Lauren B. Gerson

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5–10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Complete Elimination of Reflux Symptoms Does not Guarantee Normalization of Intraesophageal and Intragastric pH in Patients with Gastroesophageal Reflux Disease (GERD)

BACKGROUND:Acid plays a significant role in the development of gastroesophageal reflux symptoms, such as heartburn and regurgitation. It is generally assumed that acid suppressive therapy improves or eliminates symptoms by normalizing intraesophageal pH.AIMS:The aim of this article was to assess the efficacy of proton-pump inhibitors (PPIs) in normalizing intraesophageal and intragastric pH in patients with GERD without Barretts esophagus (BE) rendered symptom free by therapy.METHODS:Patients were evaluated by dual-sensor 24-h pH monitoring while receiving PPI therapy for complete control of GERD symptoms. Analyses of intraesophageal and intragastric pH profiles were then made.RESULTS:Fifty patients, 39 men and 11 women, with GERD, without BE, were studied. All tolerated PPIs well and were asymptomatic at the time of the study. Fifty percent of patients had abnormal intraesophageal pH profiles despite adequate symptom control on PPIs, which was associated with significant breakthrough of intraesophageal acid control in both the upright and supine positions. Low intragastric pH correlated highly with intraesophageal acid reflux only in patients with persistent abnormal esophageal acid exposure (p = 0.001).CONCLUSIONS:Fifty percent of patients with GERD without BE continue to exhibit pathologic GERD and low intragastric pH despite PPI therapy that achieves complete reflux symptom control.

GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis

BACKGROUNDnPatients with left ventricular assist devices (LVADs) are at increased risk of GI bleeding (GIB), primarily from GI angiodysplastic lesions (GIAD).nnnOBJECTIVEnTo perform meta-analysis of the medical literature in order to determine prevalence and risk factorsxa0for GIB.nnnDESIGNnA literature search was performed to identify studies reporting GIB in LVAD patients. We extracted rates of prevalence, rebleeding, and overall mortality from each study. Pooled event rates and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.nnnSETTINGnMeta-analysis of 17 case-control and cohort studies.nnnPATIENTSnA total of 1839 LVAD patients of whom 1697 (92%) had continuous-flow LVADs.nnnRESULTSnThe pooled prevalence of GIB in LVAD patients was 23% (95% CI, 20.5%-27%). Subgroup analysis demonstrated that older age (standard difference in means (SDm), 0.69; 95% CI, 0.23-1.15), and elevated creatinine (SDm,xa00.65; 95% CI, 0.12-1.18, P = .02) were associated with GIB. Risk factors not associated with GIB included LVAD as destination therapy (OR 1.85; 95% CI, 0.8-4.3), prior history of GIB (OR 2.22; 95% CI, 0.83-5.96), hypertension (ORxa01.6; 95% CI, 0.87-2.97), and/or the presence of a continuous-flow LVAD (OR 4.5; 95% CI, 2.1-9.5). Recurrence of GIB occurred in 9.3% (95% CI, 7%-12%), with a GIB mortality rate of 23% (95% CI, 16%-32%). The pooled event rates were 48% (95% CI, 39%-57%) for upper GIB, 22% (95% CI, 16%-31%) for lower GIB, and 15% (95% CI, 8%-25%) for small-bowel bleeding. GIAD in the proximal GI tract were the most common cause of GIB (29%).nnnLIMITATIONSnLack of information regarding endoscopic therapy and follow-up in most studies.nnnCONCLUSIONSnThe prevalence of GIB is increased in patients with continuous-flow LVADs, primarily secondary to the presence of GIAD.

Double-balloon enteroscopy in Crohn's disease: findings and impact on management in a multicenter retrospective study.

