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1
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Barshay M, Cowan M, Beucher M. Dieulafoy Lesion in a Pediatric Patient. Pediatr Emerg Care 2025:00006565-990000000-00600. [PMID: 39982012 DOI: 10.1097/pec.0000000000003347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 01/03/2025] [Indexed: 02/22/2025]
Abstract
OBJECTIVE Our aim is to describe a rare etiology of an upper gastrointestinal bleeding (UGIB) to help pediatric emergency medicine clinicians improve their understanding of its presentation as well as the standard therapeutic approach to UGIB. METHODS This is a retrospective case report of a patient who presented to the Pediatric Emergency Department of Hasbro Children's Hospital and who was found to have a UGIB secondary to a Dieulafoy lesion. RESULTS The etiology of UGIBs varies by geography and patient age but includes esophagitis, Mallory-Weiss tears, gastritis, peptic ulcers, and foreign body ingestion. Given the overlapping presenting symptoms, history and physical are critical to identifying likely etiology and guiding treatment. This patient improved after definitive treatment with endoscopy and hemo-clips. CONCLUSIONS Children with symptoms of UGIB should receive prompt resuscitation and stabilization, and clinicians should maintain an index of clinical suspicion for less common pediatric pathologies, such as malignancy or arterial bleeding.
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Affiliation(s)
| | - Maiya Cowan
- The Warren Alpert Medical School of Brown University
- Department of Emergency Medicine, Rhode Island Hospital
| | - Meghan Beucher
- The Warren Alpert Medical School of Brown University
- Department of Emergency Medicine, Rhode Island Hospital
- Departments of Pediatrics, Hasbro Children's Hospital, Providence, RI
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2
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Becq A, Sidhu R, Goltstein LCMJ, Dray X. Recent advances in the treatment of refractory gastrointestinal angiodysplasia. United European Gastroenterol J 2024; 12:1128-1135. [PMID: 39229890 PMCID: PMC11485408 DOI: 10.1002/ueg2.12648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024] Open
Abstract
Gastrointestinal angiodysplasia (GIA) is a common, acquired, vascular abnormality of the digestive tract, and a frequent cause of bleeding. Refractory GIA criteria usually include recurrent bleeding, transfusions and/or repeat endoscopy. Pharmacological and interventional treatments have been the subject of recent high-quality publications. This review provides an overview of the latest updates on non-endoscopic management of refractory GIA. Aortic valve replacement has shown its efficacy in Heyde syndrome and should be considered if indicated. Anti-angiogenic drugs, such as Octreotide and Thalidomide, are efficient treatments of refractory GIA-related bleeding. Somatostatin analogs should, based on efficacy and tolerance profile, be considered first. In the future, a better understanding of the physiopathology of GIA might help develop new-targeted therapies.
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Affiliation(s)
- Aymeric Becq
- Gastroenterology DepartmentParis‐Est Créteil UniversityHenri Mondor Hospital, AP HPCréteilFrance
| | - Reena Sidhu
- Division of Clinical MedicineSchool of Medicine and Population HealthUniversity of SheffieldSheffieldUK
- Academic Unit of Gastroenterology and HepatologySheffield Teaching HospitalsNHS Foundation TrustSheffieldUK
| | - Lia C. M. J. Goltstein
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Xavier Dray
- Sorbonne UniversityCenter for Digestive EndoscopySaint Antoine Hospital, AP HPParisFrance
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3
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Alhamid A, Aljarad Z, Chaar A, Grimshaw A, Hanafi I. Endoscopic therapy for gastrointestinal angiodysplasia. Cochrane Database Syst Rev 2024; 9:CD014582. [PMID: 39297500 PMCID: PMC11411905 DOI: 10.1002/14651858.cd014582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of the different endoscopic management approaches for gastrointestinal angiodysplasia in symptomatic adults.
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Affiliation(s)
- Ahmad Alhamid
- Department of stem cell biology, Nagasaki University, Graduate school of biomedical sciences, Atomic Bomb Disease Institute, Nagasaki, Japan
| | - Ziad Aljarad
- Department of Internal Medicine, Faculty of Medicine, Aleppo University, Aleppo, Syrian Arab Republic
| | | | - Alyssa Grimshaw
- Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Ibrahem Hanafi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
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4
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Renaud A, Jirka A, Durant C, Connault J, Espitia O, Takoudju C, Agard C. [Gastrointestinal tract involvement in systemic sclerosis]. Rev Med Interne 2023; 44:410-422. [PMID: 37270380 DOI: 10.1016/j.revmed.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
Gastrointestinal tract involvement in systemic sclerosis concerns more than 90% of patients but is of heterogeneous clinical expression. It can involve the entire intestinal tract and be responsible for multifactorial malnutrition, which is frequent in this disease. It is a major source of deterioration in the quality of life and can even be life-threatening. Management is complex and multidisciplinary, ranging from simple hygienic and dietary measures, to specialized endoscopic or surgical interventional procedures, also including medical treatments, particularly proton pump inhibitors and prokinetics, with potential side effects. Ongoing research for new diagnostic and therapeutic tools promises to improve the management and prognosis of these patients.
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Affiliation(s)
- A Renaud
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - A Jirka
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Durant
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - J Connault
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - O Espitia
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Takoudju
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Agard
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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6
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Strategic Management of Bleeding Small Bowel Gastrointestinal Angiodysplasias (GIADs): A 12 Year Retrospective Review in a Veteran Population and Cost Comparison. Diagnostics (Basel) 2023; 13:diagnostics13030525. [PMID: 36766630 PMCID: PMC9914120 DOI: 10.3390/diagnostics13030525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs), also known as gastrointestinal angioectasias, are dilated, abnormally thin-walled blood vessels that occur in the mucosa and submucosa throughout the gastrointestinal tract. As a common cause of small bowel bleeding, GIADs have a significant impact on patient's morbidity and healthcare costs. Presently, somatostatin has been used widely to treat GIADs, but it is unclear if other therapies are as beneficial and cost-effective as somatostatin in managing GIADs. (2) Methods: A retrospective chart review was performed, which included subjects treated with Lanreotide, a somatostatin analog, and other therapies at the VA Loma Linda Healthcare System (VALLHCC) from January 2006 to December 2018. Patients who had symptomatic GIADs were detected by video capsule endoscopy (VCE), a device-assisted enteroscopy (DAE) or, in our case, push enteroscopy (PE) with an Endocuff. (3) Results: Three hundred twelve patients were diagnosed with GIADs. In this group of patients, 72 underwent ablation (endoscopic BICAP) with the addition of Lanreotide (SST), 63 underwent ablation therapy, eight were treated with SST only, 128 received iron replacement only, 25 received iron plus SST therapy, and 61 were observed with no therapy. Each group was followed via their hemoglobin (Hgb) level immediately thereafter, and Hgb levels were then obtained every 3 months for a 12-month period. After ablation therapy, 63 patients maintained stable Hgb levels over the course of the study, suggesting a significant therapeutic effect by controlling active bleeding. The 27 patients receiving ablation +SST therapy did not show improvements when compared to ablation only and the 128 patients who received iron therapy alone. (4) Conclusions: Importantly, 12 years of managing these patients has given us a cost- and time-sensitive strategy to maintain the patients' Hgb levels and avoid hospital admissions for acute bleeding. Iron treatment alone is effective compared to SST treatment in recovering from GIADs. Eliminating SST treatment from therapeutic intervention would save $89,100-445,550 per patient, depending on the number of doses for private care patients and $14,286-28,772 for VA patients, respectively. A suggested therapy would be to perform DAE on actively bleeding patients, ablate the lesions using a coagulation method, and place the patient on iron. If that fails, gastroenterologists should repeat VCE and perform either PE with Endocuff or balloon enteroscopy (all DAEs).
