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Papantoniou K, Aggeletopoulou I, Pastras P, Triantos C. The Role of Somatostatin in the Gastrointestinal Tract. BIOLOGY 2025; 14:558. [PMID: 40427747 PMCID: PMC12109247 DOI: 10.3390/biology14050558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2025] [Revised: 05/12/2025] [Accepted: 05/13/2025] [Indexed: 05/29/2025]
Abstract
The gastrointestinal (GI) tract is responsible for food digestion and host protection from harmful stimuli; however, its function as an endocrine organ is also well documented. Somatostatin (SST) was first discovered in the hypothalamus, but the GI tract is its main producer and target organ. SST is a potent inhibitor of many GI functions, including peristalsis, hormone secretion, and gastric acid production, while its anti-inflammatory effects contribute to the integrity of the intestinal barrier. These data make SST and its analogs useful agents in clinical practice. As our understanding of SST metabolism and function evolves, their use in a wide variety of medical conditions can improve patient care.
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Affiliation(s)
| | | | | | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University of Patras, 26504 Patras, Greece; (K.P.); (I.A.); (P.P.)
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Hirata I, Tsuboi A, Matsubara Y, Sumioka A, Takasago T, Tanaka H, Yamashita K, Takigawa H, Urabe Y, Oka S. Clinical usefulness and acceptability of small-bowel capsule endoscopy with panoramic imaging compared with axial imaging in Japanese patients. DEN OPEN 2025; 5:e389. [PMID: 38845631 PMCID: PMC11154819 DOI: 10.1002/deo2.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/25/2024] [Accepted: 05/05/2024] [Indexed: 06/09/2024]
Abstract
Objectives We aimed to evaluate the usefulness and acceptability of CapsoCam Plus (CapsoCam) in Japanese patients. Methods This retrospective single-center study enrolled 930 patients with suspected small-bowel bleeding (SSBB) who underwent capsule endoscopy. Thirty-three patients using CapsoCam and PillCam SB3 (SB3) were matched using propensity score matching. The diagnostic yield and the acceptability of CapsoCam were evaluated. Results There was no SSBB case where capsule endoscopy was performed within 48 h of bleeding. CapsoCam had a significantly higher observation rate of the entire small bowel (97% vs. 73%, p = 0.006) and Vater's papilla (82% vs. 15%, p < 0.001) than SB3. The reading time of CapsoCam was significantly longer than that of SB3 (30 vs. 25 min, p < 0.001), and CapsoCam's time from the capsule endoscopy swallowing to read completion was longer than that of SB3 (37 vs. 12 h, p < 0.001). The two groups showed no difference in the capsule endoscopy findings according to the P classification. Notably, 85% of the patients using CapsoCam reported examination distress as "not at all" or "almost not," and 94% reported swallowing difficulty as "very easy" or "easy." Conclusions CapsoCam took time to read; however, it is a well-tolerated examination with a high observation rate of Vater's papilla and entire small-bowel mucosa. Detectability of bleeding sources was comparable in both modalities for cases of occult SSBB and overt SSBB more than 48 h after bleeding. CapsoCam is a useful modality for patients with SSBB.
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Affiliation(s)
- Issei Hirata
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Akiyoshi Tsuboi
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Yuka Matsubara
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Akihiko Sumioka
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Takeshi Takasago
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Hidenori Tanaka
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Ken Yamashita
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Hidehiko Takigawa
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Yuji Urabe
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Shiro Oka
- Department of GastroenterologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
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Lu MC, Huang TY, Chen PJ, Chen HW, Yang CW, Lin JC, Huang WC, Lin HH, Shih YL, Hsieh TY, Chen BC. Predictors of active and recurrent bleeding in upper gastrointestinal angiodysplasia: Results from 10-year esophagogastroduodenoscopy of a tertiary center in Taiwan. Medicine (Baltimore) 2024; 103:e40921. [PMID: 39686487 PMCID: PMC11651466 DOI: 10.1097/md.0000000000040921] [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: 04/16/2023] [Accepted: 11/14/2024] [Indexed: 12/18/2024] Open
Abstract
Upper gastrointestinal angiodysplasia (UGIA) is a unique mucosal vascular lesion that causes acute or recurrent gastrointestinal bleeding. Despite the increasing incidence of UGIA, the risk factors for bleeding in this condition remain unclear. We investigated the predictors of active and recurrent bleeding among patients with UGIA. We conducted a retrospective cohort study of 104,086 patients who underwent esophagogastroduodenoscopy (EGD) at the Tri-Service General Hospital in Taiwan between October 2011 and September 2021. UGIA was diagnosed in 112 patients, and the data from these patients were comprehensively analyzed. EGD documented UGIA in 112 patients, which corresponded with an overall diagnostic yield of 1.1%. Active bleeding was documented in 28 (25%) patients. Patients in the active bleeding group were older than the patients in the asymptomatic group (71.6 ± 11.7-years vs 61.3 ± 18.5-years). Most of the UGIA lesions were singular and measured 2 to 5 mm. Nearly 1-quarter of the patients (24.1%) underwent endoscopic hemostasis, and rebleeding occurred in 6 (21.4%) patients during the follow-up period. Multivariate analysis identified diabetes mellitus (DM), chronic kidney disease (CKD), and lesions in the duodenum as significant risk factors for active bleeding (P = .019; P = .006; P = .004). Our cohort study provided real-world data on the clinical and endoscopic features of UGIA. DM, CKD, and lesions in the duodenum were independent predictors of active bleeding.
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Affiliation(s)
- Meng-Chuan Lu
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Huang
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Peng-Jen Chen
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Wei Chen
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Yang
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jung-Chun Lin
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chen Huang
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Hwai Lin
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Lueng Shih
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsai-Yuan Hsieh
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Bao-Chung Chen
- Department of Internal Medicine, Division of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Azancot S, Dray X, Moshiri P, Soualy A, Guilloux A, Michel PA, Boffa JJ, Becq A. Gastrointestinal Angiectasia in patients with chronic kidney disease: A matched case-control study. Clin Res Hepatol Gastroenterol 2024; 48:102454. [PMID: 39179202 DOI: 10.1016/j.clinre.2024.102454] [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: 06/28/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND AND STUDY AIMS Chronic kidney disease (CKD) is a well-known risk factor of gastrointestinal angiectasia (GIA). The aim was to compare this population with CDK patients without GIA. METHODS Patients followed in the Nephrology Department of Tenon Hospital for which an endoscopy was performed between 2012 and 2022 were identified. Those with at least one GIA lesion were included ("GIA+" group). A matched control group for age, sex and GFR stage of patients with CKD and no GIA lesion ("GIA-" group) was constituted. A subgroup analysis compared patients with (SB+) and without (SB-) small-bowel involvement. RESULTS A total of 55 patients were included in the GIA+ group. 36.3 % (n = 20) were active smokers and 29.1 % (n = 16) had peripheral arterial disease versus 16.4 % (n = 9) (OR 2.89, p = 0.03), and 9.1 % (n = 5) (OR 4.05, p = 0.015) in the GIA- group. Thirteen patients (23.6 %) had a SB lesion. Duodenal involvement was present in 69.2 % of cases in the SB+ group versus 28.6 % in the SB- group (p = 0.02). Median number of endoscopies, hemostatic technics and hospitalizations was 7, 3 and 6, versus 2 (p = 0.0001), 1 (p = 0.001) and 1 (p = 0.0002) in the SB- group. CONCLUSIONS CKD patients with GIA had a greater cardiovascular risk with a higher incidence of vascular nephropathy. Small-bowel GIA were associated with a higher morbidity.
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Affiliation(s)
- Sarah Azancot
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France
| | - Xavier Dray
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Adil Soualy
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France
| | - Antoine Guilloux
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Jean Jacques Boffa
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France; Sorbonne University, INSERM U1155 CORAKID, Paris, France
| | - Aymeric Becq
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France.
