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Background Methods Results Discussion Despite prophylactic platelet transfusions, hypoproliferative thrombocytopenia is associated with bleeding; historical risk factors include hematocrit (HCT) ≤$$ \le $$25%, activated partial thromboplastin time ≥$$ \ge $$30 s, international normalized ratio ≥$$ \ge $$1.2, and platelets≤$$ \le $$5000/μL.We performed a post hoc analysis of bleeding outcomes and risk factors in participants with hematologic malignancy and hypoproliferative thrombocytopenia enrolled in the American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (A‐TREAT) and randomized to receive either tranexamic acid (TXA) or placebo.World Health Organization (WHO) grade 2+ bleeding occurred in 46% of 330 participants, with no difference between the TXA (44%) and placebo (47%) groups (p = 0.66). Overall, the most common sites of bleeding were oronasal (18%), skin (17%), gastrointestinal (11%), and genitourinary (11%). Among participants of childbearing potential, 28% experienced vaginal bleeding. Platelets ≤5000/μL and HCT < 21% (after adjusting for severe thrombocytopenia) were independently associated with increased bleeding risk (HR 3.78, 95% CI 2.16–6.61; HR 2.67, 95% CI 1.35–5.27, respectively). Allogeneic stem cell transplant was associated with nonsignificant increased risk of bleeding versus chemotherapy alone (HR 1.34, 95% CI 0.94–1.91).The overall rate of WHO grade 2+ bleeding was similar to previous reports, albeit with lower rates of gastrointestinal bleeding. Vaginal bleeding was common in participants of childbearing potential. Platelets ≤5000/μL remained a risk factor for bleeding. Regardless of platelet count, bleeding risk increased with HCT < 21%, suggesting a red blood cell transfusion threshold above 21% should be considered to mitigate bleeding. More investigation is needed on strategies to reduce bleeding in this population. [ABSTRACT FROM AUTHOR]

Background: Vancomycin-induced bleeding has been reported, attributed to the mechanism of immune thrombocytopenia. A rare case of vancomycin-induced gastrointestinal hemorrhage in a young patient with no underlying disease, receiving intravenous vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) infection, is presented. This occurrence occurred without thrombocytopenia. Relevant cases reported in the literature were also reviewed. Case presentation: A 34-year-old male patient presented with maxillofacial multiple spaces infection accompanying left temporal abscess, bilateral lung abscesses. Culture results from both blood and secretion indicated that the infection was caused by MRSA. The patient received standard-dose vancomycin (1 g q12h intravenously guttae) for treatment. On the 5th day of therapy, he presented with bright red blood in his stool; however, vancomycin treatment was continued. By the 9th day, a decrease in hemoglobin level to 76 g/L and a platelet (PLT) count of 424 × 109/L raised concerns about gastrointestinal hemorrhage. The hemoglobin level decreased to 62 g/L on day 12. Due to the high tissue concentration of linezolid, administration of linezolid at a dose of 600 mg q12h intravenously guttae commenced on the 13th day as an alternative to vancomycin(D13-D17). Subsequently, on the 17th day, there was an improvement in hemoglobin level to 78 g/L. However, despite treatment with linezolid, the patient's fever showed no significant improvement, prompting a switch back to vancomycin at a dosage of 1 g q12h intravenously guttae(D18-D22). On the 21st day, there was a recurrence of gastrointestinal hemorrhage, accompanied by a hemoglobin level of 42 g/L and a PLT count of 224 × 109/L. Gastroscopy revealed the presence of a gastroduodenal ulcer. The patient had no prior history of hemorrhoids, gastrointestinal ulcers, liver cirrhosis, or purpura. Prior to admission, he had not been administered non-steroidal anti-inflammatory drugs (NSAIDs) or steroids. During hospitalization, the only medications given were vancomycin, ambroxol and lidocaine. Additional tests ruled out immunological disorders as the cause of gastrointestinal ulcers, and a positive vancomycin rechallenge test indicated an association between vancomycin and bleeding. After discontinuation of vancomycin, no further bleeding occurred. This case highlights a rare occurrence of vancomycin-induced bleeding without thrombocytopenia, classified as "Certain" according to the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale for standardized case causality assessment. Conclusion: This case represents the first documented instance of vancomycin-induced bleeding without thrombocytopenia, as confirmed by a positive rechallenge test. This discovery will aid in the early detection of this rare adverse reaction in future cases. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Acute gastrointestinal bleeding is a common gastrointestinal emergency. Only limited studies are available regarding the clinical outcomes after computed tomographic angiography (CTA) mesentery showed negative for active bleed. This study aims to determine the clinical outcome of negative mesentery CTA in patients with clinically active acute gastrointestinal (GI) bleeding. MATERIAL AND METHODS: A cross-sectional study with a universal sampling method was used. Patients who underwent CTA to detect gastrointestinal bleeding in the National University Hospital of Malaysia from December 2015 until March 2021 were retrospectively analysed. The outcome of each patient, risk of re-bleeding, and 30-days mortality rate were evaluated and assessed. RESULTS: In total, 280 CTAs were performed on 232 patients, with 186 of them showing negative results on their first initial CTA. 40.8% (76/186) of those with negative initial CTA had recurrent bleeding and 73.6% (56/76) of them required active intervention. We found that the risk of re-bleeding is lower in the upper gastrointestinal group compared to the lower gastrointestinal group (OR=1.5, 95% CI: 0.877-2.852, p: 0.128). The overall 30 days mortality rate after the first negative CTA was 23.1% (43/186). Among those patients who experienced re-bleeding, 32.8% (25/76) died within 30 days, with 18.4% (14/76) succumbing to massive bleeding. CONCLUSION: From our analysis, it can be concluded that a clinically active GI bleeding with negative mesentery CTA has a 40.8% chance to re-bleed with 23.1% 30-day mortality rate. Close observation and follow-up of this population is recommended due to high rate of active intervention needed. [ABSTRACT FROM AUTHOR]