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7
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Iqbal H, Maharaj D, Chaudhry H, Gulati A, Roytman M. Refractory gastric ulcer bleeding responsive to long-term octreotide. SAGE Open Med Case Rep 2023; 11:2050313X231164856. [PMID: 37051262 PMCID: PMC10084531 DOI: 10.1177/2050313x231164856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/03/2023] [Indexed: 04/14/2023] Open
Abstract
Upper gastrointestinal tract bleeding is a common condition that can cause hemodynamic instability and death if left untreated. Endoscopic hemostasis is often successful; however, some patients may develop refractory bleeding. Pharmacologic management with octreotide is beneficial in patients with variceal bleeding and has been shown in some studies to be effective in refractory bleeding due to angiodysplasia. There is a paucity of literature regarding the usage of long-term octreotide in refractory bleeding secondary to a peptic ulcer. We present a case of a bleeding gastric ulcer that was refractory to endoscopic management but responsive to long-term octreotide therapy.
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Affiliation(s)
- Humzah Iqbal
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
- Humzah Iqbal, Department of Internal Medicine, University of California, San Francisco, 155 N. Fresno St., Fresno, CA 93701, USA.
| | - Dashmeet Maharaj
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Alakh Gulati
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
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8
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Suzuki K, Ikenoyama Y, Hirasawa T, Yoshimizu S, Horiuchi Y, Ishiyama A, Yoshio T, Taguchi S, Yoshioka Y, Fujisaki J. Clinical course and treatment of radiation-induced hemorrhagic gastritis: a case series study. Clin J Gastroenterol 2022; 16:152-158. [PMID: 36586090 DOI: 10.1007/s12328-022-01750-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/19/2022] [Indexed: 01/01/2023]
Abstract
Radiation-induced hemorrhagic gastritis is a relatively uncommon complication of irradiation that can be severe. However, appropriate treatment guidelines have not yet been established because of the small number of known cases. At our hospital, we encountered nine cases of radiation-induced hemorrhagic gastritis between July 2005 and July 2018. All patients initially underwent argon plasma coagulation (APC) for hemostasis. The treatment was highly effective, and hemostasis was successfully achieved in eight of the cases. Hemostasis could not be achieved in one case treated with APC; therefore, surgical resection was required. This patient had risk factors, such as liver cirrhosis and a history of abdominal surgery. Our case series suggests that APC is an effective hemostatic method that should be considered as the initial treatment option for radiation-induced hemorrhagic gastritis; however, surgical resection may be considered when the patient is at high risk for rebleeding.
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Affiliation(s)
- Keita Suzuki
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Yohei Ikenoyama
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan.
| | - Shoichi Yoshimizu
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Yusuke Horiuchi
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Akiyoshi Ishiyama
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Senzo Taguchi
- Department of Radiation Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
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9
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Cheema HI, Roark R, Hassan S, Chakrala K, Tharian B, Anastasiou J. Comparison Between Intravenous and Intramuscular Octreotide in the Management of Heyde’s Syndrome. Cureus 2022; 14:e25461. [PMID: 35783893 PMCID: PMC9239735 DOI: 10.7759/cureus.25461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 11/17/2022] Open
Abstract
Heyde’s syndrome is defined as a triad of aortic stenosis, anemia due to angiodysplasia-related bleeding, and von Willebrand syndrome type 2A. It is a rare disease and a diagnostic challenge. Treatment modalities include symptomatic management, blood transfusions, aortic valve replacement, and medications such as octreotide. Here, we report the case of a patient who was resistant to symptomatic management, aortic valve replacement, as well as intravenous octreotide.
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10
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Goltstein LCMJ, Grooteman KV, Rocco A, Holleran G, Frago S, Salgueiro PS, Aparicio T, Scaglione G, Chetcuti Zammit S, Prados-Manzano R, Benamouzig R, Nardone G, McNamara D, Benallaoua M, Michopoulos S, Sidhu R, Kievit W, Drenth JPH, van Geenen EJM. Effectiveness and predictors of response to somatostatin analogues in patients with gastrointestinal angiodysplasias: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:922-932. [PMID: 34508668 DOI: 10.1016/s2468-1253(21)00262-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are vascular malformations that often cause red blood cell transfusion-dependent anaemia. Several studies suggest that somatostatin analogues might decrease rebleeding rates, but the true effect size is unknown. We therefore aimed to investigate the efficacy of somatostatin analogues on red blood cell transfusion requirements of patients with gastrointestinal angiodysplasias and to identify subgroups that might benefit the most from somatostatin analogue therapy. METHODS We did a systematic review and individual patient data meta-analysis. We searched MEDLINE, Embase, and Cochrane on Jan 15, 2016, with an updated search on April 25, 2021. All published randomised controlled trials and cohort studies that reported on somatostatin analogue therapy in patients with gastrointestinal angiodysplasias were eligible for screening. We excluded studies without original patient data, single case reports, small case series (ie, <10 participants), studies in which patients had a specific aetiology of gastrointestinal angiodysplasias, and studies in which somatostatin analogue therapy was initiated simultaneously with other treatment modalities. Authors of eligible studies were invited to share individual patient data. Aggregated data was used if individual patient data were not provided. The primary outcome was the mean reduction in the number of red blood cell transfusions during somatostatin analogue therapy, compared with baseline, expressed as the incidence rate ratio (IRR) and absolute mean decrease. We defined patients as either good responders (≥50% reduction in the number of red blood cell transfusions) or poor responders (<50% reduction). A mixed-effects negative binomial regression was used to account for clustering of patients and skewness in data. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42020213985. FINDINGS We identified 11 eligible studies (one randomised controlled trial and ten cohort studies) of moderate-to-high quality and obtained individual patient data from the authors of nine (82%) studies. The remaining two (18%) studies provided sufficient information in the published manuscript to extract individual patient data. In total, we analysed data from 212 patients. Somatostatin analogues reduced the number of red blood cell transfusions with an IRR of 0·18 (95% CI 0·14-0·24; p<0·0001) during a median treatment duration of 12 months (IQR 6·0-12·0) and follow-up period of 12 months (12·0-12·0), correlating with a mean absolute decrease in the number of red blood cell transfusions from 12·8 (95% CI 10·4-15·8) during baseline to 2·3 (1·9-2·9) during follow-up-ie, a reduction of 10·5 red blood cell transfusions (p<0·0001). 177 (83%) of 212 patients had a good response to somatostatin analogue therapy (defined as at least a 50% reduction in the number of red blood cell transfusions). Heterogeneity across studies was moderate (I2=53%; p=0·02). Location of gastrointestinal angiodysplasias in the stomach compared with angiodysplasias in the small bowel and colon (IRR interaction 1·92 [95% CI 1·13-3·26]; p=0·02) was associated with worse treatment response. Octreotide was associated with a better treatment response than lanreotide therapy (IRR interaction 2·13 [95% CI 1·12-4·04]; p=0·02). The certainty of evidence was high for the randomised controlled trial and low for the ten cohort studies. Adverse events occurred in 38 (18%) of 212 patients receiving somatostatin analogue therapy, with ten (5%) discontinuing this therapy because of adverse events. The most common adverse events were loose stools (seven [3%] of 212), cholelithiasis (five [2%]), flatulence (four [2%]), and administration site reactions (erythema, five [2%]). INTERPRETATION Somatostatin analogue therapy is safe and effective in most patients with red blood cell transfusion-dependent bleeding due to gastrointestinal angiodysplasias. Somatostatin analogue therapy is more effective in patients with angiodysplasias located in the small bowel and colon, and octreotide therapy seems to be more effective than lanreotide therapy. FUNDING The Netherlands Organisation for Health Research and Development and the Radboud University Medical Center.
