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Mo1620 Gastrointestinal Bleeding Following Implantation of Ventricular Assist Device: Incidence, Endoscopic Lesions and Prognosis
Abstracts
Mo1618 Retrograde Double Balloon Enteroscopy Detects Significant Colonic Lesions When Performed for Obscure GI Bleeding David Tenembaum*, Masud Habibullah, Jose E. Najul, Moshe Rubin New York Hospital Queens Medical Center, Weill-Cornell Medical College, New York, NY Background: Evaluation of the distal small bowel with Double Balloon Enteroscopy (DBE) requires passage of the scope through the colon prior to intubation of the ileum. Nevertheless, careful inspection of the colon may not be performed in all cases since patients with obscure GI bleeding have already undergone a complete colonoscopy with reportedly negative results. There is limited data on the frequency of clinically significant colonic findings missed at colonoscopy and subsequently detected at retrograde DBE. Objectives: To evaluate the detection rate of missed colonic angioectasia, ulcers and polyps at retrograde DBE in patients with obscure GI bleeding. Methods: We performed a retrospective cohort study on 134 sequential patients undergoing retrograde DBE. All patients had a negative colonoscopy (excluding diverticulosis and hemorrhoids) and were referred for obscure bleeding. The median time between colonoscopy and DBE were 12.89 days. The detection rate of angioectasia, ulcers and polyps (⬎ 5 mm) were calculated. Results: 134 patients, ages 24-94 with a mean age of 63.2 were evaluated. There were 56 women (41.18%) with a median age of 65.5 and 78 men (58.82%) with a median age of 59.4. DBE detected colonic lesions in 36 patients (28.36%) overall. Of those patients, 28 (20.90%) had polyps, 13 had angioectasia (9.70%) and 2 had ulcers (1.49%). Conclusions: Retrograde DBE following reportedly negative colonoscopy detects a significant number of clinically relevant colonic lesions in patients with obscure bleeding. This data suggests that a careful reexamination of the colon at the time of retrograde DBE may be warranted.
Mo1619 Radiofrequency Ablation Treatment of Radiation Proctitis: Results From an European Collaborative Study Xavier Dray1, Alessandra Carlino4, Dov Wengrower3, Pedro Gonzalez2, Tomer Adar3, Francisco PéRez-RoldáN2, Marine Camus*1, Philippe R. Marteau1, Alessandro Repici4 1 APHP Lariboisière & iTEC, Paris 7 Paris Diderot University, Paris, France; 2Digestive Unit, Hospital General Mancha Centro, Alcazar de San Juan, Spain; 3Digestive Diseases Institute, Shaare Zedek Medical Center and Hebrew University Medical School, Jerusalem, Israel; 4 Istituto Clinico Humanitas, Milano, Italy Introduction: Chronic radiation proctitis (RP) occurs in 5 to 20% of patients with pelvic radiation therapy. Conventional endoscopic treatments, including argon coagulation plasma (APC), sometimes fail. Our aim was to evaluate the feasibility, efficacy and safety of radiofrequency ablation (RFA) for management of RP. Patients and Methods: Data from patients with RP treated by RFA were retrospectively collected from 4 European centers. Main outcomes measurements were the following: a three-item symptom scale (from 0 to 10 points) including diarrhoea (0 to 3 points), bleeding (0 to 4 points), and tenesmus/rectal pain (0 to 3 points) (see reference), red blood cell (RBC) transfusions (number of RBC packs, number of patients weaned off transfusions), lowest hemoglobin rates (g/dL), and complications. The Wilcoxon matched-pairs signed-ranks test was used to estimate the difference in response in the 6 months before and after RFA treatment. Results: 11 patients had RFA for treatment of RP (3 female and 8 male patients, aged 63 to 87 (mean age 74 ⫾ 8)). Past history included prostate cancer (7), bladder cancer (1), and cervix cancer (3). Three patients were treated with aspirin, 2 with anticoagulants. Five patients had received previous APC treatment (1 to 5 sessions), 1 had bipolar coagulation (1 session) and 2 patients had laser therapy (1 to 5 sessions). RFA was performed with the Halo90 ablation catheter and the