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Viazis N, Christodoulou D, Papastergiou V, Mousourakis K, Kozompoli D, Stasinos G, Dimopoulou K, Apostolopoulos P, Fousekis F, Liatsos C, Kyriakos N, Argyropoulos T, Tribonias G. Diagnostic Yield and Outcomes of Small Bowel Capsule Endoscopy in Patients with Small Bowel Bleeding Receiving Antithrombotics. Diagnostics (Basel) 2024; 14:1361. [PMID: 39001251 PMCID: PMC11240733 DOI: 10.3390/diagnostics14131361] [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: 04/08/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
We aimed to determine the diagnostic yield and outcome of patients receiving antithrombotic drug therapy subjected to small bowel capsule endoscopy (SBCE) for the investigation of small bowel bleeding (SBB). A multicenter retrospective analysis of collected data from all patients undergoing SBCE for the investigation of SBB from March 2003 to June 2023 was performed. The diagnostic yield of SBCE was defined as the detection of positive findings that could explain the cause of the patient's bleeding. Rebleeding was defined as evidence of bleeding within 1 year after the index episode. During the study period, 8401 patients underwent SBCE for SBB investigation. Bleeding lesions were detected in 1103/2535 (43.5%) antithrombotic users, compared to 1113/5866 (18.9%) in nonusers (p < 0.00001). Following capsule endoscopy, a therapeutic intervention was possible in 390/2216 (17.5%) patients with a bleeding lesion. Rebleeding occurred in 927 (36.5%) of antithrombotic users (36.5%), compared to 795 (13.5%) of nonusers (13.5%, p < 0.00001). Both the diagnostic yield of SBCE and the rebleeding rates were higher in patients with SBB receiving antithrombotics. Therapeutic intervention was possible in a real-world setting only for a minority of patients with positive findings.
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Affiliation(s)
- Nikos Viazis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitris Christodoulou
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Vasilis Papastergiou
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Konstantinos Mousourakis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitra Kozompoli
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Giannis Stasinos
- Gastroenterology Department, NIMTS, 19010 Kalivia, Greece; (G.S.); (P.A.)
| | - Konstantina Dimopoulou
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | | | - Fotios Fousekis
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Christos Liatsos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Nikolaos Kyriakos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Theodoros Argyropoulos
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | - George Tribonias
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
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Johnson CM, Nandi N, Sidhu R. Pharmacotherapy for Gastrointestinal Angiodysplasia: is it effective? Expert Opin Pharmacother 2024:1-4. [PMID: 38682489 DOI: 10.1080/14656566.2024.2348091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Calvin M Johnson
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Reena Sidhu
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Academic Unit of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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7
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Hirata I, Tsuboi A, Matsubara Y, Sumioka A, Takasago T, Tanaka H, Yamashita K, Takigawa H, Kotachi T, Yuge R, Urabe Y, Oka S. Long-term outcomes of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. J Gastroenterol Hepatol 2024; 39:165-171. [PMID: 37837361 DOI: 10.1111/jgh.16379] [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: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND AND AIM Although small-bowel capsule endoscopy (CE) is widely used for obscure gastrointestinal bleeding (OGIB), long-term outcomes for OGIB patients after negative CE remain unclear. Herein, we defined negative CE as P0 (no bleeding potential) or P1 (less likely to bleed), based on the P classification using CE. We aimed to clarify long-term outcomes of patients with OGIB after negative CE. METHODS This single-center observational study enrolled 461 consecutive patients with OGIB who underwent CE from March 2014 to October 2021 and were followed up for >1 year. We examined rebleeding rates and predictive factors. RESULTS Two hundred and twenty-four (49%) patients had P0, and 237 (51%) had P1 findings. Rebleeding occurred in 9% and 16% of patients in the P0 and P1 groups, respectively. Two patients in the P0 group and 15 in the P1 group showed rebleeding from the small bowel. The rate of small-bowel rebleeding was significantly lower in the P0 group than that in the P1 group (1% vs 6%, P = 0.002), as was the cumulative rebleeding rate (P = 0.004). In the multivariate analysis, history of endoscopic hemostasis (hazard ratio [HR] = 15.958, 95% confidence interval [CI]:4.950-51.447, P < 0.001) and P1 CE findings (HR = 9.989, 95% CI: 2.077-48.030, P = 0.004) were independently predicted small-bowel rebleeding. CONCLUSIONS OGIB with P0 CE findings rarely showed rebleeding from the small bowel. Rebleeding may occur in patients with OGIB. Patients with history of endoscopic hemostasis for small-bowel lesions or P1 CE findings should be followed up intensively.
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Affiliation(s)
- Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahiro Kotachi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ryo Yuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Oka P, Ray M, Sidhu R. Small Bowel Bleeding: Clinical Diagnosis and Management in the Elderly. Expert Rev Gastroenterol Hepatol 2023:1-8. [PMID: 37184832 DOI: 10.1080/17474124.2023.2214726] [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] [Indexed: 05/16/2023]
Abstract
INTRODUCTION With the global increase in life expectancy, there is an increase in gastrointestinal presentations in the elderly. Small bowel bleeding (SBB) is a cause of significant morbidity in the elderly requiring multiple hospital visits, investigations and potentially expensive therapy. AREAS COVERED In this review we will outline the different modalities which are used for the diagnosis and management of SBB. We will also discuss the common causes of SBB in the elderly. EXPERT OPINION SBB in elderly has a significant impact on the quality of life of the elderly. Larger randomized studies in the elderly are urgently required to help guide clinicians on the best and most cost-effective treatment algorithm in this challenging cohort.
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Affiliation(s)
- Priya Oka
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
| | - Meghna Ray
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
| | - Reena Sidhu
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
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Kobayashi M, Akiyama S, Narasaka T, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Tsuchiya K, Kaise M, Nagata N. Nationwide cohort study identifies clinical outcomes of angioectasia in patients with acute hematochezia. J Gastroenterol 2023; 58:367-378. [PMID: 36564578 DOI: 10.1007/s00535-022-01945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND While angioectasia is an important cause of acute hematochezia, relevant clinical features remain unclear. This study aims to reveal risk factors, clinical outcomes, and the effectiveness of therapeutic endoscopy for patients with acute hematochezia due to angioectasia. METHODS This retrospective cohort study was conducted at 49 Japanese hospitals between January 2010 and December 2019, enrolling patients hospitalized for acute hematochezia (CODE BLUE-J study). Baseline factors and clinical outcomes for angioectasia were analyzed. RESULTS Among 10,342 patients with acute hematochezia, 129 patients (1.2%) were diagnosed with angioectasia by colonoscopy. The following factors were significantly associated with angioectasia: chronic kidney disease, liver disease, female, body mass index < 25, and anticoagulant use. Patients with angioectasia were at a significant increased risk of blood transfusions compared to those without angioectasia (odds ratio [OR] 2.61; 95% confidence interval [CI] 1.69-4.02). Among patients with angioectasia, 36 patients (28%) experienced rebleeding during 1-year follow-up. The 1-year cumulative rebleeding rates were 37.0% in the endoscopic clipping group, 14.3% in the coagulation group, and 32.8% in the conservative management group. Compared to conservative management, coagulation therapy significantly reduced rebleeding risk (P = 0.038), while clipping did not (P = 0.81). Multivariate analysis showed coagulation therapy was an independent factor for reducing rebleeding risk (hazard ratio [HR] 0.40; 95% CI 0.16-0.96). CONCLUSIONS Our data showed patients with angioectasia had a greater comorbidity burden and needed more blood transfusions in comparison with those without angioectasia. To reduce rebleeding risk, coagulation therapy can be superior for controlling hematochezia secondary to angioectasia.
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Affiliation(s)
- Mariko Kobayashi
- Division of Endoscopic Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Shintaro Akiyama
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiaki Narasaka
- Division of Endoscopic Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan.