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Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Karina V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Santiago Frago
- Department of Digestive Diseases, Miguel Servet University Hospital, Zaragoza, Spain
| | - Paulo S Salgueiro
- Gastroenterology Department, Centro Hospitalar Universitário do Porto-Hospital de Santo António, Porto, Portugal
| | - Thomas Aparicio
- Department of Gastroenterology, Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | | | | | - Raul Prados-Manzano
- Department of Gastroenterology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Robert Benamouzig
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Mourad Benallaoua
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | | | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Wietske Kievit
- Radboud Institute for Health Science, Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
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11
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Pasricha TS, Bazerbachi F, Kuo B. A Baffling Case of Recurrent Hematochezia. Gastroenterology 2021; 160:e10-e11. [PMID: 33039471 DOI: 10.1053/j.gastro.2020.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/29/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Trisha S Pasricha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts.
| | - Fateh Bazerbachi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
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12
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Kojima Y, Takeuchi T, Nishida S, Iwatsubo T, Kawaguchi S, Harada S, Ota K, Akutagawa H, Higuchi K. A Case Series of Radiation-induced Hemorrhagic Gastroduodenitis. Intern Med 2021; 60:2529-2535. [PMID: 34393154 PMCID: PMC8429291 DOI: 10.2169/internalmedicine.6465-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective We examined the clinical course and treatment method of a case series of radiation-induced hemorrhagic gastroduodenitis with clinical signs. Methods This was a single-center retrospective observational study. Patients We included seven patients with radiation-induced hemorrhagic gastroduodenitis treated at our hospital between April 2014 and May 2020. Results One male patient each had cancer of the head of the pancreas, bile duct cancer, hepatocellular carcinoma, and ureteral cancer, whereas two women had recurrent endometrial cancer and one woman had recurrent cervical cancer. The onset occurred 3-5 months after the end of radiation treatment. Endoscopic examinations showed a red edematous mucous membrane in a fragile condition stretching from the antrum of the stomach to the duodenum, with telangiectasia and ulcer. For endoscopic hemostasis, five patients underwent argon plasma coagulation (APC), which was successful in three patients. Two of these were being administered an antithrombotic at the time. One case resistant to conservative treatment required repeated transfusion for recurring hemorrhaging over a short period of time and therefore underwent surgical treatment. Thereafter, the postoperative course was favorable. Conclusions Actively attempting hemostasis through APC and surgery is effective for treating radiation-induced hemorrhagic gastroduodenitis. The use of an antithrombotic agent might lead to a risk of repeated hemorrhaging. Therefore, repeated hemostasis through APC is crucial.
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Affiliation(s)
| | | | | | - Taro Iwatsubo
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Shinpei Kawaguchi
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Satoshi Harada
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Kazuhiro Ota
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | | | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College, Japan
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13
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Verma S, Attallah MA, Jarrin Jara MD, Gautam AS, Khan S. Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients. Cureus 2020; 12:e9784. [PMID: 32953300 PMCID: PMC7491692 DOI: 10.7759/cureus.9784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Gastrointestinal bleeding due to angiodysplasia is a common problem in patients with renal insufficiency. There are several theories to explain the increased occurrence of these lesions in this specific group of patients, including various metabolic factors and existence of comorbidities. Advancements made in diagnostic measures have helped route the approach in patients with different risk factors and have also helped solve the dual purpose involving therapeutic intervention with endoscopy. We conducted a thorough literature search on PubMed to extract relevant data. A total of 29 articles were chosen after applying the inclusion and exclusion criteria. Although the clinical presentations may vary in this cohort of patients, and bleeding is known to stop spontaneously, a conservative approach may not be enough. Endoscopic treatment, use of hormones like estrogen, octreotide, and vasopressin, arterial embolization, and lastly surgery are valuable therapeutic tools.
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Affiliation(s)
- Sadhika Verma
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Marline A Attallah
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfiled, USA
| | | | - Avneesh S Gautam
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
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14
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Lara LF, Silva R, Thakkar S, Stanich PP, Mai D, Samarasena JB. Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter. VideoGIE 2020; 5:162-167. [PMID: 32258850 PMCID: PMC7125393 DOI: 10.1016/j.vgie.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background and Aims GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. Methods Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. Results Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization. Conclusions In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rogelio Silva
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Mai
- University of California, Irvine, California USA
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15
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Tortora A, Marmo C, Gasbarrini A, Costamagna G, Riccioni ME. Management of Gastrointestinal Bleeding in Rendu-Osler Disease. Rev Recent Clin Trials 2020; 15:321-327. [PMID: 32493201 DOI: 10.2174/1574887115666200603160033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT, or Rendu-Osler-Weber disease) is a rare inherited syndrome, characterized by artero-venous malformations (AVMs or telangiectasia) with autosomal dominant transmission. AVMs can occur in any organ of the body but most commonly it occurs in the nose, pulmonary, hepatic and cerebral circulations. In patients with HHT, we report teleangectasia of mucosa of the gastrointestinal tract. METHODS Research and online content related to HHT online activity is reviewed, and DOC writing excerpts are used to illustrate key themes. RESULTS Patients with HHT have a high rate of complications related to bleeding; of them gastrointestinal bleeding accounts for 10.8%. Several therapies, both medical and endoscopic, were utilized to reduce the need for transfusions and hospitalization. CONCLUSION A combination of medical and endoscopic therapy is probably the best option.
