC-325) emerged as an effective method in managing patients with non-variceal upper GIB. We conducted this systematic review with meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB.

METHODS:

A comprehensive literature search of PubMed, Cochrane, and Google Scholar was performed. Our search strategy was restricted to cohort studies and randomized controlled trials (RCTs). Our primary outcomes were clinical and technical success, while our secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality rate, and treatment failure. We used the R package “metafor” (version 2.1-0) and R Studio (version 3.6.0, Boston, Massachusetts) for statistical assessment.

RESULTS:

A total of 19 studies with 747 patients were included for final analysis. Technical success of Hemospray was seen in 96.8% of applications (95% confidence interval (CI) 93%-98%, P < 0.0001, I2 = 44.62%). Clinical success of Hemospray was seen in 92% of applications (95% CI 87%-95%, P < 0.0001, I2 = 44.62%).

CONCLUSION:

To our knowledge, this is the first systematic review and meta-analysis evaluating the efficacy of Hemospray in the management of non-variceal UGIB. The results herein indicate that Hemospray is non-inferior to conventional hemostatic modalities in terms of efficacious cessation of GIB. Hence, Hemospray can be used as an alternative option for the management of upper GIB. Given its ease of use in tandem with its reduced technical expertise for deployment relative to other modalities, Hemospray has the potential to become the new standard therapy for the management of upper GIB. Future research, including RCTs and large cohort studies are needed, to specifically compare Hemospray to other hemostatic powders as well as to other individual, mechanical modalities. Additionally, for the future, larger studies are needed to more accurately comment on the efficacy of Hemospray in upper variceal hemorrhage and lower bleeds, in an attempt to widen its scope of application to all GIB.
620 Enterography May Not Provide Additional Diagnostic Yield After Small Bowel Capsule Endoscopy in Patients With Obscure GI Bleeding
Authors: Barsky Maria , Kwon Alvin Guyun , Yoo Heesoo , Nguyen Nghia , Kalmaz Denise
Published: October 2019

INTRODUCTION:

Approximately 5% of gastrointestinal bleeding presentations are due to suspected small bowel bleeding or obscure gastrointestinal bleeding (OGIB). Small bowel capsule endoscopy (SBCE) and CT/MR enterography are common modalities used to evaluate the small bowel for possible lesions. The miss rate of SBCE for small bowel tumors has been reported as high as 25%. Due to a concern for possible missed small bowel lesion, CTE/MRE is often performed after SBCE in patients with obscure GI bleeding, however the diagnostic yield of these studies is unknown. The primary aim of this study was to investigate the diagnostic yield of CTE/MRE performed after SBCE in patients with obscure GI bleeding.

METHODS:

A retrospective chart review was performed of patients who underwent both SBCE and CT or MR enterography for evaluation of obscure GI bleeding – both occult and overt. The capsule endoscopy database at a single tertiary academic medical center was reviewed for studies performed from 1/2010-4/2019. Only cases with clinical suspicion of small bowel bleeding were included. Charts were reviewed to determine whether patients had a subsequent CT or MR enterography. Exclusion criteria included more than 6 months between SBCE and enterography, incomplete SBCE and IBD diagnosis. Descriptive statistics were performed.

RESULTS:

A total of n = 11 were included. The indications of the studies were evaluation of anemia and occult blood loss in the setting of unrevealing endoscopies in 72.7% of patients and evaluation of overt bleeding without source on endoscopy for 22.3% of patients. There were five (45.5%) significant small bowel findings on SBCE. There were no small bowel lesions identified by enterography. In the patients with overt bleeding, SBCE identified possible culprit lesions in 66.7% of patients and enterography didn't show any culprit lesions. In patients with occult blood loss, SBCE identified potential culprit lesions in 50% of the patients, while enterography didn't identify any. All patients with a negative SBCE also had a negative enterography study.

CONCLUSION:

These findings suggest that there may be no additional diagnostic yield from enterography performed after SBCE in patients with suspicion of GI bleeding from a small bowel source. SBCE seems to have a high negative predictive value for significant small bowel lesions. Larger studies need to be performed to evaluate the utility of performing enterography after SBCE in the evaluation of suspected small bowel bleeding, both occult and overt.