Safety and efficacy of thalidomide in treatment of gastrointestinal bleeding secondary to angioectasias: a systematic review and meta-analysis.

BACKGROUND: Thalidomide has been used for angioectasia-associated refractory gastrointestinal bleeding (GIB), with studies showing variable efficacy and side effects profile. We conducted a meta-analysis to reconcile the data. METHODS: Online databases were searched for studies evaluating thalidomide in patients with refractory/recurrent GIB due to angioectasias. The outcomes of interest were cessation of bleeding, rebleeding, need for blood transfusion, hospitalization and adverse events. Pooled proportions for incidence, and odds ratios (OR) for comparison with control were calculated along with 95% confidence interval (CI). RESULTS: A total of seven studies with 346 patients (n = 269 thalidomide, n = 77 control) were included. Thalidomide dose was usually started at 50-100mg/day. The mean age was 65 years, 45% patients were men, and mean follow-up was 1.8 years. The pooled clinical outcomes with thalidomide were: cessation of bleeding 42.2% (95% CI 36.02 to 48.41), rebleeding 30%, need for blood transfusion 20.1%, hospitalization 40% and adverse events 55.9%. When compared with the control group in 2 studies, patients on thalidomide had significantly higher odds of cessation of bleeding (OR 21.40, 95% CI 5.78 to 79.29, p < 0.00001) and adverse events, with lower need for blood transfusion and hospitalization. DISCUSSION: In patients with angioectasias-related refractory/recurrent GIB, the use of thalidomide results in significantly decreased bleeding risk and may play a role in the management of such patients.

Deep Learning and Device-Assisted Enteroscopy: Automatic Detection of Gastrointestinal Angioectasia.

Background and Objectives: Device-assisted enteroscopy (DAE) allows deep exploration of the small bowel and combines diagnostic and therapeutic capacities. Suspected mid-gastrointestinal bleeding is the most frequent indication for DAE, and vascular lesions, particularly angioectasia, are the most common etiology. Nevertheless, the diagnostic yield of DAE for the detection of these lesions is suboptimal. Deep learning algorithms have shown great potential for automatic detection of lesions in endoscopy. We aimed to develop an artificial intelligence (AI) model for the automatic detection of angioectasia DAE images. Materials and Methods: A convolutional neural network (CNN) was developed using DAE images. Each frame was labeled as normal/mucosa or angioectasia. The image dataset was split for the constitution of training and validation datasets. The latter was used for assessing the performance of the CNN. Results: A total of 72 DAE exams were included, and 6740 images were extracted (5345 of normal mucosa and 1395 of angioectasia). The model had a sensitivity of 88.5%, a specificity of 97.1% and an AUC of 0.988. The image processing speed was 6.4 ms/frame. Conclusions: The application of AI to DAE may have a significant impact on the management of patients with suspected mid-gastrointestinal bleeding.

Contribution of Capsule Endoscopy Early in a Bleeding Episode to Treatment of Small Bowel Angioectasia: A Case Report.

Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy's lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.

Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study.

BACKGROUND: Small bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding. METHODS: We retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital. RESULTS: Of the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18-84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases). CONCLUSIONS: Contrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.

Artificial intelligence using a convolutional neural network for automatic detection of small-bowel angioectasia in capsule endoscopy images.

BACKGROUND AND AIM: Although small-bowel angioectasia is reported as the most common cause of bleeding in patients and frequently diagnosed by capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding, a computer-aided detection method has not been established. We developed an artificial intelligence system with deep learning that can automatically detect small-bowel angioectasia in CE images. METHODS: We trained a deep convolutional neural network (CNN) system based on Single Shot Multibox Detector using 2237 CE images of angioectasia. We assessed its diagnostic accuracy by calculating the area under the receiver operating characteristic curve (ROC-AUC), sensitivity, specificity, positive predictive value, and negative predictive value using an independent test set of 10 488 small-bowel images, including 488 images of small-bowel angioectasia. RESULTS: The AUC to detect angioectasia was 0.998. Sensitivity, specificity, positive predictive value, and negative predictive value of CNN were 98.8%, 98.4%, 75.4%, and 99.9%, respectively, at a cut-off value of 0.36 for the probability score. CONCLUSIONS: We developed and validated a new system based on CNN to automatically detect angioectasia in CE images. This may be well applicable to daily clinical practice to reduce the burden of physicians as well as to reduce oversight.

