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Mo1606 Outcomes for Patients With Transfusion-Dependent Obscure GI Bleeding Undergoing Double Balloon Enteroscopy and Therapy for Small Bowel Angioectasias
Abstracts
Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*1, Frank Lukens1, Joseph L. Blackshear2, Carlos R. Simons Linares1, Paul T. Kroner1, Abhishek Bhurwal1, Mark E. Stark1, Michael J. Bartel1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.
Mo1605 Transfusion RATES Are Increased in Patients Diagnosed With Non-Isolated Gastrointestinal Angiodysplasias Stephanie H. Mai*1,2, Thai Bui1,2, Christian S. Jackson2 1 Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; 2Gastroenterology, VA Loma Linda Healthcare System, Loma Linda, CA Background: While gastrointestinal angiodysplasias (GIAD) are commonly diagnosed in the small bowel, they can be located in other areas of the gastrointestinal tract. Complications of GIAD, which include re-bleeding and readmission, have not been extensively analyzed in non-isolated GIAD. We performed a retrospective study to determine re-bleeding and readmission rates between patients with GIAD isolated to the small bowel (ISGIAD) and those with non-isolated angiodysplasias (NIGIAD) seen on video capsule endoscopy. Aim: To investigate the clinical impact of GIAD on re-bleeding and readmission rates between patients with ISGIAD and those with NIGIAD at a single institution over a seven-year period. Materials and Methods: 425 patients underwent video capsule endoscopy (VCE) between 2006-2013 at the VA Loma Linda Healthcare System. All 425 patients also underwent esophagogastroduodenoscopy (EGD) and colonoscopy prior to VCE. 96 patients were diagnosed with small bowel GIAD on VCE. The primary indications for VCE were obscure occult and obscure overt GI bleeds. Patients with other indications including irritable bowel syndrome (nZ6) and malignancy evaluations (nZ3) were excluded. Of the 87 patients included in the study, 57 were diagnosed with ISGIAD and 30 with NIGIAD. We compared rebleeding rates and readmission rates between the two groups. Re-bleeding was defined as a transfusion of two units of packed red blood cells or more in a oneyear period after video endoscopic evaluation. Readmission was defined as any hospitalization during a six-month period after discharge. Results: Risk factors associated with higher transfusion rates included coronary artery disease (CAD), chronic kidney disease (CKD) and congestive heart failure (CHF) on univariate analysis. When adjusted for these risk factors on multivariate analysis, the odds
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ratio (OR) for transfusions in patients with NIGIAD was found to be 4.222 (CI 1.102-16.171, pZ 0.036). No association was found between NIGIAD and readmission rates. Conclusion: In this retrospective analysis of GIAD at a single institution over a seven-year period, patients with NIGIAD had a four times odds of receiving transfusions within one year after endoscopic evaluation, when adjusted for potential confounders.
Mo1606 Outcomes for Patients With Transfusion-Dependent Obscure GI Bleeding Undergoing Double Balloon Enteroscopy and Therapy for Small Bowel Angioectasias Kunal Dalal*1, Nicholas a. Rogers1, Michael V. Chiorean2, Debra J. Helper1, Monika Fischer1 1 Indiana University School of Medicine, Indianapolis, IN; 2 Gastroenterology, Virginia Mason Medical Center, Seattle, WA Introduction: Double balloon enteroscopy (DBE) is often undertaken for evaluation of obscure gastrointestinal bleeding (OGIB). Small bowel angioectasias (SBAs) are frequently diagnosed lesions during DBE for OGIB and targeted for therapy. The natural history of SBAs is not well characterized, and data on longterm efficacy, bleeding recurrence, and effect on transfusion requirement posttherapy are limited. Objective: To determine the risk of recurrent bleeding during long-term follow-up after treatment of SBAs with DBE. Methods: Using a prospective IRB-approved research database, we identified patients who underwent DBE for OGIB between 3/2006 and 9/2013 at a tertiary center. Patients with transfusion-dependent anemia prior to DBE who were found to have at least one SBA and had successful therapy were included. Patients with other vascular lesions without SBAs were excluded. Comorbidities, index DBE characteristics and findings, and repeat endoscopic findings were documented. Follow-up was conducted through 10/2014. Primary outcome was bleeding recurrence, defined as requirement for blood transfusion(s) post-DBE, repeat endoscopy to evaluate new or worsening anemia or suspected GI bleeding, or intravenous iron infusions. Recurrence was assessed by review of electronic medical records (EMR), including our center’s blood bank and endoscopy records. For patients who did not have these outcomes definitively documented, phone follow-up was attempted. Results: 137 patients (47.4% female) with mean age 69.8 10.5 were included. Outcomes were assessed in 105 patients (30 by phone); outcomes could not be determined in 32 due to insufficient follow-up, death, or inability to establish phone contact. Of those assessed, 84 (80.0%) had confirmed recurrence, including 66 (62.9%) who required further transfusions. For recurrence confirmed via EMR (nZ75), median time to recurrence was 3.2 months (range, 0.2-53.9), with median follow-up of 16.4 months (range, 0.4-89.7). 67 patients (63.8% of those assessed) required a total of 171 repeat endoscopies, including 35 patients (33.3%) requiring 55 repeat DBEs. 49 patients (46.7% of those assessed) were found to have additional SBAs on repeat endoscopy; these SBAs were felt to represent a likely cause for recurrence in 42 patients (40.0%). Location of these SBAs correlated with index findings in 57.1%. On bivariate analysis, recurrence was not associated with age, sex, comorbidities, bi-directional DBE, bleeding AVM(s) or multiple locations of AVMs on index DBE (all pO0.05); transfusion-dependent recurrence was associated with baseline overt bleeding (pZ0.029). Conclusions: Bleeding recurrence with further transfusion requirement was common after DBE treatment for SBAs in patients with a history of transfusion-dependent anemia. Additional SBAs were commonly implicated in these recurrent cases.