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Affiliation(s)
- Annalisa Tortora
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Clelia Marmo
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Antonio Gasbarrini
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Guido Costamagna
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Maria Elena Riccioni
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
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16
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Gastrointestinal Bleeding in Patients with Hereditary Hemorrhagic Telangiectasia: Risk Factors and Endoscopic Findings. J Clin Med 2019; 9:jcm9010082. [PMID: 31905627 PMCID: PMC7019907 DOI: 10.3390/jcm9010082] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/20/2019] [Accepted: 12/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background: We aimed to describe risk factors for gastrointestinal (GI) bleeding and endoscopic findings in patients with hereditary hemorrhagic telangiectasia (HHT). Methods: This is a prospective study from a referral HHT unit. Endoscopic tests were performed when there was suspicion of GI bleeding, and patients were divided as follows: with, without, and with unsuspected GI involvement. Results: 67 (27.9%) patients with, 28 (11.7%) patients without, and 145 (60.4%) with unsuspected GI involvement were included. Age, tobacco use, endoglin (ENG) mutation, and hemoglobin were associated with GI involvement. Telangiectases were mostly in the stomach and duodenum, but 18.5% of patients with normal esophagogastroduodenoscopy (EGD) had GI involvement in video capsule endoscopy (VCE). Telangiectases ≤ 3 mm and ≤10 per location were most common. Among patients with GI disease, those with hemoglobin < 8 g/dL or transfusion requirements (65.7%) were older and had higher epistaxis severity score (ESS) and larger telangiectases (>3 mm). After a mean follow-up of 34.2 months, patients with GI involvement required more transfusions and more emergency department and hospital admissions, with no differences in mortality. Conclusions: Risk factors for GI involvement have been identified. Patients with GI involvement and severe anemia had larger telangiectases and higher ESS. VCE should be considered in patients with suspicion of GI bleeding, even if EGD is normal.
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17
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Kroon S, Snijder RJ, Mager JJ, Post MC, Tenthof van Noorden J, van Geenen EJM, Drenth JPH, Grooteman KV. Octreotide for gastrointestinal bleeding in hereditary hemorrhagic telangiectasia: A prospective case series. Am J Hematol 2019; 94:E247-E249. [PMID: 31251413 DOI: 10.1002/ajh.25563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Steven Kroon
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Repke J. Snijder
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Johannes J. Mager
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Martijn C. Post
- Department of CardiologySt Antonius Hospital Nieuwegein The Netherlands
| | | | | | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud UMC Nijmegen The Netherlands
| | - Karina V. Grooteman
- Department of Gastroenterology and HepatologyRadboud UMC Nijmegen The Netherlands
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18
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Leite TFDO, Pereira OI. Superselective Transcatheter Arterial Embolization in the Treatment of Angiodysplasia. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2019; 12:1179547619842581. [PMID: 31205432 PMCID: PMC6537290 DOI: 10.1177/1179547619842581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/16/2019] [Indexed: 11/15/2022]
Abstract
Acute nonvariceal upper gastrointestinal hemorrhage is a frequent condition
associated with significant morbidity and mortality. Angiodysplasia is a common
cause of bleeding in the gastrointestinal tract in the elderly. This case report
discusses about a 75-year-old woman clinically stable with melena for 2 years
due to arteriovenous fistula of upper mesenteric artery branches without
adequate clinical and therapeutic treatment. The goal of this article is to
report the safety and efficacy of superselective transcatheter arterial
embolization with coils in treating lower gastrointestinal bleeding caused by
angiodysplasia that was unresponsive to internal medicine treatment and
enteroscopy management.
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Affiliation(s)
- Túlio Fabiano de Oliveira Leite
- Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.,Department of Interventional Radiology and Endovascular Surgery, Santa Genoveva Hospital, Uberlândia, Brazil
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19
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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20
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Successful Treatment of Hereditary Hemorrhagic Telangiectasia With Octreotide. ACG Case Rep J 2019; 6:e00088. [PMID: 31616764 PMCID: PMC6722341 DOI: 10.14309/crj.0000000000000088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/28/2019] [Indexed: 01/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by telangiectasias and arteriovenous malformations. We present a case report of a 74-year-old man diagnosed with HHT having a favorable response to a somatostatin analogue for treatment. This patient had been suffering from chronic anemia from recurrent gastrointestinal bleeding, requiring oral/intravenous iron replacement, frequent endoscopic ablations, and blood transfusions. Due to insufficient treatment, he was started on subcutaneous octreotide, with significant improvement as evidenced by a steady increase in the hemoglobin level, decreased endoscopic interventions, and decreased blood transfusions, making this the first case of HHT successfully treated with octreotide.
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21
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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22
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An immunological determination of somatostatin in pharmaceutical by sandwich ELISA based on IgY and polyclonal antibody. Microchem J 2019. [DOI: 10.1016/j.microc.2018.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Muftah M, Mulki R, Dhere T, Keilin S, Chawla S. Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Ann Gastroenterol 2019; 32:113-123. [PMID: 30837783 PMCID: PMC6394262 DOI: 10.20524/aog.2018.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.
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Affiliation(s)
- Mayssan Muftah
- Department of Medicine (Mayssan Muftah), Atlanta, United States
| | - Ramzi Mulki
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Tanvi Dhere
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Steven Keilin
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Saurabh Chawla
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
- Grady Memorial Hospital (Saurabh Chawla), Atlanta, United States
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24
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Frago S, Alcedo J, Martín Pena-Galo E, Lázaro M, Ollero L, de la Llama N. Long-term results with lanreotide in patients with recurrent gastrointestinal angiodysplasias bleeding or obscure gastrointestinal bleeding. Benefits in efficacy and procedures consumption. Scand J Gastroenterol 2018; 53:1496-1502. [PMID: 30621520 DOI: 10.1080/00365521.2018.1547921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIAD) bleeding and obscure gastrointestinal bleeding (OGIB) are increasing health problems. Somatostatin analogues have been proposed as rescue therapy, but data for lanreotide are scarce. OBJECTIVE To determine the efficacy, safety and resource saving of long-acting lanreotide for GIAD and OGIB. METHODS Retrospective study including adults with GIAD bleeding or OGIB and lanreotide treatment for at least 6 consecutive months. Demographics, comorbidities and treatments were collected. Anaemia and health resource consumption were analysed and compared between the year before and three years after starting lanreotide. Complete response was defined as a lack of new blood transfusion or endovenous iron dose need. RESULTS Twenty-seven patients (mean age 76.8 years) were included, 63% taking anticoagulants/antiplatelets. The bleeding was attributable to angiodysplasia in 85.2%, of whom half had multi-site lesions. Lanreotide was administered for a median of 27.1 months. During follow-up of up to 3 years (mean 32.5 months), 18.5% of patients achieved complete response and around 60% a 50% reduction of health resource consumption. Haemoglobin values improved (p = .007), while admission time, blood/iron infusions, and the number of endoscopies decreased significantly (p<.05) at least up to the second year. There were no relevant side effects during the follow-up period. CONCLUSION Long-term treatment with lanreotide significantly improves anaemia and decreases health resource consumption in patients with recurrent GIAD bleeding or OGIB.
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Affiliation(s)
- Santiago Frago
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Javier Alcedo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragon)
| | - Edgar Martín Pena-Galo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - María Lázaro
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Leticia Ollero
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Natalia de la Llama
- c Department of Pharmacy , Miguel Servet University Hospital , Zaragoza , Spain
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25
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Kim JH, Brophy DF, Shah KB. Continuous-Flow Left Ventricular Assist Device–Related Gastrointestinal Bleeding. Cardiol Clin 2018; 36:519-529. [DOI: 10.1016/j.ccl.2018.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.
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Affiliation(s)
- Grainne Holleran
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
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27
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Nardone G, Compare D, Martino A, Rocco A. Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis 2018; 50:542-548. [PMID: 29610020 DOI: 10.1016/j.dld.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
Angioectasias (AD) belong to benign vascular malformations of the gastrointestinal tract and are responsible for about 4-7% of upper non variceal bleeding, 30-40% of small bowel occult bleeding and 3-40% of colonic bleeding episodes. Gastrointestinal haemorrhage secondary to AD represents an important diagnostic and therapeutic problem that negatively impacts on the quality of life of patients and heath care costs. Endoscopic interventions are the mainstay in both diagnosis and treatment of vascular malformations. However, in a substantial percentage of the cases, age of the patients, comorbidities, clinical severity of anaemia and blood loss as well as size, site and number of lesions prevent this therapeutic approach. Hormonal therapy, thalidomide and somatostatin analogues have been investigated for their potential role as rescue therapies in controlling AD bleeding although, thus far, no recommendations have been provided on their use in this clinical setting. In order to implement appropriate prescription of pharmacological agents to manage gastrointestinal bleeding due to ADs, the Italian Society of Gastroenterology (SIGE) nominated a panel of experts who reviewed the available clinical literature and produced practical clinical recommendations.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alberto Martino
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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28
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Benamouzig R, Benallaoua M, Saurin JC, Boubaya M, Cellier C, Laugier R, Vincent M, Boustière C, Gincul R, Samaha E, Grandval P, Aparicio T, Airinei G, Bejou B, Bon C, Raynaud JJ, Levy V, Sautereau D. Efficacy and safety of pasireotide-LAR for the treatment of refractory bleeding due to gastrointestinal angiodysplasias: results of the ANGIOPAS multicenter phase II noncomparative prospective double-blinded randomized study. Therap Adv Gastroenterol 2018; 11:1756283X18756260. [PMID: 29479375 PMCID: PMC5818089 DOI: 10.1177/1756283x18756260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/31/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding. METHODS A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg (n = 10) or placebo (n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment. RESULTS The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0-26) and 11.5 pRBC units in the placebo group (range 0-23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes. CONCLUSION This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.
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Affiliation(s)
| | | | | | | | | | - René Laugier
- Gastroenterology Unit, Timone Hospital, Marseille, France
| | | | | | - Rodica Gincul
- Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Elia Samaha
- Gastroenterology Unit, Georges-Pompidou Hospital, Paris, France
| | | | | | | | - Bakhtiar Bejou
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | - Cyriaque Bon
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | | | - Vincent Levy
- Clinical Research Unit, Avicenne Hospital, Bobigny, France
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Loyaga-Rendon RY, Jani M, Fermin D, McDermott JK, Vancamp D, Lee S. Prevention and Treatment of Thrombotic and Hemorrhagic Complications in Patients Supported by Continuous-Flow Left Ventricular Assist Devices. Curr Heart Fail Rep 2018; 14:465-477. [PMID: 29075955 DOI: 10.1007/s11897-017-0367-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the current knowledge in prevention and treatment of thrombotic (pump thrombosis and ischemic stroke) and bleeding (gastrointestinal and hemorrhagic stroke) complications in patients supported by continuous-flow left ventricular assist devices (CF-LVAD). RECENT FINDINGS Left ventricular assist devices (LVADs) are now widely used for the management of end-stage heart failure. Unfortunately, in spite of the indisputable positive impact LVADs have on patients, the frequency and severity of complications are limitations of this therapy. Stroke, pump thrombosis, and gastrointestinal bleeding are among the most serious and frequent complications in these patients. The balance between hemorrhagic and thrombotic complications in patients supported with CF-LVAD is difficult as most patients do not necessarily fit a "bleeder" or a "clotter" profile but rather move from one side to the other of the thrombotic/bleeding spectrum. Further research is necessary to better understand the risk factors and mechanisms involved in the development of these complications.
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Affiliation(s)
- Renzo Y Loyaga-Rendon
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA.
| | - Milena Jani
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - David Fermin
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Jennifer K McDermott
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Diane Vancamp
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Sangjin Lee
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
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Tolerability and Biological Effects of Long-Acting Octreotide in Patients With Continuous Flow Left Ventricular Assist Devices. ASAIO J 2018; 63:367-370. [PMID: 27922890 DOI: 10.1097/mat.0000000000000491] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Patients with implanted continuous, nonpulsatile, left ventricular assist devices (LVADs) have increased the occurrence of gastrointestinal bleeding (GIB). Although the pathophysiology is multifactorial, there are few treatments beyond supportive care. Octreotide acetate is a somatostatin analog that reduces GIB in various patient populations. However, there are sparse case series that suggest octreotide acetate may reduce GIB in LVAD patients. This 10 patient, 28 week phase I study evaluated the safety and tolerability of octreotide acetate long-acting release (LAR) 20 mg depot injection every 4 weeks until week 16 after LVAD placement. Secondary aims were occurrence of GIB and measurement of vascular endothelial growth factor, fibrinogen, von Willebrand factor, and platelet aggregation across the study period. Ten patients were enrolled, and eight completed the study. The two study dropouts were not related to octreotide. None of the patients experienced side effects or safety concerns related to octreotide nor did GIB occur in the study population. Vascular endothelial growth factor levels were maintained in the reference range throughout the duration of the study. There did appear to be laboratory evidence of acquired von Willebrand syndrome, with mildly low platelet aggregation studies. In conclusion, octreotide acetate LAR 20 mg depot injection was safe and effective in this population.
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Dar T, Yarlagadda B, Vacek J, Dawn B, Lakkireddy D. Management of Stroke risk in atrial fibrillation patients with bleeding on Oral Anticoagulation Therapy-Role of Left Atrial Appendage Closure, Octreotide and more. J Atr Fibrillation 2017; 10:1729. [PMID: 29487685 DOI: 10.4022/jafib.1729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/19/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022]
Abstract
Background Bleeding complications especially gastrointestinal bleeding remains a major challenge associated with oral anticoagulation therapy (OAT) and often leads clinicians to withdraw oral anticoagulation therapy (OAT) . This exposes patients to risk of stroke and systemic thromboembolism (STE). Novel oral anticoagulants (NOACs) have proved no better when it comes to bleeding events and in fact studies have shown that overall NOACs are associated with higher incidence of gastrointestinal (GI) bleeding compared to warfarin . Objectives In this review, we describe the difficulties encountered in managing OAT in patients with bleeding and strategies to maneuver around these bleeding complications particularly gastrointestinal bleeding secondary to arteriovenous malformations (AVM) and other vascular abnormalities. Findings Left atrial appendage closure (LAAC) has emerged as a very elegant and promising tool for stroke prevention in non-valvular atrial fibrillation (AF) patients who are intolerant to OAT. But the need for OAT post procedure for a brief period is becoming a major hurdle for clinicians to pursue in this direction in patients with recurrent gastrointestinal bleeds. And in majority of cases, recurrent or refractory gastrointestinal bleeds are usually secondary to arteriovenous malformations/angiodysplasias (AVM/AD). We suggest that the problem has to be approached by decreasing or eliminating the acute bleeding risk and closing the LAA in the long term, to enable the patients to come off of OAT and minimize the risk of recurrent bleeding.