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | | | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
- Emergency and Critical Care Center, Saiseikai Yokohama Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Naha, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, and Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
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10
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Hussain K, Kattoor AJ, Liu B, Parfieniuk A, Achebe I, Doukky R. Left-Sided Prosthetic Valve Dysfunction and Gastrointestinal Bleeding. Cureus 2023; 15:e37042. [PMID: 37143635 PMCID: PMC10153790 DOI: 10.7759/cureus.37042] [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] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction We sought to investigate the association between left-sided prosthetic valve dysfunction and gastrointestinal (GI) bleeding. Methods In a retrospective cohort of patients with left-sided prostheses, we identified those who experienced one or more GI bleeds. The latest or chronologically closest echocardiogram to the GI bleed was analyzed by a blinded investigator for prosthetic valve dysfunction. Results Among 334 unique patients, 166 had aortic prostheses, 127 had mitral prostheses, and 41 had both. A total of 58 (17.4%) subjects had GI bleeding events. Patients in the "GI Bleed" group had higher mean ejection fraction (56±14% vs. 49±15%; P = 0.003) and higher prevalence of hypertension, end-stage renal disease, and liver cirrhosis compared to the "No GI Bleed" group. There was a higher prevalence of moderate or severe prosthetic valve regurgitation in the GI Bleed vs. No GI Bleed group (8.6% vs. 2.2%; P = 0.027). Moderate or severe prosthetic valve regurgitation was independently associated with GI bleeding (odds ratio, 6.18; 95% confidence interval, 1.27-30.05; P = 0.024), after adjusting for ejection fraction, hypertension, end-stage renal disease and liver cirrhosis. Paravalvular regurgitation was associated with a higher incidence of GI bleeding compared to transvalvular regurgitation (35.7% vs. 11.9%; P = 0.044). The prevalence of prosthetic valve stenosis was similar between the GI Bleed and No GI Bleed groups (6.9% vs. 5.8%; P = 0.761). Conclusion In a cohort of patients with predominantly surgically placed prosthetic valves, moderate to severe left-sided prosthetic valve regurgitation was independently associated with GI bleeding.
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Affiliation(s)
- Kifah Hussain
- Department of Cardiology, University of Chicago (NorthShore University Health System), Chicago, USA
| | - Ajoe J Kattoor
- Department of Cardiology, University at Buffalo/Kaleida Health, Buffalo, USA
| | - Bolun Liu
- Department of Hospital Medicine, Mayo Clinic Health System, Mankato, USA
| | - Agata Parfieniuk
- Department of Medicine, Advocate Christ Medical Center, Oak Lawn, USA
| | - Ikechukwu Achebe
- Department of Gastroenterology, University of Massachusetts Chan Medical School, Worcester, USA
| | - Rami Doukky
- Department of Cardiology, John H Stroger Jr. Hospital of Cook County, Chicago, USA
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11
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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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12
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Dawra S, Behl P, Srivastava S, Manrai M, Chandra A, Kumar A, Kumar A, Tevatia MS. Non-neoplastic disorders in an aging gut: concise review. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023; 35:7. [DOI: 10.1186/s43162-023-00189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/15/2023] [Indexed: 01/31/2023] Open
Abstract
AbstractThe spectrum of gastrointestinal (GI) issues in the older population varies from common physiological age-related changes to devastating, less common sinister pathological illness. GI system has direct exposure to external environment. Thus, it is modeled to embrace the pathophysiological changes that occur due to interaction with external factors. Gastrointestinal tract (GIT) per se is more resilient to aging as compared to other organ systems. On the other hand, elderly may present with a large plethora of GI symptoms. This presents a challenge to all echelons of medical consultation for accurate attribution for the aging process or pathophysiological causation of GI symptoms. This dichotomy leads to hindrance in adequate and appropriate treatment of GI ailments. In GI system, non-neoplastic disorders are far more common than neoplastic disorders. Hence, it becomes imperative to understand the aging evolution of the GI system and management of GI disorders in the older population.
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13
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Ghosh NK, Singh A, Rahul R, Singh RK, Goel A, Saxena R. Multifocal Small Bowel Angioectasias: Managed with Innovative, Nonresectional Surgical Procedure. Surg J (N Y) 2022; 8:e169-e173. [PMID: 35991490 PMCID: PMC9381361 DOI: 10.1055/s-0042-1744151] [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] [Received: 06/14/2021] [Accepted: 02/01/2022] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.
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Affiliation(s)
| | - Ashish Singh
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rahul Rahul
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajneesh Kumar Singh
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Goel
- Department of Medical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajan Saxena
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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14
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Ali H, Bolick NL, Pamarthy R, Farooq MF, Farooq MH, Eslam A. Inpatient outcomes of Dieulafoy’s lesions in the United States. Proc AMIA Symp 2022; 35:291-296. [DOI: 10.1080/08998280.2022.2043806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hassam Ali
- Department of Internal Medicine, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | | | - Rahul Pamarthy
- Department of Internal Medicine, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | - Muhammad Fahd Farooq
- Department of Gastroenterology, East Carolina University/Vidant Medical Center, Greenville, North Carolina
| | | | - Ali Eslam
- Department of Gastroenterology, East Carolina University/Vidant Medical Center, Greenville, North Carolina
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15
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Zhao R, Nakamura M, Wu S, Uchida G, Yamamura T, Gao YJ, Goto H, Fujishiro M, Ge ZZ. The role of early video capsule endoscopy in the diagnosis and prognosis of obscure gastrointestinal bleeding: A multi-center propensity score matching study. J Gastroenterol Hepatol 2021; 36:2540-2548. [PMID: 33724526 DOI: 10.1111/jgh.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Video capsule endoscopy (VCE) is a first-line procedure for the diagnosis of obscure gastrointestinal bleeding (OGIB). The opinions on the timing for such diagnostic evaluation remain unclear. We aimed to explore the role of early VCE in OGIB patients. METHODS A total of 997 patients that underwent VCE at Renji Hospital and Nagoya University from May 15, 2002, to December 28, 2016, were included in this study. We matched patients that underwent early VCE within 14 days of bleeding (early group, n = 678) to patients that did not (late group, n = 319) via 1:1 propensity score matching (PSM). We then compared VCE diagnostic rates and the prevalence of post-VCE rebleeding in patients with initial negative VCE findings within 1 year between these groups before and after PSM. RESULTS Following PSM, early VCE was associated with a significantly higher rate of OGIB diagnosis (56.4% vs 45.5%, P = 0.001) and with a significantly lower incidence of rebleeding within 1 year following treatment (24.7% vs 36.7%, P = 0.041). In univariate and multivariate analyses, VCE timing (odds ratio 0.648; 95% confidence interval 0.496-0.847, P = 0.001 and odds ratio 0.666; 95% confidence interval 0.496-0.894, P = 0.007, respectively) was found to be linked with a higher rate of positive findings. CONCLUSION Early VCE can improve the reliability of OGIB diagnosis while also reducing rates of post-VCE rebleeding. This suggests that timely and accurate diagnosis can help to improve OGIB patient treatment and prognosis.