Mo1607 No Significant Differences in the Clinical Outcome of Japanese Patients With Upper Gastrointestinal Bleeding After Endoscopic Hemostasis Between Weekday and Weekend Admission Minoru Fujita*1, Noriaki Manabe2, Takahisa Murao1, Manabu Ishii1, Hiroshi Matsumoto1, Ken-Ichi Tarumi1, Tomoari Kamada1, Akiko Shiotani1, Ken Haruma1 1 Division of Gastroenterology, Department of Medicine, Kawasaki Medical school, Kurashiki, Japan; 2Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Kurashiki, Japan Background and Aim: With the recent technological advances in the field of endoscopic hemostasis (EH), the prognosis of patients with gastrointestinal (GI) bleeding has been improved. In western countries, it has been suggested that patients with upper GI bleeding (UGIB) during the weekend have a worse outcome compared with weekdays. However, there have been no data regarding these matters in Japan. The aim of this study was to evaluate the clinical course of UGIB patients after emergency endoscopy (EE), and elucidate differences in clinical outcomes between the daytime on weekday admission and others. Methods: From January 2011 to December 2013, the medical records of patients who had undergone EE for UGIB were retrospectively reviewed. The severity of UGIB was evaluated by Glasgow-Blatchford (GS) score and AIMS65 score. Patients who stopped
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB481
Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*1, Frank Lukens1, Joseph L. Blackshear2, Carlos R. Simons Linares1, Paul T. Kroner1, Abhishek Bhurwal1, Mark E. Stark1, Michael J. Bartel1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.
Mo1605 Transfusion RATES Are Increased in Patients Diagnosed With Non-Isolated Gastrointestinal Angiodysplasias Stephanie H. Mai*1,2, Thai Bui1,2, Christian S. Jackson2 1 Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; 2Gastroenterology, VA Loma Linda Healthcare System, Loma Linda, CA Background: While gastrointestinal angiodysplasias (GIAD) are commonly diagnosed in the small bowel, they can be located in other areas of the gastrointestinal tract. Complications of GIAD, which include re-bleeding and readmission, have not been extensively analyzed in non-isolated GIAD. We performed a retrospective study to determine re-bleeding and readmission rates between patients with GIAD isolated to the small bowel (ISGIAD) and those with non-isolated angiodysplasias (NIGIAD) seen on video capsule endoscopy. Aim: To investigate the clinical impact of GIAD on re-bleeding and readmission rates between patients with ISGIAD and those with NIGIAD at a single institution over a seven-year period. Materials and Methods: 425 patients underwent video capsule endoscopy (VCE) between 2006-2013 at the VA Loma Linda Healthcare System. All 425 patients also underwent esophagogastroduodenoscopy (EGD) and colonoscopy prior to VCE. 96 patients were diagnosed with small bowel GIAD on VCE. The primary indications for VCE were obscure occult and obscure overt GI bleeds. Patients with other indications including irritable bowel syndrome (nZ6) and malignancy evaluations (nZ3) were excluded. Of the 87 patients included in the study, 57 were diagnosed with ISGIAD and 30 with NIGIAD. We compared rebleeding rates and readmission rates between the two groups. Re-bleeding was defined as a transfusion of two units of packed red blood cells or more in a oneyear period after video endoscopic evaluation. Readmission was defined as any hospitalization during a six-month period after discharge. Results: Risk factors associated with higher transfusion rates included coronary artery disease (CAD), chronic kidney disease (CKD) and congestive heart failure (CHF) on univariate analysis. When adjusted for these risk factors on multivariate analysis, the odds
www.giejournal.org
ratio (OR) for transfusions in patients with NIGIAD was found to be 4.222 (CI 1.102-16.171, pZ 0.036). No association was found between NIGIAD and readmission rates. Conclusion: In this retrospective analysis of GIAD at a single institution over a seven-year period, patients with NIGIAD had a four times odds of receiving transfusions within one year after endoscopic evaluation, when adjusted for potential confounders.