Clinical Impact of Small Bowel Capsule Endoscopy in Obscure Gastrointestinal Bleeding.

Background and objectives: The most frequent indications for small bowel capsule endoscopy (SBCE) are obscure gastrointestinal bleeding (OGIB) and iron deficiency anemia (IDA). The aim of this study was to evaluate the diagnostic yield (DY) of SBCE in overt and occult OGIB, as well as its impact on the clinical outcome. Materials and Methods: This study retrospectively included all cases of OGIB investigated by SBCE in a tertiary care referral center, between 1st January 2016 and 31st December 2018. OGIB was defined by overt or occult gastrointestinal bleeding, with negative upper and lower endoscopy. Occult gastrointestinal bleeding was either proved by a fecal test or presumptively incriminated as a cause for IDA. DY was defined as the detection rate for what were thought to be clinically significant findings. DYs for overt and occult bleeding were assessed and compared. Gender, age, hemoglobin levels, NSAID consumption and the use of anticoagulants were recorded. Following SBCE results, individual therapeutic decisions were made, and follow-up data were recorded. Results: 224 SBCE examinations were performed for OGIB, of which 148 were for overt OGIB, and 76 for unexplained IDA. Positive findings were found in 139 patients, resulting in an overall DY for OGIB of 62%, higher in overt OGIB (75%) compared to IDA (37%). The most frequent findings were small bowel angioectasias (62.2% in overt OGIB and 78.5% in IDA). On multivariate logistic regression analysis, only hemoglobin level <10 g/dL and anticoagulants were the variables independently associated with positive findings. All patients received medical, endoscopic or surgical treatment and had good clinical outcome during follow-up. Conclusion: SBCE has a high diagnostic yield and a positive impact on management of patients with OGIB.

Analysis of small bowel angioectasia in asymptomatic individuals depending on patients' age and gender.

Objectives: Small bowel angioectasia (SBA) plays an important role in the etiologies of obscure gastrointestinal haemorrhage. But the exact prevalence of the disease is unknown, especially in asymptomatic populations. Therefore, we aimed to evaluate the prevalence of asymptomatic angioectasia in the small bowel (SB) with magnetically controlled capsule gastroscopy (MCCG).Methods: We retrospectively collected a multicentre clinical data of 508 asymptomatic patients who underwent MCCG from June 2018 to May 2019. Bowel cleanliness was rated as four grades according to the criteria, and the excellent or good preparation was classified as the adequate group. The detection rates of small bowel lesions were analysed according to the ages, genders and bowel preparations.Results: A total of 508 individuals have completed the examination. There were 316 men and 192 women with an average age of 44.5 years old. The prevalence of SBA was 11.8% (95% CI: 9.0-14.6%). 70.0% of them were over 40 years old and 73.3% were male although there was no obvious disparity found in age and gender for the SBA. Most findings were located in the proximal small bowel (jejunum). The incidence of small bowel lesions was not related to bowel preparations (p > .05).Conclusions: SBA is not uncommon in asymptomatic individuals. Age and gender may be risk factors for bleeding of angioectasia in the small bowel, but they seem to have little to do with the occurrence of it. MCCG showed no difference in ages, genders or bowel preparations of small bowel lesions among our study population.

Mapping the distribution of small bowel angioectasias.

Background: Angioectasias are a prominent cause of small bowel (SB) bleeding frequently identified during capsule endoscopy (CE). Subsequent management depends upon grade/severity and location. There is increasing evidence that the location of SB angioectasias is not random. We aimed to map the distribution of SB angioectasias, and assess whether this impacted clinical outcomes. Materials and methods: Retrospective study examining CEs performed over a 10-year period at a tertiary referral centre. Information regarding number, location, and Saurin classification (P0-2) of SB angioectasias was collected. Clinically significant angioectasias (P1/P2) and active SB bleeding were analysed further. Outcomes of patients with P2 angioectasias or active SB bleeding were recorded. Results: 164 SBCE examinations reported angioectasias. 554 P1-2 angioectasias and active bleeds were seen, 435 (78.52%) within the first tertile of SB transit time (SBTT). 277 (50%) angioectasias were identified within the first 10% of SBTT. 40/75 (53.3%) patients with >1 P2 angioectasia and/or active bleed were referred for intervention. Of initial interventions, 24 patients underwent upper GI endoscopy; 13 underwent double balloon enteroscopy (DBE). 9/37(24.3%) had no identifiable angioectasias on endoscopy. Of those receiving ablative therapy, 20/28 (71.4%) re-presented with iron-deficiency anaemia or bleeding. In this group, average angioectasia position was 15.6% of SBTT, compared with 7.9% in those who did not re-represent (p = 0.344). Patients who re-presented had an average 1.6 additional P1 angioectasias, compared with 7.6 amongst those who did not return (p = 0.017). Conclusions: Clinically significant angioectasias are overwhelmingly located within the proximal SB. The majority are within reach of conventional endoscopy. However, AEs are often multiple and many patients re-present following intervention.