BACKGROUNDnDouble-balloon enteroscopy (DBE) is effective in visualizing the small bowel to perform biopsy sampling and interventions. Few studies have evaluated the utility of DBE in patients with known or suspected Crohns disease (CD).nnnOBJECTIVEnTo evaluate the use of DBE in the diagnosis and impact on patient management in known and suspected CD and to compare capsule endoscopy (CE) with DBE findings.nnnDESIGNnRetrospective study from August 2004 to August 2009 of DBE procedures.nnnSETTINGnFive academic, tertiary U.S. centers.nnnPATIENTSnPatients with known or suspected CD.nnnMAIN OUTCOME MEASURESnDiagnostic yield, impact on patient management, and comparison of DBE to CE findings in patients with known and suspected CD.nnnRESULTSnWe analyzed 98 DBE procedures performed in 81 patients (38 with known CD and 43 with suspected CD). For patients with CD, common indications were abdominal pain and bleeding/anemia. The diagnostic yield was 87% (33/38 patients). The impact on subsequent management decisions was 82% (31/38). Common indications for DBE in patients with suspected CD were abnormal CE or other imaging. The diagnostic yield was 79% (34/43 patients). The impact on subsequent management decisions was 77% (33/43). In 17% of patients (14/81), DBE failed to reach the target lesion. There was 1 perforation, 3 strictures dilated, and 1 of 2 retained capsules recovered. When CE was followed by DBE, 46% of lesions were confirmed on DBE.nnnLIMITATIONSnRetrospective analysis, imperfect criterion standard.nnnCONCLUSIONSnDBE is an effective technique for assessment of the small bowel in known and suspected CD and affects management. Failure to reach target areas with DBE is not uncommon, and perforations can occur. There is poor correlation between CE and DBE.

ACG Clinical Guideline: Management of Crohn's Disease in Adults

Crohn’s disease is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. The incidence of Crohn’s disease has steadily increased over the past several decades. The diagnosis and treatment of patients with Crohn’s disease has evolved since the last practice guideline was published. These guidelines represent the official practice recommendations of the American College of Gastroenterology and were developed under the auspices of the Practice Parameters Committee for the management of adult patients with Crohn’s disease. These guidelines are established for clinical practice with the intent of suggesting preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When exercising clinical judgment, health-care providers should incorporate this guideline along with patient’s needs, desires, and their values in order to fully and appropriately care for patients with Crohn’s disease. This guideline is intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. To evaluate the level of evidence and strength of recommendations, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.

Retention associated with video capsule endoscopy: systematic review and meta-analysis

BACKGROUND AND AIMSnVideo capsule endoscopy (VCE) has become a major diagnostic tool for small-bowel evaluation. However, retention of the video capsule endoscope remains a major concern.nnnMETHODSnWe performed a systematic review of VCE retention rates by using Pubmed and SCOPUS (1995-2015). We included studies that enrolled at least 10 patients, included VCE retention rates, and separated retention rates by indication. We used Comprehensive Meta-Analysis (Version 3.0) to calculate pooled prevalence rates with 95% confidence intervals (CIs) and assessed heterogeneity by using the Cochran Q statistic.nnnRESULTSnWe included 25 studies (Nxa0= 5876) for patients undergoing VCE for evaluation of potential small-bowel bleeding, 9 studies (Nxa0= 968) for patients with suspected inflammatory bowel disease (IBD), 11 studies (Nxa0= 558) for patients with established IBD, and 8 studies for patients (Nxa0= 111) undergoing VCE for evaluation of abdominal pain and/or diarrhea. We used a random effects model and found that the pooled retention rate was 2.1% for patients with suspected small-bowel bleeding (95% CI, 1.5%-2.8%). Retention rates were 3.6% (95% CI, 1.7%-8.6%) for suspected IBD, 8.2% (95% CI, 6.0%-11.0%) for established IBD, and 2.2% (95% CI, 0.9%-5.0%) for abdominal pain and/or diarrhea. Based on subgroup analysis, subsequent VCE completion rates after performance of a patency capsule or CT enterography in patients with IBD to exclude retentions due to strictures was 2.7% (95% CI, 1.1%-6.4%). Reasons for retention were provided in 60 (77%) studies. The most common reasons for retention were small-bowel strictures, although etiology was not provided in all studies.nnnCONCLUSIONnVCE retention occurs in approximately 2% of patients undergoing evaluation for small-bowel bleeding and is most likely due to small-bowel strictures. Retention rates in patients with suspected or known IBD were approximately 4% and 8%, based on our meta-analysis. These rates decreased by half in those studies that used either a patency capsule or CT enterography to assess patency before performing VCE.