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Affiliation(s)
- Tawseef Dar
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Bharat Yarlagadda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - James Vacek
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Buddhadeb Dawn
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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Shah KB, Gunda S, Emani S, Kanwar MK, Uriel N, Colombo PC, Uber PA, Sears ML, Chuang J, Farrar DJ, Brophy DF, Smallfield GB. Multicenter Evaluation of Octreotide as Secondary Prophylaxis in Patients With Left Ventricular Assist Devices and Gastrointestinal Bleeding. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004500. [DOI: 10.1161/circheartfailure.117.004500] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/19/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Keyur B. Shah
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sampath Gunda
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sitaramesh Emani
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Manreet K. Kanwar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Nir Uriel
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Paolo C. Colombo
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Patricia A. Uber
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Melissa L. Sears
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Joyce Chuang
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - David J. Farrar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Donald F. Brophy
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - George B. Smallfield
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
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Chetcuti Zammit S, Sanders DS, Sidhu R. Lanreotide in the management of small bowel angioectasias: seven-year data from a tertiary centre. Scand J Gastroenterol 2017; 52:962-968. [PMID: 28506132 DOI: 10.1080/00365521.2017.1325929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Haemorrhage from small bowel angioectasias (SBAs) can be debilitating to patients who are very often elderly and have multiple comorbidities. Our aim was to assess the use of lanreotide in addition to endotherapy in patients with SBAs. METHOD Patients with SBAs on capsule endoscopy (CE) who received lanreotide injections from January 2010 to till the present day at the Royal Hallamshire Hospital in Sheffield were included. Baseline demographics were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes. RESULTS Twelve patients (67% males, mean age 74 SD ± 15.5 years) were included. All patients had multiple comorbidities. Lanreotide was given at a dosage of 60 mg (42%), 90 mg (33%) or 120 mg (25%). It was given at a four-week interval in 75% of patients and at a six-week interval in 17% of patients. One patient (8%) received a single dose. The mean duration of treatment was 19 months SD ± 14.5. Only 17% of patients had their lanreotide stopped due to cholelithiasis. There was a significant improvement in mean haemoglobin: 86.8 versus 98.0 (131-166 g/L, p = .012). The mean number of bleeding episodes (4.18 versus 1.09, p = .010) and packed red cells (323 versus 152, p = .006) received improved. Patients required less DBEs ± APCs after starting lanreotide (19 versus 11 p = .048). CONCLUSION Lanreotide is a useful adjuvant treatment to therapeutic enteroscopy in patients with refractory obscure gastrointestinal bleeding due to SBAs. It improves haemoglobin levels, reduces transfusion requirements, bleeding episodes and number of DBEs. Overall, it has a good safety profile.
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Affiliation(s)
- S Chetcuti Zammit
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - D S Sanders
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - R Sidhu
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
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Beg S, Ragunath K. Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract. Best Pract Res Clin Gastroenterol 2017; 31:119-125. [PMID: 28395783 DOI: 10.1016/j.bpg.2016.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 11/27/2016] [Accepted: 11/29/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.
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Affiliation(s)
- Sabina Beg
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Queen Medical Centre, Nottingham, United Kingdom.
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Queen Medical Centre, Nottingham, United Kingdom.
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Martins NB, Chaput KJ, Stawicki SP, Modi R. Octreotide as an adjunct in the management of arterial gastrointestinal bleeding: Should it be considered in refractory cases of obscure origin? Int J Crit Illn Inj Sci 2017; 7:8-11. [PMID: 28382252 PMCID: PMC5364774 DOI: 10.4103/ijciis.ijciis_14_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Noel B Martins
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Kimberly J Chaput
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ronak Modi
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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Arribas Anta J, Zaera de la Fuente C, Martín Mateos R, González Martín J, Cañete Ruiz A, Boixeda de Miquel D, Albillos Martínez A. Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Abstract
Gastrointestinal angiodysplasia (GIAD) are red flat arborized lesions that are found throughout the entire gastrointestinal tract. GIAD can vary in size and have a range of presentation from occult to life-threatening bleeding. The typical presentation is intermittent bleeding in the setting of iron deficiency anemia. Endoscopy is the primary means of diagnosis and endoscopic therapy is noted to be initially effective. However, rebleeding can be as high as 40% to 50% in patients with small bowel GIAD. This review describes the pathophysiology for the development of GIAD and the current roles of endoscopic, medical, and surgical therapy in its treatment.
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40
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Dhar Chowdhury S, Simon EG, Kirubakaran R, Goel A. Efficacy of thalidomide in management of bleeding from gastrointestinal angiodysplasia. Hippokratia 2016. [DOI: 10.1002/14651858.cd012461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sudipta Dhar Chowdhury
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Ebby G Simon
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Richard Kirubakaran
- Christian Medical College; Cochrane South Asia, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Ashish Goel
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
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Arribas Anta J, Zaera de la Fuente C, Martín Mateos R, González Martín JA, Cañete Ruiz A, Boixeda de Miquel D, Albillos Martínez A. Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 82:26-31. [PMID: 27894604 DOI: 10.1016/j.rgmx.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 05/08/2016] [Accepted: 05/23/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Gastrointestinal angiodysplasias are defined as vascular dilations that communicate capillaries and veins in the walls of the digestive tract. The clinical presentation of these lesions varies from chronic occult bleeding to severe gastrointestinal hemorrhage. AIM The primary aim of our study was to analyze lesion location, the efficacy of therapeutic endoscopy with argon plasma coagulation, and the factors associated with rebleeding in patients with gastrointestinal angiodysplasias. MATERIAL AND METHODS A retrospective study of 32,042 endoscopies was carried out within the time frame of January 2012 and December 2013 at our hospital center. Gastrointestinal angiodysplasia was the diagnosis in 331 of the endoscopies. The procedures included upper gastrointestinal endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy. RESULTS The most frequent location of the angiodysplasias was the cecum (49%), followed by the ascending colon (17%) and the sigmoid colon (16%). They were most frequently found in the duodenum (60%) and gastric body (49%) at upper gastrointestinal endoscopy. Therapeutic endoscopy was performed in 163 cases (49.8%) and the most predominant methods were fulguration with argon (90%) and combination treatment (argon plasma coagulation and injection sclerotherapy) (6.7%). The macroscopic rebleeding rate after therapeutic endoscopy was 7.4%. Patients that had rebleeding presented with a lower hemoglobin concentration, higher mean age, and the presence of multiple angiodysplasias at endoscopy (P<.05). CONCLUSIONS Therapeutic endoscopy was performed in 49.8% of the patients with angiodysplasias. The macroscopic rebleeding rate after treatment was 7.4%. There were statistically significant differences in the patients with rebleeding in relation to mean age, hemoglobin values, and the presence of multiple angiodysplasias.
