Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia.

BACKGROUND: Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex. Some of these symptoms might arise from serious underlying diseases, so the promotion of evidence-based guidelines could potentially better align evaluation and treatment. AIM: To determine the value of alarm features as a predictive factor for significant endoscopic findings (SEFs) among hospitalized patients presenting with dyspepsia. METHODS: We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients. Patients were divided into two groups, with and without SEFs, and compared to elucidate the ability of the different alarm features to predict SEFs. RESULTS: During the study, 605 patients fulfilled the inclusion criteria. When the demographics and clinical characteristics of the two groups were compared, tachycardia (P < 0.05), normocytic anemia, (P < 0.05), leukocytosis (P < 0.05), and hypoalbuminemia (P < 0.05) documented on admission prior to endoscopy were strong predictors of SEFs. Among the alarm features, upper gastrointestinal bleeding, persistent vomiting, odynophagia [odds ratio (OR) = 3.81, P < 0.05; OR = 1.75, P = 0.03; and OR = 7.81, P = 0.07, respectively] were associated with SEFs. Unexplained weight loss was strongly associated with malignancy as an endoscopic finding (OR = 2.05; P < 0.05). In addition, long-term use of anti-aggregate medications other than aspirin (P < 0.05) was correlated to SEFs. CONCLUSION: Novel predictors of SEFs were elucidated in this study. These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia.

Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Motorized spiral enteroscopy (MSE) is the latest advance in device-assisted enteroscopy. Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial. Following the real-life application of MSE, an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market, despite encouraging results in terms of diagnostic and therapeutic yield. We conducted an Italian multicenter real-life prospective study, which was prematurely terminated after the withdrawal of MSE from the market. The primary goals were the evaluation of MSE performance (both diagnostic and therapeutic) and its safety in routine endoscopic practice, particularly in the early phase of introduction in the endoscopic unit. A subanalysis, which involved patients who underwent MSE after unsuccessful balloon enteroscopy, demonstrated, for the first time, the promising performance of MSE as a rescue procedure. Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy, it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.

Cytomegalovirus Ileitis in a Patient With Post-severe Trauma: A Case Report.

BACKGROUND/AIM: The mortality rate for alimentary tract hemorrhage remains high due to a variety of contributing factors. In this report, we present a case of post-severe trauma patient with life-threatening gastrointestinal bleeding caused by cytomegalovirus (CMV)-induced damage to the terminal ileum. CASE REPORT: A 76-year-old female with a history of hypertension and gastrointestinal bleeding developed CMV ileitis post-severe trauma. Despite negative CMV IgM antibodies, PCR testing confirmed CMV infection in the biopsy tissue. Histopathological examination revealed viral inclusion bodies, with immunohistochemistry confirming CMV presence. RESULTS: Intravenous ganciclovir effectively managed symptoms and halted bleeding. CMV ileitis, typically seen in immunocompromised states, may occur sporadically in immunocompetent individuals, including post-orthopedic surgery patients. The exact mechanism remains unclear, possibly related to surgical stress. Diagnosis relies on histopathology and immunohistochemistry. CONCLUSION: Early recognition and treatment are vital for optimal outcomes, emphasizing the need for awareness among orthopedic surgeons regarding CMV as a potential cause of postoperative complications.

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes.

BACKGROUND: Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. METHODS: This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. RESULTS: Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). CONCLUSIONS: Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Endoscopic Characteristics of Small-Bowel Gastrointestinal Stromal Tumors Detected During Single-Balloon Enteroscopy: A Retrospective Analysis.