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Affiliation(s)
- Ran Zhao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Shan Wu
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Genta Uchida
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yun-Jie Gao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Zhi-Zheng Ge
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
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16
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Rosa B, Margalit-Yehuda R, Gatt K, Sciberras M, Girelli C, Saurin JC, Cortegoso Valdivia P, Cotter J, Eliakim R, Caprioli F, Baatrup G, Keuchel M, Ellul P, Toth E, Koulaouzidis A. Scoring systems in clinical small-bowel capsule endoscopy: all you need to know! Endosc Int Open 2021; 9:E802-E823. [PMID: 34079861 PMCID: PMC8159625 DOI: 10.1055/a-1372-4051] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2
3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4
5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8
9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
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Affiliation(s)
- Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Kelly Gatt
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Carlo Girelli
- Department of Internal Medicine, Gastroenterology & Digestive Endoscopy, Hospital of Busto Arsizio, Italy
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Lyon, France
| | - Pablo Cortegoso Valdivia
- Gastroenterology & Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Flavio Caprioli
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Ervin Toth
- Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anastasios Koulaouzidis
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Scotland, UK
- Department of Social Medicine & Public Health, Pomeranian Medical University, Szczecin, Poland
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Tomasević R, Gluvić Z, Mijač D, Sokić-Milutinović A, Lukić S, Milosavljević T. Anemia as a Problem: GEH Approach. Dig Dis 2021; 40:133-141. [PMID: 33866318 DOI: 10.1159/000516480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anemia is present in almost 5% of adults worldwide and accompanies clinical findings in many diseases. Diseases of the gastrointestinal (GI) tract and liver are a common cause of anemia, so patients with anemia are often referred to a gastroenterologist. SUMMARY Anemia could be caused by various factors such as chronic bleeding, malabsorption, or chronic inflammation. In clinical practice, iron deficiency anemia and the combined forms of anemia due to different pathophysiological mechanisms are most common. Esophagogastroduodenoscopy, colonoscopy, and the small intestine examinations in specific situations play a crucial role in diagnosing anemia. In anemic, GI asymptomatic patients, there are recommendations for bidirectional endoscopy. Although GI malignancies are the most common cause of chronic bleeding, all conditions leading to blood loss, malabsorption, and chronic inflammation should be considered. From a gastroenterologist's perspective, the clinical spectrum of anemia is vast because many different digestive tract diseases lead to bleeding. Key Messages: The gastroenterological approach in solving anemia's problem requires an optimal strategy, consideration of the accompanying clinical signs, and the fastest possible diagnosis. Although patients with symptoms of anemia are often referred to gastroenterologists, the diagnostic approach requires further improvement in everyday clinical practice.
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Affiliation(s)
- Ratko Tomasević
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zoran Gluvić
- University Clinical-Hospital Centre Zemun-Belgrade, Clinic of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Mijač
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandra Sokić-Milutinović
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Snežana Lukić
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
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18
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García-Compeán D, Cueto-Aguilera ÁND, González-González JA, Jáquez-Quintana JO, Borjas-Almaguer OD, Jiménez-Rodríguez AR, Muñoz-Ayala JM, Maldonado-Garza HJ. Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy. Dig Dis 2021; 40:62-67. [PMID: 33780938 DOI: 10.1159/000516163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/26/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available. AIMS The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD). METHODS Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests. RESULTS The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use. CONCLUSIONS CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Ángel Noe Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - José Alberto González-González
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Joel Omar Jáquez-Quintana
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Omar David Borjas-Almaguer
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Alan Rafael Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Juan Manuel Muñoz-Ayala
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Héctor Jesús Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Arieira C, Magalhães R, Dias de Castro F, Boal Carvalho P, Rosa B, Moreira MJ, Cotter J. Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients. Dig Dis Sci 2021; 66:175-180. [PMID: 32072436 DOI: 10.1007/s10620-020-06137-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions. METHODS This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12 months. Rebleeding was defined as a drop of hemoglobin ≥ 2 g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding. RESULTS From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9 months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding. CONCLUSION Heart failure, smoking status, and angioectasias with a size superior to 5 mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.
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Affiliation(s)
- Cátia Arieira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal.
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal.
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.
| | - Rui Magalhães
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Francisca Dias de Castro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Maria João Moreira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Patel H, Mehershahi S, Shaikh DH, Makker J, Nayudu S, Remy P, Chilimuri S. Thalidomide for the treatment of angiodysplasia-related recurrent gastrointestinal hemorrhage: Is low dose a safe and viable option? Clin Case Rep 2019; 7:2363-2367. [PMID: 31893059 PMCID: PMC6935600 DOI: 10.1002/ccr3.2501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/01/2019] [Accepted: 08/25/2019] [Indexed: 12/16/2022] Open
Abstract
Thalidomide is often used for the management of refractory gastrointestinal angiodysplasia (GIAD). The tolerance, toxic profile, and compliance of thalidomide are dose-dependent. The low-dose thalidomide (50 mg) is safe and a viable option for bleeding related to GIAD.
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Affiliation(s)
- Harish Patel
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Shehriyar Mehershahi
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Danial Haris Shaikh
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Jasbir Makker
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Sureshkumar Nayudu
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Prospere Remy
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Sridhar Chilimuri
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
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Tariq T, Karabon P, Irfan FB, Goyal S, Mayeda MM, Parsons A, Judd S, Ehrinpreis M. Secondary angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease: Results from the nationwide inpatient sample. World J Gastrointest Endosc 2019; 11:504-514. [PMID: 31798771 PMCID: PMC6885446 DOI: 10.4253/wjge.v11.i10.504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/21/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic kidney disease is associated with angiodysplasia of gastrointestinal tract leading to increased risk of gastrointestinal bleeding.
AIM To determine the nationwide prevalence, trends, predictors and resource utilization of angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalizations.
METHODS The Nationwide Inpatient Sample database from 2009 to 2014, was utilized to conduct a retrospective study on patients with angiodysplasia associated- gastrointestinal bleeding and end-stage renal disease. Hospitalizations with end-stage renal disease were included in the Nationwide Inpatient Sample database and a subset of hospitalizations with end-stage renal disease and angiodysplasia-associated gastrointestinal bleeding were identified with International Classification of Diseases, 9th revision, Clinical Modification codes for both end-stage renal disease (585.6) and Angiodysplasia (569.85, 537.83).
RESULTS The prevalence of angiodysplasia-associated gastrointestinal bleeding was 0.45% (n = 24709) among all end-stage renal disease patients (n = 5505252) that were hospitalized. Multivariate analysis indicated that the following were significant factors associated with higher odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients: an increasing trend from 2009-2014 (P < 0.01), increasing age (P < 0.0001); African American race (P = 0.0206); increasing Charlson-Deyo Comorbidity Index (P < 0.01); hypertension (P < 0.0001); and tobacco use (P < 0.0001). Diabetes mellitus (P < 0.0001) was associated with lower odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients. In comparison with urban teaching hospitals, rural and urban nonteaching hospitals were associated with decreased odds of angiodysplasia associated-gastrointestinal hemorrhage.
CONCLUSION Angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease patients showed an increasing trend from 2009-2014. Advanced age, African American race, overall high comorbidities, hypertension and smoking were significant factors for angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalized patients.