Repeat capsule endoscopy in suspected gastrointestinal bleeding.

Objectives: This study aims to review the utility of repeat capsule endoscopy (CE) with on-going concern of small bowel (SB) bleeding following initial SB investigation with CE. Materials and methods: A specifically designed database of CE examinations performed over 13 years, with hospital records, was retrospectively interrogated for patients undergoing multiple CEs to investigate iron deficiency anaemia (IDA) or suspected SB bleeding. Results: 1335/2276 (58.7%) of CEs were performed to investigate IDA or SB bleeding; 92 were repeat CEs carried out for ongoing clinical concern. The median time interval between initial and repeat CE procedures was 466.5 (range 1-3066) days. Twenty-four patients had initially normal CE; on repeat examination, abnormalities were detected in 11/24 (45.8%). 3/21 (14.2%) of patients with angioectasia on first CE had alternative causes for IDA or GI bleeding detected on repeat CE. Six patients with active bleeding, without an identifiable source on initial CE, undergoing repeat CE had a cause isolated in 5/6 (83.3%). Changing CE device did not affect diagnostic yield (DY) compared to repeat CE using the same device (27.5% to 26.8%). Conclusions: It is known that CE can miss clinically relevant and serious lesions. Our results suggest that patients with an initially negative or inconclusive CE frequently have a cause of SB bleeding detected on repeat CE. The DY of repeat CE is highest in those with bleeding on their initial CE (83.3%) and lower in those with initially normal examinations (45.8%) or when an alternative cause, such as angioectasia is seen (14.2%).

A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds.

BACKGROUND: Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease. AIMS: To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias. METHODS: We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size. RESULTS: Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3). CONCLUSIONS: This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.

Use of a Transparent Cap Increases the Diagnostic Yield in Antegrade Single-Balloon Enteroscopy for Obscure GI Bleed.

BACKGROUND AND AIMS: Single-balloon enteroscopy (SBE) is utilized in the evaluation of obscure gastrointestinal bleeding, but 40-50% of these patients experience continued GI blood loss, in part due to missed lesions. The utilization of a transparent cap attached to the end of the endoscope can improve mucosal visualization in other endoscopic applications, but has not yet been evaluated in SBE. The aim of this study was to evaluate the impact of a cap on the diagnostic yield of SBE. METHODS: Consecutive adult patients scheduled for anterograde SBE for the evaluation of obscure GI bleeding were screened for inclusion from 2014 to 2017. Patients were randomized to SBE with or without a transparent cap. The primary outcome was the proportion of enteroscopies in which a P2 lesion (high potential for bleeding) was identified. RESULTS: A total of 90 patients (65.7 ± 12.7 years old, 47.7% female) were analyzed. There were significantly more P2 arteriovenous malformations identified in the cap group (14.8% vs. 0%, p = 0.02). Additionally, the use of a cap was associated with a significantly greater depth of small bowel insertion (191.9 cm vs. 156.2 cm, p = 0.01). There was one perforation in the group without a cap, successfully treated with clip placement, and no adverse events in the cap group. CONCLUSIONS: The use of a transparent cap during SBE performed for the evaluation of obscure gastrointestinal bleeding may be an important, safe augmentation to standard SBE techniques.

Historical analysis of experience with small bowel capsule endoscopy in a spanish tertiary hospital. / Análisis histórico de la experiencia en cápsula endoscópica de intestino delgado en un hospital terciario español.

