Adarsh M. Thaker

The risks of thromboembolism vs. recurrent gastrointestinal bleeding after interruption of systemic anticoagulation in hospitalized inpatients with gastrointestinal bleeding: a prospective study

OBJECTIVES:Anticoagulants carry a significant risk of gastrointestinal bleeding (GIB). Data regarding the safety of anticoagulation continuation/cessation after GIB are limited. We sought to determine the safety and risk of continuation of anticoagulation after GIB.METHODS:We conducted a prospective observational cohort study on consecutive patients admitted to the hospital who had GIB while on systemic anticoagulation. Patients were classified into two groups at hospital discharge after GIB: those who resumed anticoagulation and those who had anticoagulation discontinued. Patients in both groups were contacted by phone 90 days after discharge to determine the following outcomes: (i) thromboembolic events, (ii) hospital readmissions related to GIB, and (iii) mortality. Univariate and multivariate Cox proportional hazards were used to determine factors associated with thrombotic events, rebleeding, and death.RESULTS:We identified 197 patients who developed GIB while on systemic anticoagulation (n=145, 74% on warfarin). Following index GIB, anticoagulation was discontinued in 76 patients (39%) at discharge. In-hospital transfusion requirements, need for intensive care unit care, and etiology of GIB were similar between the two groups. During the follow-up period, 7 (4%) patients suffered a thrombotic event and 27 (14%) patients were readmitted for GIB. Anticoagulation continuation was independently associated on multivariate regression with a lower risk of major thrombotic episodes within 90 days (hazard ratio (HR)=0.121, 95% confidence interval (CI)=0.006–0.812, P=0.03). Patients with any malignancy at time of GIB had an increased risk of thromboembolism in follow-up (HR=6.1, 95% CI=1.18–28.3, P=0.03). Anticoagulation continuation at discharge was not significantly associated with an increased risk of recurrent GIB at 90 days (HR=2.17, 95% CI=0.861–6.67, P=0.10) or death within 90 days (HR=0.632, 95% CI=0.216–1.89, P=0.40).CONCLUSIONS:Restarting anticoagulation at discharge after GIB was associated with fewer thromboembolic events without a significantly increased risk of recurrent GIB at 90 days. The benefits of continuing anticoagulation at discharge may outweigh the risks of recurrent GIB.

Propofol versus traditional sedative agents for advanced endoscopic procedures: A meta-analysis

The optimum method for sedation for advanced endoscopic procedures is not known. Propofol deep sedation has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. The aim of the present study was to pool data from all available studies to systematically compare the efficacy and safety of propofol with traditional sedative agents for advanced endoscopic procedures.

Post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). It is reported to occur in 2–10% of unselected patient samples and up to 40% of high-risk patients. The purpose of this article is to review the evidence behind the known risk factors for post-ERCP pancreatitis, as well as the technical and medical approaches developed to prevent it. There have been many advances in identifying the causes of this condition. Based on this knowledge, a variety of preventive strategies have been developed and studied. The approach to prevention begins with careful patient selection and performing ERCP for specific indications, while considering alternative diagnostic modalities when appropriate. Patients should also be classified by high-risk factors such as young age, female sex, suspected sphincter of Oddi dysfunction, a history of post-ERCP pancreatitis, and normal serum bilirubin, all of which have been identified in numerous research studies. The pathways of injury that are believed to cause post-ERCP pancreatitis eventually lead to the common endpoint of inflammation, and these individual steps can be targeted for preventive therapies through procedural techniques and medical management. This includes the use of a guide wire for cannulation, minimizing the number of cannulation attempts, avoiding contrast injections or trauma to the pancreatic duct, and placement of a temporary pancreatic duct stent in high-risk patients. Administration of rectal non-steroidal anti-inflammatory agents (NSAIDs) in high-risk patients is the proven pharmacological measure for prevention of post-ERCP pancreatitis. The evidence for or against numerous other attempted therapies is still unclear, and ongoing investigation is required.

Risk Factors for Adverse Outcomes in Patients Hospitalized With Lower Gastrointestinal Bleeding

