Incidence, Predictors, and Outcomes of Clinically Significant Post-ERCP Bleeding: a Contemporary Multi-center Study.

BACKGROUND AIMS: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors for and outcomes following CSPEB. METHODS: We analyzed multi-center prospective ERCP data between 2018-2023 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in: hemoglobin drop ≥20 g/L or transfusion and/or endoscopy to evaluate suspected bleeding, and/or unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was employed. P-values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported. RESULTS: CSPEB occurred following 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring following higher-risk interventions (sphincterotomy, sphincteroplasty, pre-cut sphincterotomy, and/or needle-knife access). CSPEB patients required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with three cases (2.3%) being fatal. P2Y12 inhibitors were held for a median of 4 days (IQR 4) prior to higher-risk ERCP. Following higher-risk interventions, P2Y12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24) and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding post sphincterotomy (OR 2.32, 1.06-4.60), but not post sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days following CSPEB (OR 12.71, 4.75-32.54). CONCLUSIONS: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher-risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets.

The use of cap-mounted clips as a primary hemostatic modality in nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized trials.

BACKGROUND: Cap-mounted-clips, especially Over-The-Scope-Clip (OTSC™), are recommended for recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB). There has been recent interest in their use as an initial hemostatic modality. We performed a systematic review of randomized controlled trials (RCTs) assessing cap-mounted clips' efficacy as a primary hemostatic modality in NVUGIB. METHODS: A literature search of MEDLINE, EMBASE, and ISI Web of Science databases up to April 2024 identified RCTs comparing cap-mounted clips to standard endoscopic therapy (SET) as a primary hemostatic modality in NVUGIB. The primary endpoint was the composite outcome of further bleeding (persistent or recurrent) at 30 days. Secondary outcomes included persistent bleeding at index endoscopy and 30-day rebleeding, individually. Other pertinent outcomes were also recorded. A meta-analysis was performed to determine pooled risk ratios (RRs), comparing cap-mounted clip to SET. Out of 516 citations, five RCTs (n = 555), all assessing OTSC™, were included. RESULTS: The composite outcome of further bleeding was lower with cap-mounted clip versus SET (RR = 0.33 [95% confidence interval {CI}: 0.20-0.54]). There was no difference in persistent bleeding at initial endoscopy (RR = 0.30 [95% CI: 0.07-1.30]), but 30-day rebleeding was lower with cap-mounted clip (RR = 0.38 [95% CI: 0.21-0.70]). There were no differences in other outcomes. Grading of the evidence ranged from very low to moderate, mainly due to risk of bias and imprecision. CONCLUSIONS: Cap-mounted clips may be an efficacious primary hemostatic modality, associated with a lower further bleeding at 30 days compared to SET in NVUGIB. However, due to limitations in existing evidence, further research must better characterize an optimal subgroup of patients benefiting most from this approach before adopting its routine use.

The periprocedural management of patients on a direct oral anticoagulant undergoing an elective gastrointestinal endoscopic procedure.

This narrative review summarizes the current body of literature regarding the periprocedural management of direct anticoagulants (DOACs) for patients undergoing digestive endoscopy since the publication of the 2022 American College of Gastroenterology - Canadian Association of Gastroenterology guidelines. We provide a detailed analysis of TE risk, endoscopic procedure-specific bleeding risks, contemporary intra-procedural techniques to reduce bleeding risk, and a summary of major gastrointestinal societies' periprocedural DOAC guidelines, including procedure risk stratification. While there exists heterogeneity in the data, the overall trend of the current literature supports the contemporary practice of a minimal DOAC interruption without the need for heparin bridging.

Peptic ulcer disease.

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Previously undiagnosed Morgagni hernia with bowel perforation detected during repeat screening colonoscopy: A case report.