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Affiliation(s)
- J Arribas Anta
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España.
| | - C Zaera de la Fuente
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
| | - R Martín Mateos
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
| | - J A González Martín
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
| | - A Cañete Ruiz
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
| | - D Boixeda de Miquel
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
| | - A Albillos Martínez
- Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, España
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Pasha SF, Leighton JA. Detection of suspected small bowel bleeding: challenges and controversies. Expert Rev Gastroenterol Hepatol 2016; 10:1235-1244. [PMID: 27366927 DOI: 10.1080/17474124.2016.1207525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Detection of small bowel (SB) bleeding remains a challenge to gastroenterologists, with a dearth of standardized recommendations regarding evaluation and management. Areas covered: A recursive literature search was performed using PubMed, Cochrane and Medline databases for original and review articles on SB and obscure gastrointestinal bleeding (OGIB). Based upon the available literature, this review outlines the main challenges and controversies, and provides a practical and cost-effective approach towards SB bleeding. Expert commentary: SB bleeding is suspected in patients with persistent or recurrent bleeding after negative bidirectional endoscopy, and unexplained iron deficiency anemia. Selection of test(s) should be individualized based upon patient presentation and suspicion for type of underlying lesion. Endoscopic or radiologic evaluation and treatment is the mainstay in the majority of patients, while pharmacologic agents may have a role in patients with refractory bleeding, and those unable to undergo evaluation.
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Affiliation(s)
- Shabana F Pasha
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
| | - Jonathan A Leighton
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
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Grooteman KV, van Geenen EJM, Drenth JPH. Multicentre, open-label, randomised, parallel-group, superiority study to compare the efficacy of octreotide therapy 40 mg monthly versus standard of care in patients with refractory anaemia due to gastrointestinal bleeding from small bowel angiodysplasias: a protocol of the OCEAN trial. BMJ Open 2016; 6:e011442. [PMID: 27619827 PMCID: PMC5030574 DOI: 10.1136/bmjopen-2016-011442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Gastrointestinal angiodysplasias are an important cause of difficult-to-manage bleeding, especially in older patients. Endoscopic coagulation of angiodysplasias is the mainstay of treatment, but may be difficult for small bowel angiodysplasias because of the inability to reach them for endoscopic intervention. Some patients are red blood cell (RBC) transfusion dependent due to frequent rebleeding despite endoscopic treatment. In small cohort studies, octreotide appears to decrease the number of bleeding episodes in patients with RBC transfusion dependency due to gastrointestinal angiodysplasias. This trial will assess the efficacy of octreotide in decreasing the need for RBC transfusions and parenteral iron in patients with anaemia due to gastrointestinal bleeding of small bowel angiodysplasias despite endoscopic intervention. STUDY DESIGN Randomised controlled, superiority, open-label multicentre trial. PARTICIPANTS 62 patients will be included with refractory anaemia due to small bowel angiodysplasias, who are RBC transfusion or iron infusion dependent despite endoscopic intervention and oral iron supplementation. INTERVENTION Patients will be randomly assigned (1:1) to standard care or 40 mg long-acting octreotide once every 4 weeks for 52 weeks, in addition to standard care. The follow-up period is 8 weeks. MAIN OUTCOME MEASURES The primary outcome is the difference in the number of blood and iron infusions between the year prior to inclusion and the treatment period of 1 year. Important secondary outcomes are the per cent change in the number of rebleeds from baseline to end point, adverse events and quality of life. ETHICS AND DISSEMINATION The trial received ethical approval from the Central Committee on Research Involving Human Subjects and from the local accredited Medical Research Ethics Committee of the region Arnhem-Nijmegen, the Netherlands (reference number: 2014-1433). Results will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER NCT02384122; Pre-results.
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Affiliation(s)
- K V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Iannone A, Principi M, Barone M, Losurdo G, Ierardi E, Di Leo A. Gastrointestinal bleeding from vascular malformations: Is octreotide effective to rescue difficult-to-treat patients? Clin Res Hepatol Gastroenterol 2016; 40:373-377. [PMID: 27595456 DOI: 10.1016/j.clinre.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/15/2016] [Accepted: 02/09/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal vascular malformations are responsible for 2-8% of all cases of bleeding and 30-40% of all obscure hemorrhages, being the most frequent cause of occult bleeding in older people. The aim of this review was to provide an up-to-date report about the use of octreotide in bleeding from both hereditary and acquired vascular malformations of the gastrointestinal tract. A systematic literature search was performed, using the keywords "gastrointestinal vascular malformation", "octreotide", "angiodysplasia", "portal hypertensive gastropathy", "gastric antral vascular ectasia", and "hereditary vascular malformations". The first line therapy of acute/chronic bleeding from digestive vascular malformations is endoscopy, followed by angiographic embolization and surgical resection when this is unsuccessful. In the setting of difficult-to-treat patients, octreotide has been proposed as an alternative therapeutic strategy. Studies reported in the literature show a high efficacy and safety of octreotide, but described only a small number of enrolled patients, heterogeneous therapeutic schedules and short-term follow-up, with the exception of acute bleeding from esophageal varices. As a consequence, the use of octreotide is not approved in this setting and it is currently still prescribed as an off-label drug. Studies in larger populations are needed to confirm the promising results observed in the small case series reports, so as to provide physicians with a treatment option for patients without available alternatives. Octreotide could also determine a strong decrease in the management costs of these clinical conditions, and especially, could dramatically reduce hospital admission costs.
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Affiliation(s)
- Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Small Intestinal Angioectasias Are Not Randomly Distributed in the Small Bowel and Most May Be Reached by Push Enteroscopy. J Clin Gastroenterol 2016; 50:561-5. [PMID: 26485105 DOI: 10.1097/mcg.0000000000000425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
GOALS The goal was to describe the location of angioectasias within small bowel on capsule endoscopy and the utility of push enteroscopy versus deep enteroscopy in treatment of overt bleeding from these. BACKGROUND Overt bleeding from small bowel angioectasias is a clinical challenge. Thalidomide and octreotide can be difficult to prescribe and may not be effective. Endoscopy remains a mainstay of treatment for overt bleeding from angioectasias but data regarding the long-term efficacy of endoscopic therapy are limited. We sought to define the location of small bowel angioectasias using capsule endoscopy and review our outcomes for push and double-balloon enteroscopy. METHODS We retrospectively reviewed all 428 capsule endoscopy studies from the Veterans Administration Hospital in West Haven, CT from 2005 to 2012. Location of angioectasias was evaluated using lead mapping and small bowel transit time. RESULTS We identified 69 patients with small bowel angioectasia. At least 66.8% of lesions were in duodenum or ligament of Treitz, with 78.3% within the first 25% of small bowel transit. Twenty-four patients underwent endoscopic treatment of overt bleeding from small bowel angioectasias. Thirty-three percent rebled requiring multiple procedures. Eight patients had 10 anterograde double-balloon examinations. Only 2 patients had both cessation of bleeding with double balloon and lesions outside the reach of push enteroscopy. CONCLUSIONS Push enteroscopy for bleeding angioectasias is effective in many patients. Deep enteroscopy may not benefit most patients as most angioectasias are proximal. Patients with deeper lesions tended to have multiple lesions and rebleeding despite deep enteroscopy.