BACKGROUND/AIMS:  The endoscopic features of small-bowel gastrointestinal stromal tumors (GISTs) are not well defined. The objective of this study was to describe the endoscopic features of GISTs of the small intestine detected via single-balloon enteroscopy (SBE). MATERIALS AND METHODS:  Patients with surgically confirmed small intestinal GISTs from January 2014 to September 2022 were retrospectively analyzed. The hospital's electronic medical record system was used to retrieve the patients' data, including their demographics, clinical symptoms, hemoglobin on admission, endoscopic and computerized tomography findings, clinicopathological findings, and surgical management data. RESULTS:  In total, 46 GIST patients (23 men and 23 women) with overt bleeding were included, with a mean age of 52 years (23-80 years). The typical duration of the symptoms was 48 hours. Four patients (8.70%) had lesions in the duodenum, 32 (69.56%) had lesions in the jejunum, 8 (17.39%) had lesions in the ileum, and 2 (4.35%) had lesions around the junction of the jejunum and ileum. Out of the 46 patients, 27 underwent SBE, and GISTs were visualized in 25, while the lesions could not be visualized in the remaining 2. Submucosal round (n = 13), submucosal sessile (n = 8), and invasive/penetrating (n = 4) were among the endoscopic tumor features. Twenty patients exhibited submucosal protuberant lesions, with ulceration, vascular nodules/congestion, or erosion on the surface, and 5 patients presented ulcerative infiltrative lesions. The multiple logistic regression analysis indicated that the invasive/penetrating characteristics of GISTs under SBE evaluation are significantly correlated with the risk level of GIST malignancy (P < .05). CONCLUSION:  A variety of endoscopic characteristics could be observed during the preoperative SBE evaluation of small-intestine GISTs.

Unusual Cause of Gastrointestinal Bleeding in an Elderly Adult: Gastric Kissing Ulcers.

Cite this article as: Yüksekyayla O, Batibay E, Efe C. Unusual cause of gastrointestinal bleeding in an elderly adult: Gastric kissing ulcers. Turk J Gastroenterol. 2024;35(5):421-422.

The impact of restrictive blood transfusion on the safety of patients with esophageal varices after endoscopic variceal ligation: A single-center retrospective study.

An investigation was conducted to examine the impact of restrictive blood transfusion on the safety of early rebleeding following endoscopic variceal ligation (EVL) in patients with liver cirrhosis. Data were collected from patients with cirrhosis and esophageal varices who underwent EVL at the Affiliated Hospital of North Sichuan Medical College between September 2021 and March 2023. Clinical information, including serum albumin levels, hemoglobin (Hb) levels, liver function classification, and the occurrence of early rebleeding, was recorded. Patients were divided into 2 groups based on their Hb levels: 60 g/L to 90 g/L (restrictive blood transfusion) or Hb ≥ 90 g/L after EVL. The impact of restrictive transfusion on the post-ligation safety of EVL was observed. A total of 246 cirrhotic patients were included in the analysis. Significant differences were found in Hb levels, liver function classification, early rebleeding rates, length of hospital stay, and hospitalization expenses between the restrictive transfusion and Hb ≥ 90 g/L groups. The early rebleeding rate was significantly varied between the groups with different Hb levels after EVL. Multivariate logistic analysis revealed that restrictive blood transfusion (OR = 4.61, 95% CI: 1.06-19.99; P = .041), Hb (OR = 0.96, 95% CI: 0.95-0.97; P < .001), and Child-Pugh class C (OR = 6.37, 95% CI: 1.28-31.67; P = .024) were identified as independent factors influencing early rebleeding. Our findings suggest that the risk of early rebleeding in cirrhotic patients after EVL may be increased by restrictive blood transfusion, and this should be further investigated in future research.

Polypoid heterotopic gastric mucosa: in terminal ileum causing extensive lower gastrointestinal bleeding without Meckel's diverticulum: a case report.

BACKGROUND: Heterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointestinal bleeding, and even peritonitis, leading to death. CASE PRESENTATION: This case report focuses on a 12-year-old Middle Eastern boy who presented with hematochezia and abdominal pain for a couple of days. A tagged Red blood cell (RBC) scan and Technetium scan revealed gastrointestinal bleeding at the lower abdomen, highly suggestive of the diagnosis of Meckel's diverticulum. Subsequently, exploratory laparotomy revealed contiguous and scattered mucosal lesions with multiple polyps of various sizes in the terminal ileum. Meckel's diverticulum was absent, and the patient was treated with resection and primary anastomosis. The resected tissue revealed extensive ectopic gastric mucosa and polypoid tissues. The patient recovered uneventfully and was discharged four days after the surgery. The symptoms did not recur within six months after his surgery. CONCLUSION: Our case demonstrated that despite the rarity of multiple polypoid gastric heterotopias in the terminal ileum, it should be considered as one of the differential diagnoses of gastrointestinal tract bleeding.

