Paresh P. Mehta

Features of Patients With Gastrointestinal Bleeding After Implantation of Ventricular Assist Devices

BACKGROUND & AIMS Ventricular assist devices (VADs) are used to treat patients with end-stage heart disease. However, patients with VADs frequently develop gastrointestinal (GI) bleeding. We investigated the incidence, etiology, and outcome of GI bleeding in patients with VADs. METHODS In a retrospective study, we analyzed data from 391 consecutive patients (mean age, 53.9 ± 14.2 years; 81% male) who underwent VAD implantation for end-stage heart disease from January 2000 through May 2012 at the Cleveland Clinic. Multivariable logistic regression analysis was used to identify factors independently associated with GI bleeding in patients with VADs. RESULTS Sixty-two patients (15.9%) had GI bleeding. The risk of GI bleeding increased by 10% for every 5-year increase in age (P = .006). GI bleeding was also associated with lower body mass index (P = .046), current smoking (P = .007), and lower baseline levels of hemoglobin (P < .001). Bleeding was primarily overt (79%), and most patients presented with hematochezia (43.5%). Causes of bleeding were primarily vascular malformations (26.5%) and ulcers (26.5%). Patients who received VADs as their only therapy, rather than as a bridge-to-transplantation, were more likely to have GI bleeding (P = .008). Colonoscopy detected GI bleeding with the highest diagnostic yield; most bleeding was associated with colonic lesions (51.4%). Overall mortality was 39.4%, and 2 deaths were directly related to GI bleeding. CONCLUSIONS On the basis of a large case series analysis, GI bleeding is common after implantation of VADs (15.9% of patients have at least 1 episode of bleeding). Episodes were mostly overt and predominantly from the lower GI tract; colonoscopy is the best method of detection.

Capnographic Monitoring in Routine EGD and Colonoscopy With Moderate Sedation: A Prospective, Randomized, Controlled Trial

Objectives:Regulatory changes requiring the use of capnographic monitoring for endoscopic procedures using moderate sedation have placed financial challenges on ambulatory and hospital endoscopy centers across the United States due to the increased cost of training endoscopy personnel and purchasing both capnography-monitoring devices and specialized sampling ports. To date, there has been no published data supporting the use of capnographic monitoring in adult patients undergoing routine endoscopic procedures with moderate sedation. The aim of this randomized, parallel group assignment trial was to determine whether intervention based on capnographic monitoring improves detection of hypoxemia in patients undergoing routine esophagogastroduodenoscopy (EGD) or colonoscopy with moderate sedation.Methods:Healthy patients (ASA Physical Classification (ASAPS) I and II)) scheduled for routine outpatient EGD or colonoscopy under moderate sedation utilizing opioid and benzodiazepine combinations were randomly assigned to a blinded capnography alarm or open capnography alarm group. In both study arms, standard cardiopulmonary monitoring devices were utilized with additional capnographic monitoring. The primary end point was the incidence of hypoxemia defined as a fall in oxygen saturation (SaO2) to <90% for ≥10 s. Secondary outcomes included severe hypoxemia, apnea, disordered respirations, hypotension, bradycardia, and early procedure termination for any cause.Results:A total of 452 patients were randomized; 218 in the EGD and 234 in the colonoscopy groups; 75 subjects in the EGD group (35.9%) and 114 patients (49.4%) in the colonoscopy group were male, and average body mass index was 27.9 and 29.1 (kg/m2), respectively. The blinded and open alarm groups in each study arm were similar in regards to use of opioids and/or benzodiazepines and ASAPS classification. There was no significant difference in rates of hypoxemia between the blinded and open capnography arms for EGD (54.1% vs. 49.5; P=0.5) or colonoscopy (53.8 vs. 52.1%; P=0.79).Conclusions:Capnographic monitoring in routine EGD or colonoscopy for ASAPS I and II patients does not reduce the incidence of hypoxemia (ClinicalTrials.gov number, NCT01994785).

Effect of the time of day on the success and adverse events of ERCP.