HaloFlex system (Covidien), with a power of 12 to 15 J/cm2. Patients received a mean number of 2.2 RFA sessions (range 1-4). Treatment was deemed feasible, quick and easy in all patients. No early complications were recorded. Symptom scores decreased in all patients, from mean score of 4.8 ⫾ 0.8 (range 4 to 6) to 1.4 ⫾ 0.9 (range 0 to 3) (p⬍0.001). Among 8 patients who were transfusion-dependent (mean number of 10.1 ⫾ 8.6 RBC packs, range 2 to 27, over the 6-month period), 7 patients were weaned off transfusions during the 6 following months. In the six months after RFA treatment has been completed a significant increases in hemoglobin rate was recorded (from 7.1 ⫾ 0.6 g/dL to 10.5 ⫾ 1.1 g/dL, p⬍0.001). One patient was referred for additionnal APC treatment. One patient developed a fibrotic narrowing of the rectum, with no sign of obstruction. Conclusion: RFA allows a complete treatment of RP in a safely and clinically efficient manner. RFA significantly decreaseds clinical symptoms and the need for RBC transfusions, and leadeds to a significant increase of the hemoglobine rate. A prospective evaluation
of RFA as a first-line treatment of RP should be considered.Reference: Chruscielewska-Kiliszek et al. Colorectal Dis 2012 (in press)
Mo1620 Gastrointestinal Bleeding Following Implantation of Ventricular Assist Device: Incidence, Endoscopic Lesions and Prognosis Mazen Albeldawi*2, Gurshawn Singh1, Saminder S. Kalra1, Paresh P. Mehta2, Sulieman Abdal Raheem2, Rocio Lopez3, Madhusudhan R. Sanaka2, John J. Vargo2 1 Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 2 Internal Medicine, Cleveland Clinic, Cleveland, OH; 3Quantitative Health, Clevleand Clinic, Cleveland, OH Introduction: Ventricular assist devices (VADs) have emerged as the standard of care for patients with end-stage heart disease (ESHD) requiring long-term mechanical circulatory support. Gastrointestinal bleeding (GIB) has been frequently reported within this population. We sought to determine the incidence, etiology, and outcome of GI bleeding in patients receiving VAD support. Methods: We retrospectively analyzed consecutive patients who underwent VAD implantation for ESHD as destination therapy or a bridge to transplant between January 2000 and May 2012. Patients were grouped based on type of VAD implant: 1) HeartMate II (continuous flow), 2) HeartMate XVE (pulsatile flow), 3) Total artificial heart. Data collected included patient demographics, medication usage including statins, nonsteroidal anti-inflammatory drugs (NSAIDs), anti-platelet and anti-coagulation therapy. Univariable analysis was performed to compare subjects with and without evidence of GIB. Multivariable logistic regression analysis was used to identify factors independently associated with GIB in patients receiving VAD support. Results: 387 adult patients (mean age 53.9 ⫾ 14.2 years, 81% males) with ESHD who underwent VAD implantation were studied. A total of fifty-three patients (14%) experienced GIB. Risk factors for bleeding included older age (p⬍0.001), PPI use (p⫽0.02), history of smoking (p⫽0.007), and Helicobacter pylori infection (p⫽0.012). Bleeding was primarily overt (n⫽42) rather than occult (n⫽11) and most patients presented with hematochezia (n⫽23, 52%); hemodynamic instability was observed in 34.2%. Causes of bleeding were primarily vascular malformation (33%), ulcers (26%), and erosions (19%). Patients receiving VAD implantation for destination therapy as compared to bridge to transplant were more likely to experience a GIB (p⫽0.046). Risk of bleeding was not affected by type of VAD used (continuous flow vs. pulsatile flow vs. total artificial heart). Colonoscopy provided the highest diagnostic yield with colonic lesions (46%) dominating the findings. Overall mortality was 39.4%, with only 1 death directly related to GIB. Conclusion: In this large series of consecutive patients, GIB was common following implantation of a ventricular assist device (14% experience ⬎ 1 bleeding episodes). Episodes were mostly overt and predominantly from the lower GI tract with colonoscopy providing the best yield for diagnosis.