INTRODUCTION: Capsule endoscopy was approved by the FDA in 2001. Gastrointestinal bleeding and inflammatory bowel disease are the main indications. It has been available in our hospital since 2004. METHODS: We retrospectively analysed data from patients who underwent small bowel capsule endoscopy in our hospital from October 2004 to April 2015. Indications were divided into: Obscure gastrointestinal bleeding (occult and overt), inflammatory bowel disease, and other indications. Findings were divided into: Vascular lesions, inflammatory lesions, other lesions, normal studies, and inconclusive studies. RESULTS: A total of 1027 out of 1291 small bowel studies were included. Mean patient age was 56.45 years; 471 were men and 556 women. The most common lesion observed was angiectasia, as an isolated finding or associated with other lesions. Findings were significant in up to 80% of studies when the indication was gastrointestinal bleeding, but in only 50% of studies in inflammatory bowel disease. Diagnostic yield was low in the group «other indications¼. No major complications were reported. DISCUSSION: Small bowel capsule endoscopy has high diagnostic yield in patients with gastrointestinal bleeding, but yield is lower in patients with inflammatory bowel disease. CONCLUSIONS: Our experience shows that capsule endoscopy is a safe and useful tool for the diagnosis of small bowel disease. The diagnostic yield of the technique in inflammatory bowel disease must be improved.

The Diagnostic Yield of Repeated Endoscopic Evaluation in Patients with Gastrointestinal Bleeding and Left Ventricular Assist Devices.

INTRODUCTION: Left ventricular assist devices (LVADs) are increasingly common in patients with advanced heart failure. GI bleeding (GIB) occurs in 20-30 % of these patients and can arise anywhere in the GI tract. Given the high rates of GIB in this population, our aim was to determine the diagnostic yield of repeated endoscopic evaluation in these patients. METHODS: We performed a retrospective review of all 257 patients who had LVADs placed between 2008 and 2013 at Duke University Hospital and identified all patients who underwent any endoscopic evaluation for GIB. RESULTS: Of the 257 patients with LVADs placed, 78 (30 %) underwent at least one endoscopy for GIB. A source was identified in 36 % of cases, most commonly angioectasias (53.6 %). Treatment was performed in 67.9 % of patients and hemostasis was achieved in all. 64.1 % of the cohort underwent a second endoscopy for GIB. 42.9 % of these exams revealed a bleeding source. Endoscopic treatment was employed in 76.2 %. 38.5 % of the cohort underwent a third endoscopic exam for bleeding and a source was identified in 53.3 % with angioectasias remaining most common (56.3 %). By Fisher's exact and Chi-square testing, only the presence of a bleeding source (p = 0.0034) and use of hemostatic therapy (p = 0.0127) on the index examination were significantly associated with re-bleeding. CONCLUSIONS: GIB is common in patients with LVADs. The diagnostic and therapeutic yield of endoscopy is remains high with repeated interventions. Despite these high yields, a large portion of the cohort requires repeated interventions for recurrent bleeding.

The Incidence, Predictors and Outcomes of Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device (LVAD).

OBJECTIVES: To evaluate rate, recurrence, and predictors of gastrointestinal bleeding (GIB) and impact of endoscopy in left ventricular assist device (LVAD) patients. METHODS: This is a cohort study of all patients who received the current-generation continuous-flow HeartMate II LVAD from 2005 to 2013 at our institution. Patients were followed up, and GIB events recorded until death, time of heart transplantation, or end of observation. RESULTS: LVAD was implanted in 112 patients (median age 67 years, 88% male). A total of 44 patients (39%) had 74 GIB events occurring at a rate of 42.9 per 100 p-y. Endoscopy was performed in 77% of patients, and GIB source was identified in 57% with upper GIB found in almost two-third of cases. Right ventricular dysfunction and post-LVAD ejection fraction >30% were associated with higher GIB rates. Higher pulsatility index was associated with lower GIB rates. Re-bleeding occurred in 19 (43%) patients at a rate of 62.5 per 100 p-y and was not affected by endoscopic therapy at the index endoscopy. CONCLUSIONS: GIB in LVAD patients is common, occurring primarily in the upper GI tract. Upper endoscopy is the preferred strategy though lower endoscopy is also recommended for a full workup. Endoscopy can identify GIB lesions in about 50% of patients, but re-bleeding is common. Right ventricular dysfunction and post-LVAD ejection fraction >30% are associated with higher GIB rates. Higher pulsatility index is associated with lower GIB rates. Reduction in pump speed is a potential strategy for managing and preventing GIB.

Efficacy of video capsule endoscopy with flexible spectral imaging color enhancement at setting 3 for differential diagnosis of red spots in the small bowel.