Is colorectal cancer screening necessary in the preoperative assessment of inguinal herniorrhaphy? a case-control study

OBJECTIVES:The question of whether patients presenting for inguinal hernia repair require pre-operative assessment for colon cancer has remained unanswered. A case-control study is necessary to assess whether the prevalence of premalignant or malignant colonic lesions is higher in patients presenting with inguinal hernia compared to the general population.METHODS:Between 1990–2000, 614 inguinal herniorrhaphies were performed at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). We retrospectively studied the 149 (24%) patients from this group with no prior history of colonic polyps, malignancy, or gastrointestinal bleeding who had flexible sigmoidoscopy or colonoscopy performed during the peri-operative period. Comparison was made to 149 controls undergoing colonoscopy or sigmoidoscopy during the same time period for colon cancer (CRC) screening.RESULTS:The mean (±SEM) patient age was 67 ± 0.7 (range 31–92) yr in the hernia patients and 66 ± 0.8 (range 46–93) in the control group (p = 0.7). Eighty-two of the inguinal hernia patients had screening procedures performed preoperatively with a mean time (±SEM) of 1.4 ± 0.14 yr, while endoscopy was performed in the post-operative period for the remaining 67 patients (average time 2.7 ± 0.2 yr, p < 0.001). More patients underwent colonoscopy in the control group compared to the hernia cohort (p = 0.004). Seven (5%) patients in the hernia group were found to have colorectal cancer compared to six (4%) in the control group (p = 0.8).CONCLUSIONS:This study does not support previously published findings that patients with inguinal hernias are more likely to have premalignant colonic lesions. Patients with inguinal hernias should undergo screening for colon cancer at the same rate as the general population.

Small Bowel Bleeding : Updated Algorithm and Outcomes

Patients previously classified with obscure gastrointestinal hemorrhage should now be classified as suspected small bowel bleeding according to the 2015 American College of Gastroenterology guidelines. This article provides algorithms for how to manage patients with suspected small bowel bleeding, including utilization of second-look endoscopy and/or colonoscopy, video capsule endoscopy, computed tomographic enterography, magnetic resonance enterography, angiography, and deep enteroscopy.

In-hospital weekend outcomes in patients diagnosed with bleeding gastroduodenal angiodysplasia: a population-based study, 2000 to 2011

BACKGROUND AND AIMSnGI angiodysplastic (GIAD) lesions are an important cause of blood loss throughout the GI tract, particularly in elderly persons. The aim of this study was to determine whether mortality rates in patients with GIAD were higher for weekend compared with weekday hospital admissions.nnnMETHODSnWe performed a retrospective study using the National Inpatient Sample database from 2000 to 2011 including inpatients with an International Classification of Diseases, Ninth Revision, Clinical Modification code for gastrointestinal GIAD (code 537.82 or 537.83). We assessed rates of delayed endoscopy (examinations performed >24 hours after admission), intensive care unit (ICU) admissions, and in-hospital mortality rates. Bivariate and multivariate logistic regression analyses were performed to identify risk factors for mortality.nnnRESULTSnThere were 85,971 discharges for GIAD between 2000 and 2011, of which 69,984 (81%) were weekday hospital admissions and 15,987 (19%) were weekend admissions. Patients with weekend versus weekday admissions were more likely to undergo delayed endoscopic examination (35% vs 26%, Pxa0≤ .0001). Mortality rates werexa0higher for patients with weekend admissions (2% vs 1%, Pxa0= .0002). The adjusted odds ratio (aOR) for inpatient mortality associated with weekend admissions was elevated (2.4; 95% confidence interval [CI], 1.5-3.9; Pxa0= .0005). Rates of delayed endoscopic examinations were lower in patients with higher socioeconomic status (aORxa0= 0.77; 95% CI, 0.68-0.88). ICU admission rates were higher for weekend compared with weekday admissions (8% vs 6%, Pxa0= .004). The presence of a delayed endoscopic examination was associated with an increased length of stay of 1.3 days (95% CI, 1.2-1.4 days).nnnCONCLUSIONSnWeekend admissions for angiodysplasia were associated with higher odds of mortality, ICU admissions, higher rates of delayed endoscopic procedures, longer lengths of stay, and higher hospital charges.

Palliative care in inflammatory bowel disease: an evidence-based approach.

Summary: The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid‐related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence‐based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case‐controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.