Mo1621 Patients on Continuous Flow Left Ventricular Assist Device Support Experience Gastrointestinal Bleeding and Thromboembolic Events At Significantly Higher Rates Than a Similar High-Risk Population Charles W. Shrode*, Jamie L. Kennedy, Christine C. Morrison, Vanessa M. Shami, Andrew Y. Wang, James D. Bergin, Gorav Ailawadi, Bryan G. Sauer University of Virginia, Charlottesville, VA Background: Continuous flow left ventricular assist devices (CF-LVADs) improve patient survival in bridge-to- transplant and destination therapy (patients who are not candidates for transplantation). While several studies have demonstrated increased rate of GI bleeding in patients on CF-LVAD support, no studies have compared bleeding rates to a similar high-risk cardiac population. Similarly, no studies have evaluated thromboembolic risk among these populations. Our aim was to characterize the rate and location of GI bleeds and thromboembolic events that occurred in patients with CF-LVADs compared to anticoagulated patients following cardiac valve (bioprosthetic or mechanical) replacement. Methods: We investigated 76 consecutive patients (mean age 56.1 ⫾ 13.0 years, range 20-81 years) with CF-LVAD placement (Heartmate II, Thoratec, Pleasanton CA) from January 2009-July 2011 and 159 patients (mean age 66.7 ⫾ 14.9 years, range 20-83 years) who underwent a cardiac valve replacement (aortic, mitral, or both) and were discharged on anticoagulation from January 2009-November 2011. All patients in both groups received aspirin except in cases where allergies prevented its use (LVAD n⫽1, valve replacement n ⫽5). All patients in both arms were treated with anticoagulation (warfarin, heparin infusion, lowmolecular weight heparin, or a combination). GI bleeding was defined as a drop in hemoglobin by 1 g/dL with passage of melena, bright red blood per rectum, hematemesis, coffee-ground emesis, or heme-positive stools. Thromboembolic events (CVA, DVT) were confirmed with a radiologic study (ultrasound, CT, or MRI). LVAD thrombosis was confirmed at the time of device removal. Results: Patients were followed for a mean of 0.97 ⫾ 0.93 years (CF-LVAD: 0.83 ⫾ 0.75
AB448 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Mo1618 Retrograde Double Balloon Enteroscopy Detects Significant Colonic Lesions When Performed for Obscure GI Bleeding David Tenembaum*, Masud Habibullah, Jose E. Najul, Moshe Rubin New York Hospital Queens Medical Center, Weill-Cornell Medical College, New York, NY Background: Evaluation of the distal small bowel with Double Balloon Enteroscopy (DBE) requires passage of the scope through the colon prior to intubation of the ileum. Nevertheless, careful inspection of the colon may not be performed in all cases since patients with obscure GI bleeding have already undergone a complete colonoscopy with reportedly negative results. There is limited data on the frequency of clinically significant colonic findings missed at colonoscopy and subsequently detected at retrograde DBE. Objectives: To evaluate the detection rate of missed colonic angioectasia, ulcers and polyps at retrograde DBE in patients with obscure GI bleeding. Methods: We performed a retrospective cohort study on 134 sequential patients undergoing retrograde DBE. All patients had a negative colonoscopy (excluding diverticulosis and hemorrhoids) and were referred for obscure bleeding. The median time between colonoscopy and DBE were 12.89 days. The detection rate of angioectasia, ulcers and polyps (⬎ 5 mm) were calculated. Results: 134 patients, ages 24-94 with a mean age of 63.2 were evaluated. There were 56 women (41.18%) with a median age of 65.5 and 78 men (58.82%) with a median age of 59.4. DBE detected colonic lesions in 36 patients (28.36%) overall. Of those patients, 28 (20.90%) had polyps, 13 had angioectasia (9.70%) and 2 had ulcers (1.49%). Conclusions: Retrograde DBE following reportedly negative colonoscopy detects a significant number of clinically relevant colonic lesions in patients with obscure bleeding. This data suggests that a careful reexamination of the colon at the time of retrograde DBE may be warranted.