BACKGROUND: Red spots on the small bowel mucosa are observed in patients with angioectasia and enteritis. The present study investigated the effectiveness of capsule endoscopy (CE)-flexible spectral imaging color enhancement (FICE) as a method for differential diagnosis of the two conditions. PATIENTS AND METHODS: The subjects were 30 patients who underwent CE and double-balloon endoscopy at Dokkyo Medical University Hospital between February 2007 and January 2013. Of these 30 patients, those diagnosed with angioectasia were assigned to Group A (n = 13) and those diagnosed with enteritis were assigned to Group E (n = 17). RESULTS: Using FICE at setting 3 and comparing the color intensity of the red spots on a four-step scale (0-3), no statistically significant (P = 0.712) difference was found between the twogroups (Group A: 2.69 ± 0.48, Group E: 2.76 ± 0.56). Subjects were considered to show a positive blue sign when areas of blue were observed against the yellow-green background and surrounding the red spots. A comparison of the ratio of positive blue sign for both groups (Group A: 15.4% ± 37.6%, Group E: 94.1% ± 24.2%) showed a statistically significant increase in the ratio in Group E (P < 0.001). CONCLUSION: The results of the present study suggest that blue sign may be effective in the differential diagnosis of angioectasia and enteritis in patients with red spots.

Nationwide cohort study identifies clinical outcomes of angioectasia in patients with acute hematochezia.

BACKGROUND: While angioectasia is an important cause of acute hematochezia, relevant clinical features remain unclear. This study aims to reveal risk factors, clinical outcomes, and the effectiveness of therapeutic endoscopy for patients with acute hematochezia due to angioectasia. METHODS: This retrospective cohort study was conducted at 49 Japanese hospitals between January 2010 and December 2019, enrolling patients hospitalized for acute hematochezia (CODE BLUE-J study). Baseline factors and clinical outcomes for angioectasia were analyzed. RESULTS: Among 10,342 patients with acute hematochezia, 129 patients (1.2%) were diagnosed with angioectasia by colonoscopy. The following factors were significantly associated with angioectasia: chronic kidney disease, liver disease, female, body mass index < 25, and anticoagulant use. Patients with angioectasia were at a significant increased risk of blood transfusions compared to those without angioectasia (odds ratio [OR] 2.61; 95% confidence interval [CI] 1.69-4.02). Among patients with angioectasia, 36 patients (28%) experienced rebleeding during 1-year follow-up. The 1-year cumulative rebleeding rates were 37.0% in the endoscopic clipping group, 14.3% in the coagulation group, and 32.8% in the conservative management group. Compared to conservative management, coagulation therapy significantly reduced rebleeding risk (P = 0.038), while clipping did not (P = 0.81). Multivariate analysis showed coagulation therapy was an independent factor for reducing rebleeding risk (hazard ratio [HR] 0.40; 95% CI 0.16-0.96). CONCLUSIONS: Our data showed patients with angioectasia had a greater comorbidity burden and needed more blood transfusions in comparison with those without angioectasia. To reduce rebleeding risk, coagulation therapy can be superior for controlling hematochezia secondary to angioectasia.

A case of refractory bleeding from duodenal angioectasia with acquired hemophilia A.

Acquired hemophilia A (AHA) is a coagulation disorder related to the factor VIII inhibitors, which might cause intractable bleeding of gastrointestinal tracts. However, its scarcity makes it difficult to recognize AHA as a pitfall of endoscopic hemostasis failure. An 81-year-old female with a history of endoscopic treatment for colon polyps visited a local hospital with chief compliments of bloody stool and severe anemia. During several examinations for the bleeding origin, esophagogastroduodenoscopy depicted a 5 mm-sized hemorrhagic angioectasia of the duodenum, followed by treatment with argon plasma coagulation. However, hemostasis was not achieved by multiple sessions of endoscopic hemostasis and transcatheter arterial embolization, so blood transfusion was repeatedly done and she was transferred to our hospital. Laboratory data showed severe anemia with coagulation disorder. Based on the results of von Willebrand factor activity, factor VIII activity and factor VIII inhibitor, we diagnosed AHA as a comorbidity. Endoscopic hemostasis was confirmed only after improvement of APTT level and negative for the factor VIII inhibitor by hemostatic bypass treatment with recombinant active factor VII and immunosuppressive therapy with prednisolone and cyclophosphamide. In case of refractory bleeding of gastrointestinal tract, we should suspect of a comorbidity of coagulation disorder like AHA.

Small bowel angioectasia-The clinical and cost impact of different management strategies.