BACKGROUND Physician fatigue and decreased concentration have been proposed as causes of lower completion and adenoma detection rates in afternoon colonoscopies compared with morning colonoscopies. ERCP is a technically demanding and highly operator-dependent procedure, and its success may similarly be affected in the afternoon compared with the morning. OBJECTIVE To compare cannulation success and adverse events between ERCP procedures performed in the morning and afternoon. DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Patients with no previous papillary intervention who underwent ERCP at our institution between November 2006 and November 2008. MAIN OUTCOME MEASUREMENTS Cannulation success, procedure completion rates, length of procedures, and adverse events. RESULTS A total of 296 patients were studied; 114 patients (38.5%) underwent a procedure in the morning and 182 patients (61.5%) underwent a procedure in the afternoon. There were 139 male patients (47.0%). The mean patient age was 59.1 years. The deep cannulation success rate was 95.3% overall, with similar rates when performed in the morning (98.3%) and afternoon (94.0%) (P = .08). When the start time was evaluated as a continuous hour-by-hour variable, there was also no significant difference in deep cannulation success rates (P = .30). Procedure completion rates were similar in both groups (morning, 93.9%; 94.0%, afternoon; P = .97). Adverse events (8.8% for morning procedures vs 7.1% for afternoon procedures, P = .61) and length of procedures (40 minutes for morning procedures vs 40 minutes for afternoon procedures, P = .87) were also similar between the 2 groups. LIMITATIONS Small sample size and retrospective study. CONCLUSIONS The timing of ERCP, morning versus afternoon, does not seem to affect cannulation success, procedure completion rates, length of procedures, or adverse events.

Utility of urgent colonoscopy in acute lower gastro-intestinal bleeding: a single-center experience

Background. The role of urgent colonoscopy in lower gastro-intestinal bleeding (LGIB) remains controversial. Over the last two decades, a number of studies have indicated that urgent colonoscopy may facilitate the identification and treatment of bleeding lesions; however, studies comparing this approach to elective colonoscopy for LGIB are limited. Aims. To determine the utility and assess the outcome of urgent colonoscopy as the initial test for patients admitted to the intensive care unit (ICU) with acute LGIB. Methods. Consecutive patients who underwent colonoscopy at our institution for the initial evaluation of acute LGIB between January 2011 and January 2012 were analysed retrospectively. Patients were grouped into urgent vs. elective colonoscopy, depending on the timing of colonoscopy after admission to the ICU. Urgent colonoscopy was defined as being performed within 24 hours of admission and those performed later than 24 hours were considered elective. Outcomes included length of hospital stay, early re-bleeding rates, and the need for additional diagnostic or therapeutic interventions. Multivariable logistic regression analysis was performed to identify factors associated with increased transfusion requirements. Results. Fifty-seven patients underwent colonoscopy for the evaluation of suspected LGIB, 24 of which were urgent. There was no significant difference in patient demographics, co-morbidities, or medications between the two groups. Patients who underwent urgent colonoscopy were more likely to present with hemodynamic instability (P = 0.019) and require blood transfusions (P = 0.003). No significant differences in length of hospital stay, re-bleeding rates, or the need for additional diagnostic or therapeutic interventions were found. Patients requiring blood transfusions (n = 27) were more likely to be female (P = 0.016) and diabetics (P = 0.015). Fourteen patients re-bled at a median of 2 days after index colonoscopy. Those with hemodynamic instability were more likely to re-bleed [HR 3.8 (CI 1.06–13.7)], undergo angiography [HR 9.8 (CI 1.8–54.1)], require surgery [HR 13.5 (CI 3.2–56.5)], and had an increased length of hospital stay [HR 1.1 (1.05–1.2)]. Conclusion: The use of urgent colonoscopy, as an initial approach to investigate acute LGIB, did not result in significant differences in length of ICU stay, re-bleeding rates, the need for additional diagnostic or therapeutic interventions, or 30-day mortality compared with elective colonoscopy. In a pre-specified subgroup analysis, patients with hemodynamic instability were more likely to re-bleed after index colonoscopy, to require additional interventions (angiography or surgery) and had increased length of hospital stay.

Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding

Background and Aim: Gastric varices are associated with high mortality. There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt (TIPS) is more effective in the treatment of gastric varices. We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding. Methods: The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011. Primary compared to studied between the two treatment modalities were the short-term treatment outcomes, including re-bleeding within 30 days, length of hospital stay and in-hospital mortality. Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality. Results: A total of 169 patients were included in the analysis. The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients. There was no evidence to suggest any significant differences in demographics or disease severity. There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days (17.4% vs. 17.2%; P = 0.98), median length of stay in the hospital (4.5 days vs. 6.0 days; P = 0.35) or in-hospital mortality (9.0% vs. 11.1%; P = 0.74). In-hospital mortality was evaluated for 149 patients and lower albumin (P = 0.015), higher MELD score (P < 0.001), higher CTP score (P = 0.005) and bleeding (P = 0.008) were all significantly associated with in-hospital death. Conclusion: These findings suggest that both treatments are equally effective. Cyanoacrylate offers a safe, effective alternative to TIPS for gastric varices, and physician may choose the best therapy for each patient, factoring in the availability of TIPS or cyanoacrylate, the individual patient’s presentation, and cost.

Association of procedure length on outcomes and adverse events of endoscopic retrograde cholangiopancreatography

Objective: The aims of this study were to determine the effects of length of procedure on endoscopic retrograde cholangiopancreatography (ERCP) outcomes and adverse events. Methods: All ERCP procedures, performed by experienced advanced endoscopists, in patients without prior papillary intervention from 2006 to 2008 were reviewed. Procedures were arbitrarily divided into two groups: shorter procedures (SP), with a duration shorter than the overall mean procedure length, and longer procedures (LP), with a duration longer than overall mean procedure length. Length of procedure was defined as the time from endoscope insertion to endoscope removal. Results: Two hundred and ninety-five procedures were included in the analysis. Mean procedure length was 45.6 ± 30.1 min. One hundred and seventy-seven procedures (60%) were SP and 118 (40%) were LP. There were no differences between the groups with regard to patients’ ages, genders, race, or trainee participation. SP cases were more likely to be biliary vs pancreatic or bi-ductal evaluations (P = 0.03). LP had significantly higher complexity scores (34% with >3 vs 13%; P = 0.046) and were more likely to require pre-cut papillotomy (39% vs 15%; P < 0.001). There was no significant difference between the groups in overall completion rates (91.5% LP vs 96% SP; P = 0.10) or adverse events (10.2% LP vs 6.2% SP; P = 0.21). However, LP cases were associated with higher rates of post-ERCP bleeding (4.2% vs 0.6%; P = 0.029). Conclusion: There was no significant difference in outcomes or overall adverse events between shorter and longer ERCP procedures. However, longer procedures were associated with higher procedure complexity, higher utilization of pre-cut technique, and increased risk of bleeding.

A rare cause of gastro-intestinal hemorrhage in a patient with a Roux-en-Y gastric bypass

This case illustrates a rare cause of gastro-intestinal bleeding following bariatric surgery. Though it is essential to rule out common causes of variceal formation accompanied by intermittent, profuse bleeding, there should be a high degree of suspicion of this rare etiology in patients who have previously undergone alteration of their anatomy, especially Roux-en-Y gastric bypass (RYGB). The case emphasizes the need for a multidisciplinary medical-surgical team in evaluating and treating patients who present with complex intra-abdominal pathology.

Triage, sedation and monitoring

Endoscopic emergencies provide a unique experience for the endoscopy team in regard to optimal management and interventions. These patients are often critically ill and may be at higher risk for cardiopulmonary adverse events. Hence, the triage of patients, optimal management regarding sedation issues, tools for cardiopulmonary monitoring, and the need to involve a dedicated anesthesia team for patients with endoscopic emergencies are discussed.

164 RISK FACTORS FOR COMPLICATIONS OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS AFTER LIVER TRANSPLANTATION

163 EVALUATION STUDY FOR THE INFLUENCE OF DIAGNOSTIC METHODS FOR BILIRUBIN, CREATININE AND PROTHROMBIN (INR) FOR LABORATORY MELD SCORE CALCULATIONS T. Kaiser, S. Zeuzem, R. Lichtinghagen, W.J. Geilenkeuser, R. Kruse, M. Neumaier, J. Thiery, M. Schmidt. Clinical Chemistry, Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, Leipzig, Department of Internal Medicine I, Hepatology, J. W. Goethe University Hospital, Frankfurt/Main, Clinical Chemistry, Institute of Clinical Chemistry, Hannover Medical School, Hannover, Quality Management, Reference Institute for Bioanalytics, Bonn, Clinical Chemistry, Institute for Clinical Chemistry, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany E-mail: thorsten.kaiser@medizin.uni-leipzig.de