Mo1619 Radiofrequency Ablation Treatment of Radiation Proctitis: Results From an European Collaborative Study Xavier Dray1, Alessandra Carlino4, Dov Wengrower3, Pedro Gonzalez2, Tomer Adar3, Francisco PéRez-RoldáN2, Marine Camus*1, Philippe R. Marteau1, Alessandro Repici4 1 APHP Lariboisière & iTEC, Paris 7 Paris Diderot University, Paris, France; 2Digestive Unit, Hospital General Mancha Centro, Alcazar de San Juan, Spain; 3Digestive Diseases Institute, Shaare Zedek Medical Center and Hebrew University Medical School, Jerusalem, Israel; 4 Istituto Clinico Humanitas, Milano, Italy Introduction: Chronic radiation proctitis (RP) occurs in 5 to 20% of patients with pelvic radiation therapy. Conventional endoscopic treatments, including argon coagulation plasma (APC), sometimes fail. Our aim was to evaluate the feasibility, efficacy and safety of radiofrequency ablation (RFA) for management of RP. Patients and Methods: Data from patients with RP treated by RFA were retrospectively collected from 4 European centers. Main outcomes measurements were the following: a three-item symptom scale (from 0 to 10 points) including diarrhoea (0 to 3 points), bleeding (0 to 4 points), and tenesmus/rectal pain (0 to 3 points) (see reference), red blood cell (RBC) transfusions (number of RBC packs, number of patients weaned off transfusions), lowest hemoglobin rates (g/dL), and complications. The Wilcoxon matched-pairs signed-ranks test was used to estimate the difference in response in the 6 months before and after RFA treatment. Results: 11 patients had RFA for treatment of RP (3 female and 8 male patients, aged 63 to 87 (mean age 74 ⫾ 8)). Past history included prostate cancer (7), bladder cancer (1), and cervix cancer (3). Three patients were treated with aspirin, 2 with anticoagulants. Five patients had received previous APC treatment (1 to 5 sessions), 1 had bipolar coagulation (1 session) and 2 patients had laser therapy (1 to 5 sessions). RFA was performed with the Halo90 ablation catheter and the HaloFlex system (Covidien), with a power of 12 to 15 J/cm2. Patients received a mean number of 2.2 RFA sessions (range 1-4). Treatment was deemed feasible, quick and easy in all patients. No early complications were recorded. Symptom scores decreased in all patients, from mean score of 4.8 ⫾ 0.8 (range 4 to 6) to 1.4 ⫾ 0.9 (range 0 to 3) (p⬍0.001). Among 8 patients who were transfusion-dependent (mean number of 10.1 ⫾ 8.6 RBC packs, range 2 to 27, over the 6-month period), 7 patients were weaned off transfusions during the 6 following months. In the six months after RFA treatment has been completed a significant increases in hemoglobin rate was recorded (from 7.1 ⫾ 0.6 g/dL to 10.5 ⫾ 1.1 g/dL, p⬍0.001). One patient was referred for additionnal APC treatment. One patient developed a fibrotic narrowing of the rectum, with no sign of obstruction. Conclusion: RFA allows a complete treatment of RP in a safely and clinically efficient manner. RFA significantly decreaseds clinical symptoms and the need for RBC transfusions, and leadeds to a significant increase of the hemoglobine rate. A prospective evaluation
of RFA as a first-line treatment of RP should be considered.Reference: Chruscielewska-Kiliszek et al. Colorectal Dis 2012 (in press)
Mo1620 Gastrointestinal Bleeding Following Implantation of Ventricular Assist Device: Incidence, Endoscopic Lesions and Prognosis Mazen Albeldawi*2, Gurshawn Singh1, Saminder S. Kalra1, Paresh P. Mehta2, Sulieman Abdal Raheem2, Rocio Lopez3, Madhusudhan R. Sanaka2, John J. Vargo2 1 Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 2 Internal Medicine, Cleveland Clinic, Cleveland, OH; 3Quantitative Health, Clevleand Clinic, Cleveland, OH Introduction: Ventricular assist devices (VADs) have emerged as the standard of care for patients with end-stage heart disease (ESHD) requiring long-term mechanical circulatory support. Gastrointestinal bleeding (GIB) has been frequently reported within this population. We sought to determine the incidence, etiology, and outcome of GI bleeding in patients receiving VAD support. Methods: We retrospectively analyzed consecutive patients who underwent VAD implantation for