BACKGROUND: Morgagni hernia (MH) is a form of congenital diaphragmatic hernia (CDH) characterized by an incomplete formation of diaphragm, resulting in the protrusion of abdominal organs into the thoracic cavity. The estimated incidence of CDH is between 1 in 2000 and 1 in 5000 live births, although the true incidence is unknown. MH typically presents in childhood and can be diagnosed either prenatally or postnatally. However, it can also be asymptomatic and carry the risk of developing into a life-threatening condition in adulthood. CASE SUMMARY: A 76-year-old female with no history of prior abdominal surgeries presented for an elective colonoscopy for polyp surveillance. During the procedure, when approaching the hepatic flexure, the scope could not be advanced further despite multiple attempts. The patient experienced mild abdominal discomfort, leading to the abortion of the procedure. While in the recovery area, she developed increasing abdominal pains and hypotension. Urgent abdominal imaging revealed herniation of the proximal transverse colon through a MH into the chest with evidence of perforation. The patient underwent laparoscopic urgent colonic resection and primary hernia repair and was discharged uneventfully 2 d later. CONCLUSION: A MH is a rare condition in adults that can present as a life-threatening complication of colonoscopy, even in patients with a history of uneventful colonoscopies. This case highlights the importance of considering congenital and internal hernias when faced with sudden and unexplained difficulties during colonoscopy. If there is a suspicion of MH, the endoscopist should halt the procedure and immediately obtain abdominal imaging to confirm the diagnosis.

Assessment, Resuscitation and Medical Management of Variceal and Nonvariceal Gastrointestinal Bleeding.

Upper gastrointestinal bleeding (UGIB) continues to be an important cause for emergency room visits and carries significant morbidity and mortality. Early resuscitative measures form the basis of the management of patients presenting with UGIB and can improve the outcomes of such patients including lowering mortality. In this review, using an evidence-based approach, we discuss the initial assessment and resuscitation of patients presenting with UGIB including identifying clues from history and physical examination to confirm UGIB, preendoscopic risk assessment tools, the role of early fluid resuscitation, utilization of blood products, use of pharmacologic interventions, and the optimal timing of endoscopy.

Primary and Specialty Care Trainees' Perceptions About Proton Pump Inhibitor Use.

OBJECTIVE: Proton pump inhibitors (PPIs) are widely prescribed with proven efficacy in many indications, yet longstanding controversy about potential adverse events persists. We aimed to acquire knowledge about perceptions of outpatient PPI long-term prescribing (≥8 wk) among primary and specialty care trainees at 2 Canadian Universities. METHODS: Family medicine, internal medicine, and gastroenterology trainees completed a web-based survey that included 20 clinical scenarios assessing trainee knowledge about PPI efficacy. Contextual PPI prescribing decisions were also elicited, balancing possible PPI indications versus side effects. Management strategies were compared between junior and senior trainees, as well as across training programs. RESULTS: Over a 4-month period,163 trainees (age <26 y: 12%; age 26 to 45: 88%; 59% females) participated in the survey (family medicine: 51%, internal medicine: 44%, and gastroenterology: 5%); 83% were considered junior residents. Only 42% had received formal education on prescribing PPI long-term. Overall, 93% believed they would benefit from such teaching, with 98% stating they would follow related guidelines. No between-group differences were noted in knowledge of appropriate PPI indications nor possible side effects when comparing juniors to seniors, or among different specialties. Across different management scenarios, inappropriate PPI discontinuation was chosen by 14.3% to 67.2%, whereas inappropriate PPI continuation was reported in up to 57%. Trainee seniority and specialty did not differ in appropriate deprescribing rates. CONCLUSIONS: Training level and primary versus specialty care settings are associated with frequent inappropriate PPI prescribing and deprescribing. These findings highlight the need for and may inform future educational programs on PPI usage.

Review article: Advances in the management of lower gastrointestinal bleeding.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. AIMS: To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. RESULTS: The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. CONCLUSIONS: The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Pre-Endoscopic Scores Predicting Low-Risk Patients with Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