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Affiliation(s)
- Tooba Tariq
- Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, United States
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Oakland University, Detroit, MI 48309, United States
| | - Furqan B Irfan
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, United States
| | - Sachin Goyal
- Department of Internal Medicine, Division of Gastroenterology, Detroit Medical Center/Wayne State University, Detroit, MI 48201, United States
| | - Matthew Masaru Mayeda
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, United States
| | - Austin Parsons
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, United States
| | - Stephanie Judd
- Department of Internal Medicine, Division of Gastroenterology, Detroit Medical Center/Wayne State University and John D Dingell VA Medical Center, Detroit, MI 48201, United States
| | - Murray Ehrinpreis
- Department of Internal Medicine, Division of Gastroenterology, Detroit Medical Center/Wayne State University, Detroit, MI 48201, United States
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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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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient's quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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24
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Risk factors for incidentally detected and symptomatic angiodysplasias: a case-control study with the general population as reference. Eur J Gastroenterol Hepatol 2019; 31:458-462. [PMID: 30562184 DOI: 10.1097/meg.0000000000001335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is no literature on risk factors for incidentally found angiodysplasias. In clinical practice, endoscopists may defer treatment owing to uncertainty about a causal role of any found angiodysplasia and overt or occult bleeding. The objective is to identify risk factors that distinguish incidental angiodysplasias from angiodysplasias that are the cause of symptomatic bleeding. PARTICIPANTS AND METHODS A case-control study was conducted to compare angiodysplasia groups and a random sample from the general population. Patients with angiodysplasia were diagnosed between 2010 and 2015. Controls were from a 2005 population survey. Determinants were demographics, past medical history, lifestyle, medication and angiodysplasia characteristics. Multivariable logistic regression analyses were performed to identify independent risk factors. RESULTS A total of 270 (59% men, mean age 65 years) patients with angiodysplasia and 5594 (46% men, mean age 58 years) controls were included in this study. Independent risk factors for incidental angiodysplasias are male sex [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.02-2.6], thyroid dysfunction (OR: 4.1; 95% CI: 2.0-8.4), autoimmune disease (OR: 2.3; 95% CI: 1.2-4.1), chronic obstructive pulmonary disease (OR: 1.8; 95% CI: 1.0-3.2), and blood thinners (OR: 2.8; 95% CI: 1.6-4.8). Besides angiodysplasia characteristics, factors independently associated with symptomatic angiodysplasias are increased age (OR: 1.7/10 years age band; 95% CI: 1.3-2.5), valvular heart disease (OR: 10.4; 95% CI: 1.6-69.2), diabetes mellitus (OR: 2.6; 95% CI: 1.03-6.7) and hyperlipidemia (OR: 3.7; 95% CI: 1.1-12.1). CONCLUSION The risk factor profile for incidental angiodysplasias differs from symptomatic angiodysplasias and is more profound for the latter. This knowledge could help endoscopists in the decision-making process to treat an endoscopically detected angiodysplasia.
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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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Dumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T. Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol 2019; 2019:6757524. [PMID: 30792972 PMCID: PMC6354172 DOI: 10.1155/2019/6757524] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.
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Affiliation(s)
- Igor Dumic
- Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
| | - Terri Nordin
- Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire WI, USA
| | - Mladen Jecmenica
- Gastroenterology Fellowship Program, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | | | - Tomica Milosavljevic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Tamara Milovanovic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
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A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds. Dig Dis Sci 2019; 64:2923-2932. [PMID: 31190204 PMCID: PMC6744377 DOI: 10.1007/s10620-019-05683-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease. AIMS To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias. METHODS We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size. RESULTS Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3). CONCLUSIONS This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.
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Fortinsky KJ, Barkun AN. Nonvariceal Upper Gastrointestinal Bleeding. CLINICAL GASTROINTESTINAL ENDOSCOPY 2019:153-170.e8. [DOI: 10.1016/b978-0-323-41509-5.00014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Lee JG, Galorport C, Yonge J, Enns RA. Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65. J Can Assoc Gastroenterol 2018; 3:36-43. [PMID: 34169225 PMCID: PMC8218534 DOI: 10.1093/jcag/gwy058] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/04/2018] [Indexed: 12/27/2022] Open
Abstract
Background Iron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging. Aims The goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield. Methods A retrospective review of all CE studies at St. Paul's Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 μg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study. Results There were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn's therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, P = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, P = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, P = 0.012) were associated with a negative study. Conclusions These findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn's disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.
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Affiliation(s)
- Joseph G Lee
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cherry Galorport
- Department of Medicine, Division of Gastroenterology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Yonge
- Department of Medicine, Division of Gastroenterology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert A Enns
- Department of Medicine, Division of Gastroenterology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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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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Nonisolated Small Bowel Gastrointestinal Angiodysplasias are Associated With Higher Rebleeding Rates When Compared With Isolated Small Bowel Gastrointestinal Angiodysplasia on Video Capsule Endoscopy. J Clin Gastroenterol 2018; 52:726-733. [PMID: 28617760 DOI: 10.1097/mcg.0000000000000836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIAD) are commonly diagnosed in the small bowel but can be located in other areas of the gastrointestinal tract. About half of patients diagnosed with GIAD have more than 1 lesion and 20% of patients have GIAD in both the small bowel and a source outside of the small bowel (nonisolated to small bowel GIAD or NISGIAD). The remaining patients with GIAD have lesions isolated to the small bowel (ISGIAD). Complications including rebleeding, hospitalization and mortality rates have not been previously analyzed between these 2 groups. AIM To compare rebleeding, hospitalization and mortality rates between ISGIAD and NISGIAD. The secondary goals were to evaluate comorbidities that may be associated with ISGIAD and/or NISGIAD, and to determine if any of these comorbidities are associated with a higher risk of rebleeding from GIAD. MATERIALS AND METHODS This was a retrospective study that included 425 patients who underwent video capsule endoscopy between 2006 and 2013. Patients underwent esophagogastroduodenoscopy and colonoscopy before video capsule endoscopy. The primary indications for workup included obscure gastrointestinal bleeding. After exclusion criteria, 87 patients diagnosed with GIAD remained, 57 patients with ISGIAD and 30 with NISGIAD. Categorical variables were compared by the Fisher exact test or χ test and continuous data were compared using the Student T test. RESULTS Risk factors associated with rebleeding rates included coronary artery disease, chronic kidney disease, and congestive heart failure on multivariate analysis. Odds ratios for rebleeding was found in patients with NISGIAD (odds ratio, 4.222; P=0.036). There was no difference in hospitalization rates between patients with ISGIAD and NISGIAD. There was no statistically significant difference in mortality from any cause at 30, 60, and 90 days in patients with ISGIAD and NISGIAD. CONCLUSIONS In this retrospective analysis of GIAD at a single institution, patients with NISGIAD compared with ISGIAD had a 4 times odds of rebleeding within 1 year after capsule endoscopy. This is a novel study, as the distribution of GIAD has not been previously described as being a risk factor for rebleeding.
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Preoperative Right-Sided Cardiac Congestion Is Associated with Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices. Dig Dis Sci 2018; 63:1518-1524. [PMID: 29417325 DOI: 10.1007/s10620-018-4916-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/06/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Large scale data on preoperative risk stratification for gastrointestinal bleeding (GIB) following continuous-flow left ventricular assist device (CF-LVAD) implantation are scarce. AIMS To identify independent predictors for GIB following CF-LVAD implantation. METHODS We conducted a retrospective cohort study of consecutive 243 patients who underwent CF-LVAD implantation (HeartMateII) from January 2009 to March 2015 at the University of Chicago Medical Center. GIB was defined as the presence of overt bleeding or occult GIB with ≥ 2 g/dl drop in hemoglobin (Hgb) from recorded baseline values and hemoccult-positive stool. The preoperative and postoperative data were reviewed. RESULTS Within a median follow-up duration of 408 (IQR 113-954) days, 83 (34%) patients developed GIB after a median of 149 (IQR 27-615) days after implantation of CF-LVAD. There were no significant differences between the groups of GIB and non-GIB with respect to preoperative demographics and comorbidity except for ethnicity. The source of bleeding was identified in 39 (47%) patients and arteriovenous malformation or submucosal streaming vessel was the most frequent cause of bleeding (18/39, 46%). Multivariate-adjusted analysis demonstrated preoperative central venous pressure (CVP) ≥ 18 mmHg (HR 3.56; 95% CI 1.16-10.9; p = 0.026), mean pulmonary artery pressure (mPA) ≥ 36 mmHg (HR 4.14; 95% CI 1.35-12.7; p = 0.013), and the presence of moderate/severe tricuspid valve disease (HR 1.01; 95% CI 1.01-3.86; p = 0.046) were associated with the risk of GIB. CONCLUSIONS In this study, preoperative right-sided cardiac congestion (i.e., increased CVP, mPA and the presence of moderate/severe tricuspid valve disease) was associated with GIB in patients with CF-LVAD.
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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Association of aortic valve disease with intestinal angioectasia: data from the Nationwide Inpatient Sample. Eur J Gastroenterol Hepatol 2018; 30:438-441. [PMID: 29369835 DOI: 10.1097/meg.0000000000001068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Since the description of a correlation between aortic stenosis and angioectasia, controversy has persisted about whether these diseases are truly associated or coincidental findings of older age. Our objective was to determine the association of aortic valve disease and bleeding intestinal angioectasia from a large database. PATIENTS AND METHODS We used the 2011 Nationwide Inpatient Sample database to identify hospitalizations in the USA in patients with bleeding intestinal angioectasia. International Classification of Diseases, 9th revision, Clinical Modification codes were used to identify patients with aortic valve disease, mitral valve disease, and known risk factors for angioectasia (including diagnosed von Willebrand disease, left ventricular assist device, and chronic kidney disease). Univariate and multivariate logistic regression were used to determine the odds of association between the valvular diseases and angioectasia. RESULTS A total of 32 079 intestinal angioectasia-related hospitalizations were identified of which 7.02% (n=2253) cases had coexistent aortic valve disease. The unadjusted odds of aortic valve disease in association with bleeding intestinal angioectasia versus those without bleeding angioectasia was 4.95 [95% confidence interval: (CI): 4.43-5.54, P<0.001]. The association of intestinal angioectasia with mitral valve disease was not significant (odds ratio=1.56, 95% CI: 0.59-4.14, P=0.38). When adjusted for age and known risk factors, the odds of aortic valve disease in bleeding intestinal angioectasia was still significant (odds ratio=2.37, 95% CI: 2.10-2.66, P<0.001). CONCLUSION Our findings support an important association between aortic valve disease and bleeding intestinal angioectasia, not identified in valvular heart valvular diseases with lower shear stress (mitral valve disease).
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Aoyama T, Fukumoto A, Shigita K, Asayama N, Mukai S, Nagata S. Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions. Dig Dis Sci 2018; 63:723-730. [PMID: 29372478 DOI: 10.1007/s10620-018-4930-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/11/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities. AIMS We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively. METHODS We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores. RESULTS Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023). CONCLUSIONS Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan.
| | - Akira Fukumoto
- Department of Endoscopy, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Kenjiro Shigita
- Department of Endoscopy, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Naoki Asayama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Shinichi Mukai
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabe-minami, Asakita-ku, Hiroshima, 731-0293, Japan
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Role of Octreotide in Pediatric Gastrointestinal Bleeding Secondary to Angiodysplasia in Children With Right Heart Failure. J Pediatr Gastroenterol Nutr 2018; 66:e41-e44. [PMID: 28614113 DOI: 10.1097/mpg.0000000000001659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Angiodysplasia (AD) is a relatively uncommon cause of gastrointestinal bleeding in children and may be seen in right heart failure. Octreotide has been used successfully in adult patients with gastrointestinal bleeding due to ADs. METHODS We describe 2 patients who had congenital heart disease with right heart failure and gastrointestinal bleeding from AD. RESULTS AD lesions were documented on traditional endoscopy and capsule endoscopy. Bleeding resolved after initiation of IV octreotide and did not recur on subcutaneous octreotide during the 2-year follow-up period. CONCLUSIONS Based on the successful outcomes in the 2 patients, a trial of octreotide may be considered in pediatric patients who present with gastrointestinal bleeding secondary to AD.
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Chetcuti Zammit S, Koulaouzidis A, Sanders DS, McAlindon ME, Rondonotti E, Yung DE, Sidhu R. Overview of small bowel angioectasias: clinical presentation and treatment options. Expert Rev Gastroenterol Hepatol 2018; 12:125-139. [PMID: 28994309 DOI: 10.1080/17474124.2018.1390429] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.
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Affiliation(s)
| | | | - David S Sanders
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | - Mark E McAlindon
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | | | - Diana E Yung
- b Endoscopy Unit , the Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Reena Sidhu
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
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Yung DE, Rondonotti E, Giannakou A, Avni T, Rosa B, Toth E, Lucendo AJ, Sidhu R, Beaumont H, Ellul P, Negreanu L, Jiménez-Garcia VA, McNamara D, Kopylov U, Elli L, Triantafyllou K, Shibli F, Riccioni ME, Bruno M, Dray X, Plevris JN, Koulaouzidis A, And the Capsule Endoscopy in Young Patients with IDA research group, Argüelles-Arias F, Becq A, Branchi F, Tejero-Bustos MÁ, Cotter J, Eliakim R, Ferretti F, Gralnek IM, Herrerias-Gutierrez JM, Hussey M, Jacobs M, Johansson GW, McAlindon M, Montiero S, Nemeth A, Pennazio M, Rattehalli D, Stemate A, Tortora A, Tziatzios G. Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy. United European Gastroenterol J 2017; 5:974-981. [PMID: 29163963 PMCID: PMC5676544 DOI: 10.1177/2050640617692501] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/11/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. MATERIALS AND METHODS This was a retrospective, multicentre study (2010-2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. RESULTS Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn's disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3-11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92-0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. CONCLUSION In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.
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Affiliation(s)
- Diana E Yung
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Andry Giannakou
- Faculty of Economics and Management, The Open University of Cyprus, Nicosia, Cyprus
| | - Tomer Avni
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | - Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Reena Sidhu
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield , United Kingdom
| | - Hanneke Beaumont
- Department of Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Malta
| | - Lucian Negreanu
- Internal Medicine II Gastroenterology, University Hospital, Carol Davila University Bucharest
| | | | - Deidre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Ireland
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Israel
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, 2nd Dept of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Fahmi Shibli
- Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel
| | | | - Mauro Bruno
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Xavier Dray
- Paris 6 University and APHP Hôpital Saint-Antoine, Paris, France
| | - John N Plevris
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Koulaouzidis
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - And the Capsule Endoscopy in Young Patients with IDA research group
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
- Gastroenterology Unit, Valduce Hospital, Como, Italy
- Faculty of Economics and Management, The Open University of Cyprus, Nicosia, Cyprus
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Department of Gastroenterology, Skåne University Hospital, Malmö, Lund University, Sweden
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield , United Kingdom
- Department of Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
- Division of Gastroenterology, Mater Dei Hospital, Malta
- Internal Medicine II Gastroenterology, University Hospital, Carol Davila University Bucharest
- University Hospital Virgen Macarena, Seville, Spain
- Department of Clinical Medicine, Trinity College Dublin, Ireland
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Israel
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Hepatogastroenterology Unit, 2nd Dept of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
- Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel
- Catholic University of the Sacred Heart, Milano, Italy
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
- Paris 6 University and APHP Hôpital Saint-Antoine, Paris, France
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Aymeric Becq
- Paris 6 University and APHP Hôpital Saint-Antoine, Paris, France
| | - Federica Branchi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Israel
| | - Francesca Ferretti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Mary Hussey
- Department of Clinical Medicine, Trinity College Dublin, Ireland
| | - Maarten Jacobs
- Department of Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
| | | | - Mark McAlindon
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield , United Kingdom
| | - Sara Montiero
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Artur Nemeth
- Department of Gastroenterology, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marco Pennazio
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Deepa Rattehalli
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield , United Kingdom
| | - Ana Stemate
- Internal Medicine II Gastroenterology, University Hospital, Carol Davila University Bucharest
| | | | - Georgios Tziatzios
- Hepatogastroenterology Unit, 2nd Dept of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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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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Abstract
BACKGROUND Gastrointestinal angioectasias (AEs) represent the most common vascular malformation within the gastrointestinal tract. This study sought to characterize epidemiologic/comorbid risk factors for AEs, rebleeding, and patterns of anatomic distribution within the small intestine. STUDY This retrospective observational cohort study included 158 patients with AEs on capsule endoscopy (CE) from 2007 to 2015. Epidemiologic/comorbid data were collected and incorporated into final analysis. Each AE was categorized by location using a small bowel transit time-based quartile system. Rebleeding was evaluated following CE. Multivariate logistic regression was applied to statistically significant factors on univariate analysis to determine independent risk factors for rebleeding. RESULTS Most lesions were found in the first quartile (67.1%). Rebleeding occurred in 46 (29.7%) of the 156 patients for whom data were available. Rates of rebleeding were significantly higher among older patients (74.4 vs. 67.7 y, P=0.001), those with active bleeding on CE (41.3% vs. 16.5%, P=0.001), those with a history of aortic stenosis (21.7% vs. 9.2%, P=0.033), and those with AEs presents in quartile 3 (26.1% vs. 8.3%, P=0.003). Age, active bleeding on CE, and AE presence in quartile 3 were independently associated with rebleeding in multivariate analysis (P=0.009, 0.023, and 0.008, respectively). CONCLUSIONS These data help improve our knowledge of AEs regarding risk factors for rebleeding, and utilizes a novel small bowel transit time-based quartile localization method that may simplify future research and comparisons of anatomic distribution and behavior of small bowel AEs.