Mo1606 Outcomes for Patients With Transfusion-Dependent Obscure GI Bleeding Undergoing Double Balloon Enteroscopy and Therapy for Small Bowel Angioectasias Kunal Dalal*1, Nicholas a. Rogers1, Michael V. Chiorean2, Debra J. Helper1, Monika Fischer1 1 Indiana University School of Medicine, Indianapolis, IN; 2 Gastroenterology, Virginia Mason Medical Center, Seattle, WA Introduction: Double balloon enteroscopy (DBE) is often undertaken for evaluation of obscure gastrointestinal bleeding (OGIB). Small bowel angioectasias (SBAs) are frequently diagnosed lesions during DBE for OGIB and targeted for therapy. The natural history of SBAs is not well characterized, and data on longterm efficacy, bleeding recurrence, and effect on transfusion requirement posttherapy are limited. Objective: To determine the risk of recurrent bleeding during long-term follow-up after treatment of SBAs with DBE. Methods: Using a prospective IRB-approved research database, we identified patients who underwent DBE for OGIB between 3/2006 and 9/2013 at a tertiary center. Patients with transfusion-dependent anemia prior to DBE who were found to have at least one SBA and had successful therapy were included. Patients with other vascular lesions without SBAs were excluded. Comorbidities, index DBE characteristics and findings, and repeat endoscopic findings were documented. Follow-up was conducted through 10/2014. Primary outcome was bleeding recurrence, defined as requirement for blood transfusion(s) post-DBE, repeat endoscopy to evaluate new or worsening anemia or suspected GI bleeding, or intravenous iron infusions. Recurrence was assessed by review of electronic medical records (EMR), including our center’s blood bank and endoscopy records. For patients who did not have these outcomes definitively documented, phone follow-up was attempted. Results: 137 patients (47.4% female) with mean age 69.8 10.5 were included. Outcomes were assessed in 105 patients (30 by phone); outcomes could not be determined in 32 due to insufficient follow-up, death, or inability to establish phone contact. Of those assessed, 84 (80.0%) had confirmed recurrence, including 66 (62.9%) who required further transfusions. For recurrence confirmed via EMR (nZ75), median time to recurrence was 3.2 months (range, 0.2-53.9), with median follow-up of 16.4 months (range, 0.4-89.7). 67 patients (63.8% of those assessed) required a total of 171 repeat endoscopies, including 35 patients (33.3%) requiring 55 repeat DBEs. 49 patients (46.7% of those assessed) were found to have additional SBAs on repeat endoscopy; these SBAs were felt to represent a likely cause for recurrence in 42 patients (40.0%). Location of these SBAs correlated with index findings in 57.1%. On bivariate analysis, recurrence was not associated with age, sex, comorbidities, bi-directional DBE, bleeding AVM(s) or multiple locations of AVMs on index DBE (all pO0.05); transfusion-dependent recurrence was associated with baseline overt bleeding (pZ0.029). Conclusions: Bleeding recurrence with further transfusion requirement was common after DBE treatment for SBAs in patients with a history of transfusion-dependent anemia. Additional SBAs were commonly implicated in these recurrent cases.
Mo1607 No Significant Differences in the Clinical Outcome of Japanese Patients With Upper Gastrointestinal Bleeding After Endoscopic Hemostasis Between Weekday and Weekend Admission Minoru Fujita*1, Noriaki Manabe2, Takahisa Murao1, Manabu Ishii1, Hiroshi Matsumoto1, Ken-Ichi Tarumi1, Tomoari Kamada1, Akiko Shiotani1, Ken Haruma1 1 Division of Gastroenterology, Department of Medicine, Kawasaki Medical school, Kurashiki, Japan; 2Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Kurashiki, Japan Background and Aim: With the recent technological advances in the field of endoscopic hemostasis (EH), the prognosis of patients with gastrointestinal (GI) bleeding has been improved. In western countries, it has been suggested that patients with upper GI bleeding (UGIB) during the weekend have a worse outcome compared with weekdays. However, there have been no data regarding these matters in Japan. The aim of this study was to evaluate the clinical course of UGIB patients after emergency endoscopy (EE), and elucidate differences in clinical outcomes between the daytime on weekday admission and others. Methods: From January 2011 to December 2013, the medical records of patients who had undergone EE for UGIB were retrospectively reviewed. The severity of UGIB was evaluated by Glasgow-Blatchford (GS) score and AIMS65 score. Patients who stopped
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB481