Samian Sulaiman

Risk of Gastrointestinal Bleeding with Dabigatran: A Head-to-Head Comparative Study with Rivaroxaban

Introduction: The risk of gastrointestinal (GI) bleeding of dabigatran and rivaroxaban is relatively unexplored. The aim of our study was to compare this risk in both drugs. Methods: We examined the medical records of patients on either dabigatran or rivaroxaban from October 2010 to April 2013 in two hospitals. Results: A total of 374 patients (147 rivaroxaban vs. 227 dabigatran) were identified. GI bleeding occurred in 5.3% in the dabigatran when compared to 4.8% in the rivaroxaban group (p = 0.8215). Multivariate analysis showed that the odds of GI bleeding while on dabigatran for ≤40 days when compared to ≥40 days was 8.3 (p < 0.0001). In the rivaroxaban group, patients who were on the drug for ≤40 days had a higher incidence of bleeding when compared to those >40 days (OR = 2.8, p = 0.023). Concomitant use of antiplatelets (single or dual) or non-steroidal anti-inflammatory drugs was not associated with increased bleeding in the dabigatran group; however, the use of dual antiplatelet agents with rivaroxaban was associated with an increased risk of GI bleeding (OR = 7.4, p = 0.0378). Prior GI bleeding had a higher risk of bleeding in the rivaroxaban group (OR = 15.5, p = 0.0002). Conclusion: Dabigatran was not associated with a higher incidence of GI bleeding. Both drugs had a higher bleeding risk in the first 40 days.

Ischemic colitis: A forgotten entity. Results of a retrospective study in 118 patients

The aim of our study was to document our 6‐year experiences in identifing the clinical characteristics, laboratory findings, risk factors and the outcomes of patients with ischemic colitis (IC) in a community hospital setting.

Pseudoephedrine‐induced ischemic colitis: Case report and literature review

Ischemic colitis is the consequence of a sudden reduction in colonic blood supply, which in turn results in an ischemic injury. The incidence of ischemic colitis ranges from 4.5 to 44 cases/100 000 person-year. It occurs more frequently in the elderly, in those with a mean age of early seventies, and is more common in women. Its prevalence increases with age and has increased over time in the last few decades.

Metastatic Infiltrating Ductal Carcinoma of the Breast to the Colon: A Case Report and Literature Review

True metastatic involvement of the colon is rare. Colonic metastases occur most commonly secondary to peritoneal metastases from intra-abdominal malignancies. Breast cancer is the most common malignancy that metastasizes hematogenously to the colon. Colonic metastatic disease mimics primary colonic tumors in its presentation. Colonic metastatic involvement is a poor prognostic sign, and the pathologist should be informed about the history of the primary breast cancer when examining the pathologic specimens. In this paper, we report a case of an ileocecal mass found to be histologically consistent with metastatic ductal breast cancer, and then we review the literature about breast cancer metastases to the gastrointestinal tract in general and colon in particular.

Klippel-Trenaunay Syndrome Causing Life-Threatening GI Bleeding: A Case Report and Review of the Literature

Klippel-Trenaunay syndrome (KTS) is a rare congenital syndrome of vascular malformations and soft tissue and bone hypertrophy. Vascular malformations can affect multiple organ systems. Involvement of the gastrointestinal (GI) tract is uncommon in KTS, but it can be a source of life-threatening bleeding. We report a case of a 32-year-old male with a known diagnosis of KTS who presented with a life-threatening rectal bleeding and was treated with proctosigmoidectomy and massive blood products transfusion. He expired after a long hospitalization. We then review the literature on KTS and management of some of its complications.

Gastrointestinal Bleeding with Dabigatran, a Comparative Study with Warfarin: A Multicenter Experience