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Holleran G, Hussey M, Smith S, McNamara D. Assessment of serum angiogenic factors as a diagnostic aid for small bowel angiodysplasia in patients with obscure gastrointestinal bleeding and anaemia. World J Gastrointest Pathophysiol 2017; 8:127-132. [PMID: 28868182 PMCID: PMC5561433 DOI: 10.4291/wjgp.v8.i3.127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/31/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the use of serum levels of angiopoietin-1 (Ang1), Ang2 and tumor necrosis factor-α (TNFα) as predictive factors for small bowel angiodysplasia (SBA).
METHODS Serum samples were collected from patients undergoing capsule endoscopy for any cause of obscure gastrointestinal bleeding (OGIB) or anaemia. Based on small bowel findings patients were divided into 3 groups: (1) SBA; (2) other bleeding causes; and (3) normal, according to diagnosis. Using ELISA technique we measured serum levels of Ang1, Ang2 and TNFα and compared mean and median levels between the groups based on small bowel diagnosis. Using receiver operator curve analysis we determined whether any of the factors were predictive of SBA.
RESULTS Serum samples were collected from a total of 120 patients undergoing capsule endoscopy for OGIB or anaemia: 40 with SBA, 40 with other causes of small bowel bleeding, and 40 with normal small bowel findings. Mean and median serum levels were measured and compared between groups; patients with SBA had significantly higher median serum levels of Ang2 (3759 pg/mL) compared to both other groups, with no significant differences in levels of Ang1 or TNFα based on diagnosis. There were no differences in Ang2 levels between the other bleeding causes (2261 pg/mL) and normal (2620 pg/mL) groups. Using Receiver Operator Curve analysis, an Ang2 level of > 2600 pg/mL was found to be predictive of SBA, with an area under the curve of 0.7. Neither Ang1 or TNFα were useful as predictive markers.
CONCLUSION Elevations in serum Ang2 are specific for SBA and not driven by other causes of bleeding and anaemia. Further work will determine whether Ang2 is useful as a diagnostic or prognostic marker for SBA.
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Grooteman KV, Matheeuwsen M, van Geenen EJM, Drenth JPH. Decreased health-related quality of life in angiodysplasia patients: A cross-sectional cohort. PLoS One 2017; 12:e0177522. [PMID: 28552982 PMCID: PMC5446116 DOI: 10.1371/journal.pone.0177522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/29/2017] [Indexed: 01/06/2023] Open
Abstract
Gastrointestinal angiodysplasias may cause anemia. Quality of life (QoL) is a valid patient reported outcome and improvement of QoL represents an important treatment goal. There is a paucity of data on the effect of angiodysplasias on QoL. Therefore, we aim to evaluate QoL and fatigue in angiodysplasia patients. We performed a cross-sectional patient-reported outcome study. We included patients with endoscopy proven angiodysplasias and measured QoL with Short Form-36 and level of fatigue using Multi Fatigue Inventory-20. We distinguished three subgroups of patients according to disease severity: 1) with treatment for angiodysplasias, 2) without treatment for angiodysplasias and 3) without recent hospital visits. The primary outcome was the physical component summary (PCS) score on the SF-36. Multivariate regression analysis were performed to correct for differences at baseline. A total of 144 patients completed the questionnaires (response rate = 62%; mean age 68 years; 65% men). Angiodysplasia patients have a significant lower PCS compared to the age-matched general population (respectively 41.0 vs. 43.3, p = 0.01). Disease severity is independently associated with a negative outcome on QoL (ß -4.6, 95% CI -7.8–-1.3). Similarly patients score lower on multiple QoL subdomains, i.e. role limitations due to physical health problems (40.8 vs. 44.0, p<0.01), general health (39.7 vs. 47.3, p<0.01). Angiodysplasia patients are more fatigued compared to the general population (male 56.1 vs. 48.5, p<0.01, female 59.2 vs. 51.5, p = 0.01). In conclusion, angiodysplasias are independently associated with clinically significant impairments in multiple domains of health-related QoL, especially in measures of functional limitation.
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Affiliation(s)
- Karina V. Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
| | - Mijntje Matheeuwsen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erwin J. M. van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost P. H. Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Tziatzios G, Gkolfakis P, Dimitriadis GD, Triantafyllou K. Long-term effects of video capsule endoscopy in the management of obscure gastrointestinal bleeding. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:196. [PMID: 28567376 PMCID: PMC5438793 DOI: 10.21037/atm.2017.03.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/06/2017] [Indexed: 12/13/2022]
Abstract
Obscure gastrointestinal bleeding (OGIB) accounts for approximately 5% of all gastrointestinal (GI) hemorrhages. It usually arises from a small bowel lesion beyond the reach of conventional endoscopy including esophagogastroduodenoscopy and colonoscopy. Video capsule endoscopy (VCE) revolutionized the evaluation of OGIB patients since it allows reliable and noninvasive visualization of the small bowel mucosal surface. Since 2001, VCE has evolved into an efficient technology integrated in clinical practice. It is the cornerstone in the algorithm of OGIB investigation given its high diagnostic yield, which compares favorably to that of double-balloon enteroscopy (DBE). In terms of outcomes, a positive index VCE examination usually correlates to a high re-bleeding rate, while a negative one provides adequate evidence of low re-bleeding risk, suggesting a wait and watch approach in this subset of patients. Additionally, a variety of factors has been acknowledged as significant predictors of re-bleeding episodes. While research data regarding immediate endoscopic findings have matured, data concerning the clinical utility of VCE in patients with OGIB on the long-term remain sparse. This manuscript reviews the current literature, aiming to highlight the role of VCE in the long-term management of OGIB.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | - George D Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
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Nennstiel S, Machanek A, von Delius S, Neu B, Haller B, Abdelhafez M, Schmid RM, Schlag C. Predictors and characteristics of angioectasias in patients with obscure gastrointestinal bleeding identified by video capsule endoscopy. United European Gastroenterol J 2017; 5:1129-1135. [PMID: 29238592 DOI: 10.1177/2050640617704366] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/12/2017] [Indexed: 12/13/2022] Open
Abstract
Background In obscure gastrointestinal bleeding, angioectasias are common findings in video capsule endoscopy (VCE). Objective The objective of this study was to identify predictors and characteristics of small bowel angioectasias. Methods Video capsule examinations between 1 July 2001 and 31 July 2011 were retrospectively reviewed. Patients with obscure gastrointestinal bleeding were identified, and those with small bowel angioectasia were compared with patients without a definite bleeding source. Univariate and multivariable statistical analyses for possible predictors of small bowel angioectasia were performed. Results From a total of 717 video capsule examinations, 512 patients with obscure gastrointestinal bleeding were identified. Positive findings were reported in 350 patients (68.4%) and angioectasias were documented in 153 of these patients (43.7%). These angioectasias were mostly located in the proximal small intestine (n = 86, 56.6%). Patients' age >65 years (odds ratio (OR) 2.15, 95% confidence interval (CI) 1.36-3.38, p = .001) and overt bleeding type (OR 1.89, 95% CI 1.22-2.94, p = .004) were identified as significant independent predictors of small bowel angioectasia. Conclusion Angioectasias are the most common finding in VCE in patients with obscure gastrointestinal bleeding. They are mostly located in the proximal small bowel and are associated with higher age and an overt bleeding type.