ESHD as destination therapy or a bridge to transplant between January 2000 and May 2012. Patients were grouped based on type of VAD implant: 1) HeartMate II (continuous flow), 2) HeartMate XVE (pulsatile flow), 3) Total artificial heart. Data collected included patient demographics, medication usage including statins, nonsteroidal anti-inflammatory drugs (NSAIDs), anti-platelet and anti-coagulation therapy. Univariable analysis was performed to compare subjects with and without evidence of GIB. Multivariable logistic regression analysis was used to identify factors independently associated with GIB in patients receiving VAD support. Results: 387 adult patients (mean age 53.9 ⫾ 14.2 years, 81% males) with ESHD who underwent VAD implantation were studied. A total of fifty-three patients (14%) experienced GIB. Risk factors for bleeding included older age (p⬍0.001), PPI use (p⫽0.02), history of smoking (p⫽0.007), and Helicobacter pylori infection (p⫽0.012). Bleeding was primarily overt (n⫽42) rather than occult (n⫽11) and most patients presented with hematochezia (n⫽23, 52%); hemodynamic instability was observed in 34.2%. Causes of bleeding were primarily vascular malformation (33%), ulcers (26%), and erosions (19%). Patients receiving VAD implantation for destination therapy as compared to bridge to transplant were more likely to experience a GIB (p⫽0.046). Risk of bleeding was not affected by type of VAD used (continuous flow vs. pulsatile flow vs. total artificial heart). Colonoscopy provided the highest diagnostic yield with colonic lesions (46%) dominating the findings. Overall mortality was 39.4%, with only 1 death directly related to GIB. Conclusion: In this large series of consecutive patients, GIB was common following implantation of a ventricular assist device (14% experience ⬎ 1 bleeding episodes). Episodes were mostly overt and predominantly from the lower GI tract with colonoscopy providing the best yield for diagnosis.
Mo1621 Patients on Continuous Flow Left Ventricular Assist Device Support Experience Gastrointestinal Bleeding and Thromboembolic Events At Significantly Higher Rates Than a Similar High-Risk Population Charles W. Shrode*, Jamie L. Kennedy, Christine C. Morrison, Vanessa M. Shami, Andrew Y. Wang, James D. Bergin, Gorav Ailawadi, Bryan G. Sauer University of Virginia, Charlottesville, VA Background: Continuous flow left ventricular assist devices (CF-LVADs) improve patient survival in bridge-to- transplant and destination therapy (patients who are not candidates for transplantation). While several studies have demonstrated increased rate of GI bleeding in patients on CF-LVAD support, no studies have compared bleeding rates to a similar high-risk cardiac population. Similarly, no studies have evaluated thromboembolic risk among these populations. Our aim was to characterize the rate and location of GI bleeds and thromboembolic events that occurred in patients with CF-LVADs compared to anticoagulated patients following cardiac valve (bioprosthetic or mechanical) replacement. Methods: We investigated 76 consecutive patients (mean age 56.1 ⫾ 13.0 years, range 20-81 years) with CF-LVAD placement (Heartmate II, Thoratec, Pleasanton CA) from January 2009-July 2011 and 159 patients (mean age 66.7 ⫾ 14.9 years, range 20-83 years) who underwent a cardiac valve replacement (aortic, mitral, or both) and were discharged on anticoagulation from January 2009-November 2011. All patients in both groups received aspirin except in cases where allergies prevented its use (LVAD n⫽1, valve replacement n ⫽5). All patients in both arms were treated with anticoagulation (warfarin, heparin infusion, lowmolecular weight heparin, or a combination). GI bleeding was defined as a drop in hemoglobin by 1 g/dL with passage of melena, bright red blood per rectum, hematemesis, coffee-ground emesis, or heme-positive stools. Thromboembolic events (CVA, DVT) were confirmed with a radiologic study (ultrasound, CT, or MRI). LVAD thrombosis was confirmed at the time of device removal. Results: Patients were followed for a mean of 0.97 ⫾ 0.93 years (CF-LVAD: 0.83 ⫾ 0.75
AB448 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org