OBJECTIVE To determine which risk factors and subtypes of lower gastrointestinal bleeding (LGIB) are associated with adverse outcomes after hospital discharge (30-day readmissions, recurrent LGIB, and death). PATIENTS AND METHODS We conducted a prospective observational study of consecutive patients admitted with LGIB to Beth Israel Deaconess Medical Center from April 1, 2013, through March 30, 2014. Patients were contacted 30 days after discharge to determine hospital readmissions, recurrent LGIB, and death. Multivariable Cox proportional hazards regression models were used to describe associations of variables with 30-day readmissions or recurrent LGIB. Logistic regression was used to determine association with mortality. RESULTS There were 277 patients hospitalized with LGIB. Of the 271 patients surviving to discharge, 21% (n=57) were readmitted within 30 days, 21 of whom were admitted for recurrent LGIB. The following factors were associated with 30-day readmissions: developing in-hospital LGIB (hazard ratio [HR], 2.26; 95% CI, 1.08-4.28), anticoagulation (HR, 1.82; 95% CI, 1.05-3.10), and active malignancy (HR, 2.33; 95% CI, 1.11-4.42). Patients discharged while taking anticoagulants had higher rates of recurrent bleeding (HR, 2.93; 95% CI, 1.15-6.95). Patients with higher Charlson Comorbidity Index scores (odds ratio [OR], 1.57; 95% CI, 1.25-2.08), active malignancy (OR, 6.57; 95% CI, 1.28-28.7), and in-hospital LGIB (OR, 11.5; 95% CI, 2.56-52.0) had increased 30-day mortality risk. CONCLUSION In-hospital LGIB, anticoagulation, and active malignancy are risk factors for 30-day readmissions in patients hospitalized with LGIB. In-hospital LGIB, Charlson Comorbidity Index scores, and active malignancy are risk factors for 30-day mortality.

High Glasgow Blatchford Score at admission is associated with recurrent bleeding after discharge for patients hospitalized with upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS Upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. The Glasgow Blatchford Score (GBS) can predict endoscopic intervention and in-hospital death, but the ability to predict post-discharge outcomes is unknown. The aims of the study were to determine whether the admission GBS is associated with post-discharge rebleeding and 30-day readmission following hospitalization for UGIB. PATIENTS AND METHODS In this prospective, observational, cohort study, consecutive patients who were hospitalized with UGIB were enrolled. Admission GBS scores were calculated, and patients with GBS > 7 were classified as high risk. Patients were contacted 30 days following discharge to determine: 1) rate of hospital readmission due to rebleeding, 2) all-cause readmissions, and 3) mortality. Multivariable Cox regression was used to determine associations between GBS, rebleeding, and readmission. RESULTS A total of 336 patients with UGIB were identified. Patients with high risk GBS were older (68 vs. 62 years; P = 0.01), and were more likely to receive blood (85 % vs. 39 %; P < 0.01) and require intensive care unit admission (64 % vs. 50 %; P = 0.02). Of the 309 patients who survived to discharge, 61 (20 %) were readmitted within 30 days, 25 (8 %) of whom had rebleeding. On multivariable analysis adjusting for the need for endoscopic intervention, high risk GBS patients had higher rebleeding rates (hazard ratio [HR] 3.32, 95 % confidence interval [CI] 1.26 - 11.4). On multivariable analysis, patients with more co-morbidities (HR 1.06, 95 %CI 1.01 - 1.11) and cirrhosis (HR 2.23, 95 %CI 1.19 - 4.04) had higher 30-day readmission rates. CONCLUSIONS High GBS scores were associated with higher rebleeding rates following discharge. Patients with high GBS scores (> 7) should be monitored following discharge as they have a high risk of rebleeding.

Transhiatal Herniation of the Pancreas: A Rare Cause of Acute Pancreatitis

Transhiatal herniation of the pancreas is rare. Acute pancreatitis secondary to this phenomenon is particularly unusual. A 102-year-old woman presented with 1 day of severe chest pain, vomiting, dyspnea, and diaphoresis. Serum lipase was elevated, and computed tomography angiogram of the chest and magnetic resonance cholangiopancreatography revealed a hiatal hernia containing the pancreas, with associated findings of pancreatitis. Pancreatitis in this setting may be due to repetitive trauma or ischemia from sliding, intermittent folding of the pancreatic duct, or pancreatic incarceration. Mild cases can be managed supportively, with surgery being reserved for severe cases or for younger patients with low surgical risk.

Erratum: The risks of thromboembolism Vs. Recurrent gastrointestinal bleeding after interruption of systemic anticoagulation in hospitalized inpatients with gastrointestinal bleeding: A prospective study (American Journal of Gastroenterology (2015) DOI: 10.1038/ajg.2014.424)

The American Journal of GASTROENTEROLOGY VOLUME 110 | MARCH 2015 www.amjgastro.com C O RR IG EN D U M Corrigendum: Characterization of Infl ammation and Fibrosis in Crohn’s Disease Lesions by Magnetic Resonance Imaging Jordi Rimola , Núria Planell , Sonia Rodríguez , Salvadora Delgado , Ingrid Ordás , Anna Ramírez-Morros , Carmen Ayuso , Montse Aceituno , Elena Ricart , Aranzazu Jauregui-Amezaga , Julián Panés and Míriam Cuatrecasas Am J Gastroenterol advance online publication 27 January 2015; doi: 10.1038/ajg.2014.424

Giant Cystic Arteriovenous Malformation of the Mesentery and the Role of Cross-Sectional Imaging in Occult Gastrointestinal Bleeding

A 29-year-old woman presented with profound iron-deficiency anemia. Cross-sectional imaging identified a mass in the ileal mesentery. Surgical resection was curative and revealed a giant cystic arteriovenous malformation. Our report highlights the role of cross-sectional imaging in the evaluation and management of iron-deficiency anemia and obscure gastrointestinal hemorrhage.