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Affiliation(s)
- Simon Nennstiel
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Annkathrin Machanek
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Academic Teaching Hospital, Technische Universität München, Landshut, Germany
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Mohamed Abdelhafez
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Christoph Schlag
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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Abstract
BACKGROUND Small bowel angiodysplasias (SBA) account for 50% of obscure gastrointestinal bleeding. Lesions bleed recurrently and current treatments are relatively ineffective at reducing re-bleeding. Little is known about the natural history of SBA which is needed to guide treatment decisions and counsel patients on prognosis. AIM The aim of this study is to describe the natural history of a cohort of patients with SBA. METHODS Patients with SBA were identified retrospectively and clinical and outcome information were collected. Logistic regression analysis was performed to identify factors associated with re-bleeding. RESULTS SBAs were found in 86 patients of which 54% (n = 47) were female, and the average age was 71.6 years. The majority (69%) had multiple lesions, mean of 2.76/patient, and 65% were located in the jejunum. Follow-up was available in 65% (n = 56). There was a significant increase in haemoglobin level from 10.05g/dL to 11.94g/dL, p < 0.001 after mean follow up of 31.9 (6-62) months. Re-bleeding events occurred in 80% (n = 45), with an average of 2.91/person. The mean interval between diagnosis and the first re-bleeding event was 10.7 months. Of the group overall, 70% (n = 40) required transfusions during follow up, and 67% required hospitalisation due to re-bleeding. About 50% received a directed treatment, including argon plasma coagulation, somatostatin analogues, or surgical resection. A total of 3.5% (n = 2) died as a direct consequence of bleeding from SBAs. Multiple lesions (p = 0.048) and valvular heart disease (p = 0.034) were predictive of re-bleeding. CONCLUSION Our results show the significant impact of SBA on patients' morbidity, with high rates of re-bleeding, persistent anaemia and a mortality rate of 3.5%, despite the use of currently available medical and endoscopic therapies.
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Affiliation(s)
- Grainne Holleran
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Barry Hall
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
| | - Lina Zgaga
- b Department of Public Health and Primary Care , Trinity College Dublin , Ireland
| | - Niall Breslin
- c Department of Gastroenterology , Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Clinical Medicine , Trinity College Dublin , Ireland
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Stein J, Connor S, Virgin G, Ong DEH, Pereyra L. Anemia and iron deficiency in gastrointestinal and liver conditions. World J Gastroenterol 2016; 22:7908-7925. [PMID: 27672287 PMCID: PMC5028806 DOI: 10.3748/wjg.v22.i35.7908] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/18/2016] [Accepted: 08/10/2016] [Indexed: 02/06/2023] Open
Abstract
Iron deficiency anemia (IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.
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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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Abstract
OBJECTIVE Angiodysplasias (ADs) are the second leading cause of gastrointestinal bleeding in the elderly. The impact extends from no symptoms to chronic anaemia. Treatment guidelines are lacking. The aim of this study was to assess the current practice of gastrointestinal ADs and explore possible new research areas. On the basis of existing evidence, we would like to propose a treatment algorithm. METHODS We administered a 19-item web-based survey to gastroenterologists in the Netherlands between February and April of 2015. RESULTS A total of 111 (response rate 28%) gastroenterologists completed the survey (mean age=47 years; 24% women). The respondents identified Von Willebrand disease (17%), chronic kidney disease (21%) and aortic stenosis (77%) as risk factors for the development of ADs. Colonoscopy (54%) and esophagogastroduodenoscopy (43%) were the preferred first tools to screen for ADs. The favoured (77%) first treatment option is endoscopic argon plasma coagulation, whereas 20% start iron supplementation or blood transfusions. Treatment strategy is mostly (65%) based on the location of the ADs. Small bowel ADs are considered the most difficult to treat, because of the need for balloon enteroscopy. Of the gastroenterologists, 13% would treat ADs as a coincident finding during endoscopy. Medical therapy is mostly started in refractory ADs, and thalidomide (40%) is preferred over octreotide (19%). Thalidomide is more preferred by gastroenterologists working in a teaching hospital. CONCLUSION Identification of risk factors and treatment of ADs vary widely between gastroenterologists in the Netherlands. Further research is needed to create an evidence-based guideline and thereby optimize the management of symptomatic ADs.
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Abstract
Occult gastrointestinal bleeding is not visible and may present with a positive fecal occult blood test or iron deficiency anemia. Obscure bleeding can be overt or occult, with no source identified despite an appropriate diagnostic workup. A stepwise approach to this evaluation after negative upper and lower endoscopy has been shown to be cost effective. This includes repeat endoscopies if warranted, followed by video capsule endoscopy (VCE) if no obstruction is present. If the VCE is positive then specific endoscopic intervention may be possible. If negative, patients may undergo either repeat testing or watchful waiting with iron supplements.
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Affiliation(s)
- Edgar R Naut
- Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105, USA.
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Hosoe N, Matsukawa S, Kanno Y, Naganuma M, Imaeda H, Ida Y, Tsuchiya Y, Hibi T, Ogata H, Kanai T. Cross-sectional small intestinal surveillance of maintenance hemodialysis patients using video capsule endoscopy: SCHEMA study. Endosc Int Open 2016; 4:E589-96. [PMID: 27227120 PMCID: PMC4874804 DOI: 10.1055/s-0042-105203] [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: 10/01/2015] [Accepted: 02/21/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Small intestinal pathology in hemodialysis (HD) patients has been studied in only a small number of retrospective case series. One method for noninvasively surveying small intestinal disorders is video capsule endoscopy (VCE). The primary aim of this study was to investigate the prevalence of small intestinal abnormalities among asymptomatic maintenance HD outpatients using VCE. The secondary aim was to assess the clinical impact of these abnormalities. PATIENTS AND METHODS This study consisted of two phases. In phase I, a cross-sectional study, a cohort of patients who received maintenance HD three times weekly at an outpatient hemodialysis clinic were studied using VCE. Phase II was a prospective cohort study with follow up for 1 year after VCE. RESULTS Fifty-six patients were enrolled in this study, and two were excluded from analysis due to capsule retention in the stomach. The prevalence of small bowel abnormalities in HD patients was 64.8 % (35/54) (95 % confidential interval 52.1 % - 77.6 %). Of 54 patients, 21 (38.9 %) had mucosal lesions, 10 (18.5 %) had vascular lesions, and 4 (7.4 %) had both lesion types. During the 1-year follow-up period, events occurred in four patients. A small bowel-associated event was observed in one patient, who underwent laparoscopy-assisted small intestinal partial resection 3 months after diagnosis by VCE. All patients in whom events were seen had small bowel abnormalities; no events were observed in the VCE-negative group. CONCLUSIONS Although asymptomatic maintenance HD patients had a high prevalence of small bowel abnormalities (64.8 %), they did not have a high incidence of small bowel-associated events during the 1-year follow-up.
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Affiliation(s)
- Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.,Corresponding author Naoki Hosoe, MD, PhD Center for Diagnostic and Therapeutic EndoscopySchool of MedicineKeio University35 ShinanomachiShinjuku, Tokyo 160-8582Japan+81-3-3357-2778
| | - Shigeaki Matsukawa
- Keishinkai Tama Nagayama Jin-Naika Clinic, 1-4 Nagayama, Tama city, Tokyo 206-0025, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku, Tokyo 160-0023, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Hiroyuki Imaeda
- Department of General Internal Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Yosuke Ida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yoshitsugu Tsuchiya
- Keishinkai Tama Nagayama Jin-Naika Clinic, 1-4 Nagayama, Tama city, Tokyo 206-0025, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan ,Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8642, Japan.
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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