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Evaluation of Superselective Transcatheter Arterial Embolization with n-Butyl Cyanoacrylate in Treating Lower Gastrointestinal Bleeding: A Retrospective Study on Seven Cases. Gastroenterol Res Pract 2016; 2016:8384349. [PMID: 27528867 PMCID: PMC4978829 DOI: 10.1155/2016/8384349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/19/2016] [Indexed: 12/20/2022] Open
Abstract
Background. To investigate the safety and efficacy of superselective transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate (NBCA) in treating lower gastrointestinal bleeding caused by angiodysplasia. Methods. A retrospective study was performed to evaluate the clinical data of the patients with lower gastrointestinal bleeding caused by angiodysplasia. The patients were treated with superselective TAE with NBCA between September 2013 and March 2015. Angiography was performed after the embolization. The clinical signs including melena, anemia, and blood transfusion treatment were evaluated. The complications including abdominal pain and intestinal ischemia necrosis were recorded. The patients were followed up to evaluate the efficacy in the long run. Results. Seven cases (2 males, 5 females; age of 69.55 ± 2.25) were evaluated in the study. The embolization was successfully performed in all cases. About 0.2-0.8 mL (mean 0.48 ± 0.19 mL) NCBA was used. Immediate angiography after the embolization operation showed that the abnormal symptoms disappeared. The patients were followed up for a range of 2-19 months and six patients did not reoccur. No serious complications, such as femoral artery puncture point anomaly, vascular injury, and intestinal necrosis perforation were observed. Conclusion. For the patients with refractory and repeated lower gastrointestinal hemorrhage due to angiodysplasia, superselective TAE with NBCA seem to be a safe and effective alternative therapy when endoscopy examination and treatment do not work.
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Boey JP, Hahn U, Sagheer S, McRae SJ. Thalidomide in angiodysplasia-related bleeding. Intern Med J 2016; 45:972-6. [PMID: 26332623 DOI: 10.1111/imj.12850] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 05/31/2015] [Indexed: 12/17/2022]
Abstract
Gastrointestinal haemorrhage from angiodysplastic lesions is not only difficult to identify, but often refractory to endoscopic intervention. Patients often require substantial transfusion support. Thalidomide has emerged as a promising medical strategy in angiodysplasia-related bleeding. We present our experience and report the findings from a review of the literature. Despite its side-effect profile, thalidomide remains the therapeutic modality with the best evidence in this difficult clinical scenario.
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Affiliation(s)
- J P Boey
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - U Hahn
- Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - S Sagheer
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - S J McRae
- Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Eficacia de lanreótido en pacientes con angiodisplasias gastrointestinales refractarias al tratamiento con octreótido. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:213-4. [DOI: 10.1016/j.gastrohep.2015.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 11/18/2022]
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Salzano A, Rocca A, Arcopinto M, Amato B, Marra AM, Simonelli V, Mozzillo P, Giuliani A, Tafuri D, Cinelli M. Bowel Angiodysplasia and Myocardial Infarction secondary to an ischaemic imbalance: a case report. Open Med (Wars) 2015; 10:543-548. [PMID: 28352752 PMCID: PMC5368879 DOI: 10.1515/med-2015-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 11/05/2015] [Indexed: 11/24/2022] Open
Abstract
Angiodysplasia, defined as a vascular ectasia or arteriovenous malformation, is the most frequent cause of occult bleeding in patients older than 60 years and a significant association with several cardiac condition is described. Patients with anemia and negative findings on upper endoscopy and colonoscopy should be referred for further investigation of the small bowel. The investigation of choice, when available, is wireless capsule endoscopy. Several therapeutic options are available in this cases, as we reviewed in this report. We report a case of 78-year old man admitted to our Intensive Coronary Unit for dyspnea and chest pain. A diagnosis of non-ST-segment elevation acute coronary syndrome was made and a concomintant, significant anemia was found (hemoglobin 8.2 g/dl). No cororary disease was found by an angiography though the past medical history revealed systemic hypertension, chronic kidney disease (KDOQY stage III), and diabetes mellitus type II on insuline therapy. A Wireless Video capsule examination was positive for jejunum angiodysplasia and an argon plasma coagulation was chosen as terapeutic option. No subsequent supportive therapy and interventions were required in subsequent one year of follow-up.
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Affiliation(s)
- Andrea Salzano
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Aldo Rocca
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Naples, Italy, Via Sergio Pansini, 80131 Naples, Italy
| | - Michele Arcopinto
- Department of Cardiac Surgery, IRCCS Policlinico San Donato Milanese, Milan, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Alberto Maria Marra
- Pulmonary Hypertension Center, Thoraxclinic at the University of Heidelberg, Heidelberg, Germany
| | | | - Pasquale Mozzillo
- Centre Hospitalier intercommunal de Poissy, Saint-Germain-en-Laye, France
| | - Antonio Giuliani
- Unit of Hepatobiliary Surgery and Liver Transplant Center, Department of Gastroenterology and Transplantation, "A. Cardarelli" Hospital, Naples, Italy
| | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples "Parthenope", Naples, Italy
| | - Mariapia Cinelli
- Department of Public Health, University of Naples "Federico II", Naples, Italy
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Holleran G, Hall B, Breslin N, McNamara D. Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial. United European Gastroenterol J 2015; 4:70-6. [PMID: 26966525 DOI: 10.1177/2050640614559121] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/12/2014] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Small bowel angiodysplasias account for over 50% of causes of small bowel bleeding and carry a worse prognosis than lesions located elsewhere in the gastrointestinal tract. Re-bleeding rates are high even after first-line endoscopic therapy and are associated with high levels of morbidity for affected patients. Small trials of long-acting somatostatin analogues have shown promising results but have not yet been assessed in patients with refractory small bowel disease. AIM The purpose of this study was to assess the effect of long-acting somatostatin analogues in reducing re-bleeding rates and transfusion requirements, and improving haemoglobin levels in patients with refractory small bowel angiodysplasia. METHODS Patients with refractory small bowel angiodysplasia were treated with 20 mg of long-acting octreotide for a minimum of three months. Response was assessed according to: rates of re-bleeding, haemoglobin levels, transfusion requirements, and side effects. RESULTS A total of 24 patients were initially treated and 20 received at least three doses. Rates of complete, partial and non-response were 70%, 20% and 10% respectively. Average haemoglobin rates increased from 9.19 g/dl to 11.35 g/dl (p = 0.0027, 95% confidence interval (CI) -3.5 to -1.1) in the group overall and 70% remained transfusion-free after a mean treatment duration of 8.8 months. The rate of adverse events was higher than previously reported at 30%. CONCLUSION Long-acting somatostatin analogues offer a therapeutic advantage in a significant proportion of patients with small bowel angiodysplasia. With careful patient selection and close observation, a long-acting somatostatin analogue should be considered in all patients with persistent anaemia attributable to refractory disease in conjunction with other standard treatments.
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Affiliation(s)
- Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Barry Hall
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Niall Breslin
- Department of Gastroenterology, Tallaght Hospital, Dublin, Ireland
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
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