Mo1132 A Prospective Analysis of the Rates and Predictors of Readmissions Following Hospitalization for Gastrointestinal Bleeding

Background: Most patients with gastro-esophageal reflux disease (GERD) experience relief following treatment with proton pump inhibitors (PPI). As many as 17-44% of patients, however, exhibit partial or non-response to PPI therapy. Self-report of symptoms is fundamental to diagnosing and monitoring treatment response in these patients, yet most extant GERD PRO instruments fail to meet development best-practices as described by the FDA. We therefore sought to develop and validate a PRO instrument for clinical trials involving patients with GERD who are PPI partial-responders. Methods: We conducted a systematic literature review, held patient focus groups, convened an expert panel, and conducted cognitive interviews in order to establish content validity. Eligible participants took PPI therapy for at least 8 weeks, had undergone an upper endoscopy revealing no more than L.A. Classification Grade A esophagitis, and scored at least 8 points on the GerdQ. We used ATLAS.TI software to code focus group transcripts, generating frequencies at the domain, subdomain, and primary code levels. Results informed the construction of a conceptual framework, and guided development of 26 draft items. These items and subsequent revisions were reviewed by two expert panels and debriefed with cognitive interview participants. These efforts resulted in PRISM, a 21-item instrument that underwent psychometric evaluation during a Phase IIB drug trial (Protocol SPD557-206). Results: A diverse sample participated in focus groups (N=38; mean age=50.8; 55%M), saturating the codebook and supporting a preliminary conceptual framework. Following drafting of items, a new sample of patients participated in cognitive interviews for purposes of item revision (N=20; Age=52.6; 55%M). During the trial, an exploratory item assessment (n=104) revealed that all but one of the PRISM items met expectations for internal and external indices. A confirmatory factor analysis (n=220) resulted in a 4-factor model displaying the highest goodness-of-fit scores. All domains had a high inter-item correlation (Cronbachs α>0.8). Test-retest reliability was excellent with intraclass correlation also exceeding 0.8. Evidence for convergent validity was strong, with highly significant (p<.01) correlations between average weekly PRISM scores and severity anchors, and significant (p<.05) correlations with RDQ sub-scales. Three of 4 PRISM sub-scale scores were highly responsive to changes in both self-reported severity and symptom relief. Cumulative distribution functions revealed significant differences between responders and non-responders. Conclusion: PRISM demonstrates strong validity and psychometric properties in a clinical trial setting. Developed in line with FDA guidance on PROs, PRISM represents an new outcome measure for GERD patients with partial or nonresponse to PPI therapy.

Mo1125 A Prospective Analysis of the Glasgow-Blatchford Score as a Predictor of Length of Hospital Stay for Upper Gastrointestinal Bleeding

Background Antithrombotic drugs including low-dose aspirin, antiplatelet drugs and anticoagulants increase upper gastrointestinal bleeding (UGIB). This study aimed to clarify the features of UGIB in 11,919 Japanese patients taking antithrombotic drugs, and examine the temporal changes in the pathogenic mechanism for UGIB. Methods The characteristics of the cohort with those of the 11,919 patients, who were prescribed antithrombotic drugs in Saga Medical School Hospital during 2002 and 2011, were analyzed for examination of relationships between the use of acid-secretion inhibitors and antithrombotic drugs in the UGIB patients. During the period (2002-2011), retrospective chart review revealed 430 patients who underwent emergency endoscopy for UGIB in Saga Medical School Hospital. Results Numbers of UGIB patients were 186 in 2002-2006 and 244 in 2007-2011. In the second period, the proportion of UGIB patients infected with Helicobacter pylori decreased (76.9% in the first period vs. 49.6% in the second, p<0.0001), and the proportion of UGIB patients who took antithrombotic drugs increased (21.5% vs. 32.8%, p=0.012). The most common cause of UGIB was peptic ulcer disease, and the incidence of other causes, including reflux esophagitis, and gastric antral vascular ectasia, has increased in a time dependent manner. Significant risk factors for antithrombotic-related UGIB were hypertension (OR 6.546, 95%CI 4.091-10.477, p<0.001) and diabetes mellitus (OR 2.947, 95%CI 1.7534.956, p<0.001). The survey indicated the risk of UGIB in patients taking antithrombotics was 1.01% in 11,919 patients, whichwas 5-10-fold higher than that in the general population. The increased risk in UGIB caused by antithormbotics was significantly suppressed by acidsecretion inhibitors (OR 0.146, 95%CI 0.089-0.242, p<0.001). Conclusions The present large number study of 11,919 Japanese patients indicated the prevalence of UGIB in patients, who were prescribed antithrombotics, was 1.01%, and the increased risk of UGIB was attenuated by acid-secretion inhibitors.