BACKGROUND: Several risk scores have attempted to risk stratify patients with acute upper gastrointestinal bleeding (UGIB) who are at a lower risk of requiring hospital-based interventions or negative outcomes including death. This systematic review and meta-analysis aimed to compare predictive abilities of pre-endoscopic scores in prognosticating the absence of adverse events in patients with UGIB. METHODS: We searched MEDLINE, EMBASE, Central, and ISI Web of knowledge from inception to February 2023. All fully published studies assessing a pre-endoscopic score in patients with UGIB were included. The primary outcome was a composite score for the need of a hospital-based intervention (endoscopic therapy, surgery, angiography, or blood transfusion). Secondary outcomes included: mortality, rebleeding, or the individual endpoints of the composite outcome. Both proportional and comparative analyses were performed. RESULTS: Thirty-eight studies were included from 2153 citations, (n = 36,215 patients). Few patients with a low Glasgow-Blatchford score (GBS) cutoff (0, ≤1 and ≤2) required hospital-based interventions (0.02 (0.01, 0.05), 0.04 (0.02, 0.09) and 0.03 (0.02, 0.07), respectively). The proportions of patients with clinical Rockall (CRS = 0) and ABC (≤3) scores requiring hospital-based intervention were 0.19 (0.15, 0.24) and 0.69 (0.62, 0.75), respectively. GBS (cutoffs 0, ≤1 and ≤2), CRS (cutoffs 0, ≤1 and ≤2), AIMS65 (cutoffs 0 and ≤1) and ABC (cutoffs ≤1 and ≤3) scores all were associated with few patients (0.01-0.04) dying. The proportion of patients suffering other secondary outcomes varied between scoring systems but, in general, was lowest for the GBS. GBS (using cutoffs 0, ≤1 and ≤2) showed excellent discriminative ability in predicting the need for hospital-based interventions (OR 0.02, (0.00, 0.16), 0.00 (0.00, 0.02) and 0.01 (0.00, 0.01), respectively). A CRS cutoff of 0 was less discriminative. For the other secondary outcomes, discriminative abilities varied between scores but, in general, the GBS (using cutoffs up to 2) was clinically useful for most outcomes. CONCLUSIONS: A GBS cut-off of one or less prognosticated low-risk patients the best. Expanding the GBS cut-off to 2 maintains prognostic accuracy while allowing more patients to be managed safely as outpatients. The evidence is limited by the number, homogeneity, quality, and generalizability of available data and subjectivity of deciding on clinical impact. Additional, comparative and, ideally, interventional studies are needed.

The impact of nonalcoholic fatty liver disease on inflammatory bowel disease-related hospitalization outcomes: a systematic review.

Evidence suggests that patients with inflammatory bowel disease are at higher risk of developing nonalcoholic fatty liver disease (NAFLD). However, there is limited information currently available on how NAFLD may affect the clinical course of IBD. Thus, we conducted a systematic review to evaluate the impact of NAFLD on IBD-related hospitalization outcomes. All observational studies assessing IBD-related hospitalization outcomes in patients with NAFLD were included. Exclusion criteria were studies published in languages other than English or French, or those involving pediatric population. Outcomes included IBD-related hospitalization and readmission rates, need for surgery, length of stay, inpatient mortality, and costs. Overall, 3252 citations were retrieved and seven studies met the inclusion criteria (1 574 937 patients); all were observational, of high quality, and originated in the United States. Measurable outcomes reported in these studies were few and with insufficient similarity across studies to complete a quantitative assessment. Only one study reports NAFLD severity. Two studies suggested a higher rate of hospitalization for patients with both NAFLD and IBD compared to IBD alone (incidence rate ratio of 1.54; 95% confidence interval: 1.33-1.79). This is the first systematic review to date that evaluates any possible association of NAFLD with IBD-related hospitalization outcomes. Despite the paucity and low quality of available data, our findings indicate that NAFLD may be associated with worse outcomes amongst IBD patients (especially Crohn's disease). Further and higher certainty of evidence is needed for better characterization of such clinical impact.

Strengths and limitations of risk stratification tools for patients with upper gastrointestinal bleeding: a narrative review.

INTRODUCTION: Despite advances in the management of patients with upper gastrointestinal bleeding (UGIB), associated morbidity and mortality remain significant. Most patients, however, will experience favorable outcomes without a need for hospital-based interventions. Risk assessment scores may assist in such early risk-stratification. These scales may optimize identification of low-risk patients, resulting in better resource utilization, including a reduced need for early endoscopy and fewer hospital admissions. The aim of this article is to provide an updated detailed review of risk assessment scores in UGIB. AREA COVERED: A literature review identified past and currently available pre-endoscopic risk assessment scores for UGIB, with a focus on low-risk prediction. Strengths and weaknesses of the different scales are discussed as well as their impact on clinical decision-making. EXPERT OPINION: The current evidence supports using the Glasgow Blatchford Score as it is the most accurate tool available when attempting to identify low-risk patients who can be safely managed on an outpatient basis. Currently, no risk assessment tool appears accurate enough in confidently classifying patients as high risk. Future research should utilize more standardized methodologies, while favoring interventional trial designs to better characterize the clinical impact attributable to the use of such risk stratification schemes.