BACKGROUND: The management of patients with recurrent anaemia and small bowel angioectasia (SBA) is costly and challenging. AIMS/METHODS: In this retrospective cohort study, we examined the clinical and cost implication of a combination therapy of Somatostatin analogues (SA) and endoscopic ablation, endoscopic therapy alone, and conservative management. RESULTS: Median number of bleeding episodes reduced from 3.5 (IQR 4) in the year before, to 1 (IQR 2) in the year after starting combination therapy with SA (p = 0.002). There were no differences in number of bed days (13.7 vs. 15.3, p = 0.66) and cost (£10,835 vs £11,653, p = 0.73) in the year before and after starting combination therapy. There was a trend towards a reduction in median number of blood transfusions episodes (17 vs 5, p = 0.07) and therapeutic endoscopies (1 vs. 0, p = 0.05) after starting SA. In patients suitable for endoscopic therapy alone, time spent in hospital was reduced (-3.5 days, p = 0.004), but bleeding episodes, transfusions and cost of treatment were not different. Patients requiring a combination therapy were significantly more co-morbid with a mean (± sd) Charlson comorbidity index (CCI) of 7.1 (± 2.7). Higher CCI (OR 2.1, 95% CI 1.1-3.9) and presence of chronic renal failure (OR 4.1, 95% CI 1.4-12.4) predicted escalation to combination therapy. CONCLUSIONS: SAs may be a useful adjunct to endoscopic therapy for transfusion dependent comorbid patients. In the first year they reduce bleeding episodes. Cost in the 1-year before and after adding on SA are no different suggesting additional clinical benefit can be gained without additional cost.

Characteristics and Treatment Outcomes of Small-bowel Angioectasia in Systemic Sclerosis Patients: A Retrospective Observational Study.

Objective Systemic sclerosis (SSc) is defined as an autoimmune disease presenting with fibrosis of various organs and vascular endothelial damage. Vascular lesions, including small-bowel angioectasias, are also frequently detected in SSc patients. Polidocanol injection (PDI) is a safe and effective hemostatic treatment for gastrointestinal bleeding. We evaluated the outcomes of PDI for small-bowel angioectasia in SSc patients. Methods We retrospectively evaluated 65 consecutive SSc patients (61 women; mean age, 64.3 years old) who underwent capsule endoscopy (CE) and/or double-balloon endoscopy at Hiroshima University Hospital between April 2012 and December 2019. Patients Patients were stratified according to the presence of small-bowel angioectasia. Among patients who underwent CE during the same period, those with small-bowel angioectasia without concomitant diseases were compared with SSc patients with small-bowel angioectasia. Clinical and endoscopic characteristics, treatment outcomes, and the incidence of metachronous small-bowel angioectasia after PDI were evaluated. Results SSc patients with small-bowel angioectasia exhibited significantly lower hemoglobin levels and a significantly higher incidence of skin telangiectasia than those without small-bowel angioectasia. On a multivariate analysis of the presence of small-bowel angioectasia, anemia and skin telangiectasia were significant independent factors. SSc patients with small-bowel angioectasia included a higher proportion of women and exhibited a significantly higher incidence of metachronous small-bowel angioectasia than X. The characteristics of small-bowel angioectasia and outcomes of PDI were not significantly different between the two groups. No post-treatment rebleeding cases or adverse events were noted. Conclusion CE should be performed for SSc patients with anemia and/or skin telangiectasia. PDI is effective for SSc patients with small-bowel angioectasia.

Development of a Deep-Learning Algorithm for Small Bowel-Lesion Detection and a Study of the Improvement in the False-Positive Rate.

Deep learning has recently been gaining attention as a promising technology to improve the identification of lesions, and deep-learning algorithms for lesion detection have been actively developed in small-bowel capsule endoscopy (SBCE). We developed a detection algorithm for abnormal findings by deep learning (convolutional neural network) the SBCE imaging data of 30 cases with abnormal findings. To enable the detection of a wide variety of abnormal findings, the training data were balanced to include all major findings identified in SBCE (bleeding, angiodysplasia, ulceration, and neoplastic lesions). To reduce the false-positive rate, "findings that may be responsible for hemorrhage" and "findings that may require therapeutic intervention" were extracted from the images of abnormal findings and added to the training dataset. For the performance evaluation, the sensitivity and the specificity were calculated using 271 detectable findings in 35 cases. The sensitivity was calculated using 68,494 images of non-abnormal findings. The sensitivity and specificity were 93.4% and 97.8%, respectively. The average number of images detected by the algorithm as having abnormal findings was 7514. We developed an image-reading support system using deep learning for SBCE and obtained a good detection performance.