Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde's Syndrome)?

Mo1604 Recurrent Overt Obscure GI Bleed Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*, Frank Lukens, Joseph L. Blackshear, Carlos R. Simons Linares, Paul T. Kroner, Abhishek Bhurwal, Mark E. Stark, Michael J. Bartel Gastroenterology, Mayo Clinic, Jacksonville, FL; Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.