Cost-effectiveness of Artificial Intelligence-Aided Colonoscopy for Adenoma Detection in Colon Cancer Screening.

Background and Aims: Artificial intelligence-aided colonoscopy significantly improves adenoma detection. We assessed the cost-effectiveness of the GI Genius technology, an artificial intelligence-aided computer diagnosis for polyp detection (CADe), in improving colorectal cancer outcomes, adopting a Canadian health care perspective. Methods: A Markov model with 1-year cycles and a lifetime horizon was used to estimate incremental cost-effectiveness ratio comparing CADe to conventional colonoscopy polyp detection amongst patients with a positive faecal immunochemical test. Outcomes were life years (LYs) and quality-adjusted life years (QALY) gained. The analysis applied costs associated with health care resource utilization, including procedures and follow-ups, from a provincial payer's perspective using 2022 Canadian dollars. Effectiveness and cost data were sourced from the literature and publicly available databases. Extensive probabilistic and deterministic sensitivity analyses were performed, assessing model robustness. Results: Life years and QALY gains for the CADe and conventional colonoscopy groups were 19.144 versus 19.125 and 17.137 versus 17.113, respectively. CADe and conventional colonoscopies' overall per-case costs were $2990.74 and $3004.59, respectively. With a willingness-to-pay pre-set at $50,000/QALY, the incremental cost-effectiveness ratio was dominant for both outcomes, showing that CADe colonoscopy is cost-effective. Deterministic sensitivity analysis confirmed that the model was sensitive to the incidence risk ratio of adenoma per colonoscopy for large adenomas. Probabilistic sensitivity analysis showed that the CADe strategy was cost-effective in up to 73.4% of scenarios. Conclusion: The addition of CADe solution to colonoscopy is a dominant, cost-effective strategy when used in faecal immunochemical test-positive patients in a Canadian health care setting.

Mandatory vs. optional split-dose bowel preparation for morning colonoscopies: a pragmatic noninferiority randomized controlled trial.

BACKGROUND : We compared the effectiveness of optional split-dose bowel preparation (SDBP) with mandatory SDBP for morning colonoscopies in usual clinical practice. METHODS : Adult patients undergoing outpatient early morning (8:00 AM-10:30 PM) and late morning (10:30 AM-12:00 PM) colonoscopies were included. Written bowel preparation instructions were provided based on randomization: one group were instructed to take their bowel preparation (4 L polyethylene glycol solution) as a split dose (mandatory), while the comparator group was allowed the choice of SDBP or single-dose bowel preparation administered entirely on the day before (optional). The primary end point, using noninferiority hypothesis testing with a 5 % margin, was adequate bowel cleanliness measured by the Boston Bowel Preparation Scale (BBPS) and defined by a BBPS score ≥ 6. RESULTS : Among 770 randomized patients with complete data, there were 267 mandatory SDBP and 265 optional SDBP patients for early morning colonoscopies, and 120 mandatory SDBP and 118 optional SDBP patients for late morning colonoscopies. Optional SDBP was inferior to mandatory SDBP, with a lower proportion of adequate BBPS cleanliness for early morning colonoscopies (78.9 % vs. 89.9 %; absolute risk difference [aRD] 11.0 %, 95 %CI 5.9 % to 16.1 %), but was not statistically different for late morning colonoscopies (76.3 % vs. 83.3 %; aRD 7.1 %, 95 %CI -1.5 % to 15.5 %). CONCLUSIONS : Optional SDBP is inferior to mandatory SDBP in providing adequate bowel preparation quality for early morning colonoscopies (8:00 AM-10:30 AM), and probably inferior for late morning colonoscopies (10:30 AM-12:00 PM).

Comparative Evaluation of the ABC Score to Other Risk Stratification Scales in Managing High-risk Patients Presenting With Acute Upper Gastrointestinal Bleeding.