Risk factors for gastrointestinal bleeding in patients with intracerebral hemorrhage: A propensity score matching analysis.

BACKGROUND: Gastrointestinal bleeding (GIB) is a common complication of intracerebral hemorrhage (ICH). Rate pressure product (RPP) is an objective hemodynamic index that is closely related to the prognosis of cardia-cerebrovascular disease. The purpose of this study was to investigate the relationship between RPP and GIB in ICH patients. METHODS: We retrospectively analyzed data from ICH patients admitted to the neurosurgery department of Nanchang University affiliated with Ganzhou Hospital from January 2019 to December 2021. The patients were divided into a GIB group and a non-GIB group according to whether they had GIB. Propensity score matching was used to match between the two groups. Univariate analysis was used to select factors affecting GIB, and multivariate conditional logistic regression was used to analyze the independent factors associated with GIB. RESULTS: There were 1232 patients included in the study, including 182 in the GIB group and 1050 in the non-GIB group, and 182 pairs of patients were successfully matched through propensity score matching. The univariate analysis showed that high RPP, low Glasgow coma score (GCS), fibrinogen, D-dimer and PPIs were factors associated with GIB. Multivariate conditional logistic regression showed that high RPP, low GCS and urokinase were independent risk factors for GIB, and PPIs was a protective factor for GIB. CONCLUSIONS: High RPP, low GCS and urokinase were independent risk factors for GIB, and PPIs was a protective factor for GIB. Patients with a high risk of developing GIB should be monitored closely. Nevertheless, multicenter prospective studies with more patients are needed to further validate the results.

Pediatric gastrointestinal bleeding: identification and management in the emergency department.

Pediatric gastrointestinal (GI) bleeding ranges from mild and self-limited cases to severe episodes of hemorrhagic shock. A structured, age-specific approach is essential for the correct diagnostic workup and effective management. Collaboration with a multidisciplinary team, including pediatric surgery and gastroenterology specialists, may be necessary. The goal of managing pediatric patients with GI bleeding in the emergency department is to identify and treat severe cases, while avoiding unnecessary workup and admission for patients with mild or self-resolving cases. This issue provides a comprehensive review of the definitions, causes, and management strategies for upper and lower GI bleeding in children. It also highlights existing knowledge gaps and future research directions.

Clinical characteristics and management of patient with portal hypertension at tertial level hospital in Tanzania.

BACKGROUND: Portal hypertension is a common diagnosis in Sub-Saharan African countries, with the majority of patients presenting late. This study aimed to understand Clinical characteristics, aetiology, the treatment offered in our setting, and factors associated with portal hypertension at a tertiary-level hospital, in Tanzania. METHODOLOGY: A prospective cross-sectional observational single hospital-based study was conducted at MNH, from May 2021 to April 2022. A minimum of 152 subjects were required with an error of less than 5% and a study power of 80% at a 95% confidence interval. A structured questionnaire was used to collect data. Ethical clearance was obtained from the MUHAS/MNH IRB. RESULTS: A total of 154 eligible participants consented and participated in this study. The mean age of participants was 42 ± 15.8 years (range 2-87). Most of the study participants were males 64.9% with a male-to-female (M: F) ratio of 1.8:1. Vomiting blood was the common symptom among the study participants 51.3%. Schistosomiasis 53.9% and viral infection 26.6% were the common etiologies followed by alcohol abuse 7.8%. Most were medically treated at 89.61% followed by radiological treatment at 8.44% while only 1.95% of patients received surgical treatment. There was a significant association between the grade of oesophagal varices and bleeding consequences (p-value < 0.01). CONCLUSION: The majority of patients were medically treated while patients who require surgical care are unable to assess it. We recommend the establishment of a transplant services program to counteract the unmet need and more retrospective research toward policy establishment.

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management.

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.