BACKGROUND/AIMS The risk of gastrointestinal (GI) bleeding with dabigatran when compared to warfarin has been controversial in the literature. The aim of our study was to assess this risk with the use of dabigatran. METHODS We examined the medical records of patients who were started on dabigatran or warfarin from October 2010 to October 2012. The study was conducted in two hospitals. RESULTS A total of 417 patients were included (208 dabigatran vs. 209 warfarin). GI bleeding occurred in 10 patients (4.8%) in the dabigatran group compared to 21 patients (10.1%) in the warfarin group (p=0.0375). Multivariate analysis showed that patients who were on dabigatran for ≤ 100 days had a higher incidence of GI bleeding than those who were on it for >100 days (p=0.0007). The odds of GI bleeding in patients who were on dabigatran for ≤ 100 days was 8.2 times higher compared to those who were on the drug for >100 days. The incidence of GI bleeding in patients >65 years old was higher than in those <65 years old (p=0.0453, OR=3). History of previous GI bleeding was another risk factor for GI bleeding in the dabigatran group (p=0.036, OR=6.3). The lower GI tract was the most common site for GI bleeding in the dabigatran group (80.0% vs. 38.1%, p=0.014). CONCLUSIONS The risk of GI bleeding was lower with dabigatran. The risk factors for GI bleeding with dabigatran were the first 100 days, age >65 years, and a history of previous GI bleeding.

Is CT Angiogram of the Abdominal Vessels Needed following the Diagnosis of Ischemic Colitis? A Multicenter Community Study

Background. CT angiogram is frequently obtained after diagnosis of ischemic colitis (IC). Aims. To investigate the vascular findings of CT angiogram as compared to contrast-enhanced CT scan and whether this modality changes the management or prognosis of IC. Methods. We conducted a retrospective analysis of patients with IC from 2007 to 2013. Results. CT angiogram was performed in 34 patients (28.81%), whereas contrast-enhanced CT scan was performed in 54 patients (45.76%). In CT angiogram group, 8 patients (23.5%) had atherosclerotic changes. Stenosis was found in 12 patients (35.3%) (9: celiac trunk, 3: SMA). Among this group, one patient underwent colectomy and another underwent angioplasty of the celiac trunk who died within 30 days. Among contrast-enhanced CT scan group, 5 patients (9.3%) had atherosclerotic changes. Stenosis was found in 5 patients (9.3%) (3: celiac trunk, 1: SMA, and 1: IMA). Among this group, 3 patients had colectomy and one died within 30 days. There was no statistical difference between both groups in all vascular findings except the stenosis which was higher in CT angiogram group (P = 0.0025). Neither the need for surgery nor all-cause mortality was different between both groups. Conclusion. CT angiogram did not provide any useful findings that altered the management or the prognosis of IC.

Ischemic colitis induced by the newly reformulated multicomponent weight-loss supplement Hydroxycut®

Ischemic colitis accounts for 6%-18% of causes of acute lower gastrointestinal bleeding. It is more often multifactorial and more common in elderly. Drugs are considered important causative agents of this disease with different mechanisms. In this paper, we describe a 37-year-old otherwise healthy female presented with sudden onset diffuse abdominal pain and bloody stool. Radiologic, colonoscopic and histopathologic findings were all consistent with ischemic colitis. Her only suspected factor was hydroxycut which she had been taking for a period of 1 mo prior to her presentation. Her condition improved uneventfully after cessation of hydroxycut, bowel rest, intravenous hydration, and antibiotics. This is a first case of ischemic colitis with clear relationship with hydroxycut use (Naranjo score of 7). Our case demonstrates the importance of questioning patients regarding the usage of dietary supplements; especially since many patients consider them safe and do not disclose their use voluntarily to their physicians. Hydroxycut has to be considered as a potential trigger for otherwise unexplained ischemic colitis.

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device

Background Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. Methods All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. Conclusions Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.

Metastatic Malignant Melanoma to the Colon: a Case Report and Review of the Literature

Malignant tumors metastasizing to the colon are unusual. Despite the fact that it occurs rarely, malignant melanoma was thought to be the most common tumor metastasizing to the colon [1, 2]. However, a recent study by Mourra et al. reported breast cancer as the leading cause for colonic metastases [3]. About 1–3 % of gastrointestinal (GI) malignancies are malignant melanomas [4]. Melanoma spreading to the GI tract most commonly affects the small bowel (the jejunum and ileum), followed by the stomach, rectum, and colon [5]. The relative blood supply difference between the small bowel and colon is the proposed mechanism of the higher rate of spreading melanomas to the small bowel compared to the colon [6]. Melanoma metastasizing to the GI tract can have various presentations. It may present as anemia, bleeding, abdominal pain, weight loss, or bowel obstruction secondary to intussusception [7]. In this paper, we report a case of an elderly male who was found to be anemic, and subsequent colonoscopy revealed a colon mass that was histologically consistent with metastatic melanoma.