OBJECTIVE: The ABC risk score identifies patients at high risk of mortality in acute lower and upper gastrointestinal bleeding (UGIB). We aimed to externally validate the ABC score while comparing it to other prognostication scales when assessing UGIB patients at high risk of negative outcomes before endoscopy. METHODS: UGIB patients from a national Canadian registry (REASON) were studied, with mortality prediction as a primary outcome. Secondary endpoints included prognostication of rebleeding, intensive care unit (ICU) admission, ICU and hospitalization lengths of stay (LOS), and a previously proposed composite outcome measure. Univariable and areas under the receiver operating characteristic curve analyses compared discriminatory abilities of the ABC score to the AIMS65, Glasgow Blatchford Scale (GBS), and clinical Rockall score. RESULTS: The REASON registry included 2020 patients [89.4% nonvariceal; mean age (±SD): 66.3±16.4 y; 38.4% female]. Overall mortality, rebleeding, ICU admission, transfusion and composite score rates were 9.9%, 11.4%, 21.1%, 69.0%, and 67.3%, respectively. ICU and hospitalization LOS were 5.4±9.3 and 9.1±11.5 days, respectively. The ABC score displayed superior 30-day mortality prediction [0.78 (0.73; 0.83)] compared with GBS [0.69 (0.63; 0.75)] or clinical Rockall [0.64 (0.58; 0.70)] but not AIMS65 [0.73 (0.67; 0.79)]. Although most scales significantly prognosticated secondary outcomes in the univariable analysis except for ICU LOS, discriminatory abilities on areas under the receiver operating characteristic curve analyses were poor. CONCLUSIONS: ABC and AIMS65 display similar good prediction of mortality. Clinical usefulness in prognosticating secondary outcomes was modest for all scales, limiting their adoptions when informing early management of high-risk UGIB patients.

Topical hemostatic agents in the management of upper gastrointestinal bleeding: a meta-analysis.

Background and study aims Novel topical hemostatic agents have shown promising results in treating patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, data are limited even in published meta-analyses as to their role, especially compared to conventional endoscopic approaches. The aim of this study was to perform a highly comprehensive systematic review assessing the effectiveness of topical hemostatic agents in UGIB in different clinical settings. Methods We performed a literature search of OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases through September 2021. Studies assessing the efficacy of topical hemostatic agents in UGIB were included. Main outcomes were immediate hemostasis and overall rebleeding. Results A total of 980 citations were identified and 59 studies with a total of 3,417 patients were included in the analysis. Immediate hemostasis was achieved in 93 % (91 %; 94 %), with similar results according to etiology (NVUGIB vs. variceal), topical agent used, or treatment strategy (primary vs. rescue). The overall rebleeding rate was 18 % (15%; 21 %) with the majority of rebleeds occurring in the first 7 days. Among comparative studies, topical agents achieved immediate hemostasis more often than standard endoscopic modalities (OR 3.94 [1.73; 8.96), with non-different overall rebleeding odds (OR 1.06 [0.65; 1.74]). Adverse events occurred in 2 % (1 %; 3 %). Study quality was overall low to very low. Conclusions Topical hemostatic agents are effective and safe in the management of UGIB with favorable outcomes when compared to conventional endoscopic modalities across a variety of bleeding etiologies. This is especially true in novel subgroup analyses that assessed immediate hemostasis and rebleeding among RCTs and in malignant bleeding. Due to methodological limitations of available data, additional studies are needed to ascertain their effectiveness more confidently in the management of patients with UGIB.

An update on the management of non-variceal upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) continues to be a common gastrointestinal emergency that carries significant morbidity and mortality. The epidemiology of UGIB has been changing over the last few decades with an overall decrease in peptic ulcer disease and increase in the prevalence of other etiologies including vascular lesions and malignancy. Appropriate risk assessment and patient stratification are crucial to ensuring that optimal care is delivered to patients and some risk assessment tools have shown excellent ability to define a low-risk group who can be managed as outpatients safely. Regardless of the etiology of UGIB, resuscitative interventions by primary care providers remain the most important initial measures to improve the outcome for patients including hemodynamic stabilization, an appropriate blood transfusion strategy, with or without acid-lowering agents, while also providing subsequent urgent endoscopic assessment and intervention. In addition, with increasing use of antithrombotic agents in clinical practice and its associated risk of bleeding, the management of such agents in the acute setting has become a real challenge to all physicians. In this article, we provide an up-to-date, evidence-based, practical review of recent changes and advances in UGIB with a focus on non-variceal etiologies.