Key Clinical Message: The occurrence of terlipressin‐induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin‐induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin‐induced skin necrosis. We present a 50‐year‐old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin‐induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post‐terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin‐induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash. [ABSTRACT FROM AUTHOR]

The article investigates the safety of COVID-19 vaccines in the Czech Republic by analyzing adverse events (AEs) reported in connection with different vaccine batches. Data from the State Institute for Drug Control of the Czech Republic was used to compare the findings with a previous study from Denmark. The analysis revealed batch-dependent safety signals, with early vaccine batches associated with higher numbers of AE reports. The study also highlighted differences in AE reporting systems between the Czech Republic and Denmark, suggesting potential underreporting in the Czech system. [Extracted from the article]

Background: Factor XIII plays a key role within the coagulation cascade. Objective: We aimed to investigate the relevance of factor XIII activity on the outcome of patients with gastrointestinal bleedings. Methods: In this retrospective, single-center study patients with gastrointestinal bleeding and measurement of factor XIII activity were included. The primary endpoint was the number of red blood cell transfusions in patients with reduced factor XIII activity (< 70%) compared to patients with normal activity. Additionally, the influence of factor XIII substitution was assessed. Results: Ninety-seven patients (median age: 64 [IQR 55, 77] years, 31 (32%) females) were included in the analysis. Fifty-six (58%) patients suffered from an upper gastrointestinal bleeding. 66 (68%) patients had a factor XIII activity < 70% and 24 (36%) of those received factor XIII substitution. Patients with reduced FXIII activity needed significantly more red blood cell transfusions than patients with normal activity (9 [5, 12] vs. 4 [1, 8], p < 0.001). Patients receiving factor XIII substitution showed a trend toward a decreased need for transfusions after substitution (0 [0, 5] vs. 3 [1, 6], p = 0.066). Factor XIII activity correlated negatively with the INR (rs = -0.24, p = 0.018) and positively with hemoglobin levels (rs = 0.28, p = 0.006) and with thrombocyte counts (rs = 0.30, p = 0.003). Conclusion: The present study shows an association of factor XIII activity with the requirement of blood transfusions in patients with gastrointestinal bleedings and indicates a potential benefit of factor XIII substitution. Factor XIII activity seems to be dependent from the amount of blood loss and the global coagulation parameters. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases are the leading cause of death globally, making the use of oral anticoagulants for prevention increasingly important. Historically, warfarin has played a significant role in this context. In recent years, introduction of new oral anticoagulants, such as rivaroxaban, apixaban, dabigatran, and edoxaban, has been seen. This study evaluates the risk associated with the use of oral anticoagulants by analyzing spontaneous adverse drug reactions reported to the Portuguese Pharmacovigilance System from 2012 to 2021. The study includes 951 adverse drug reactions reports, with the majority (n = 770; 80.97%) classified as serious. Of the 770 serious adverse drug reactions reports, the most commonly reported seriousness criterion was "Clinically Important" (n = 350; 45.45%). In terms of demographics, there was a higher reporting rate among the elderly population, with a greater prevalence of females. The System Organ Class group with the highest number of adverse drug reactions was "Gastrointestinal disorders," with the most commonly reported Preferred Term being "Gastrointestinal hemorrhage," and dabigatran was the most frequently reported drug. In summary, oral anticoagulants have adverse drug reactions that require continuous monitoring. Accurate identification and monitorization of adverse drug reactions is an important starting point to improve drug safety in population. [ABSTRACT FROM AUTHOR]

The article in the British Journal of Haematology offers guidelines for healthcare professionals in the UK regarding the measurement of non-coumarin anticoagulants and their effects on laboratory assays. It includes a comprehensive table of licensed anticoagulants, their measurement methods, and potential laboratory tests. The document stresses the importance of monitoring direct oral anticoagulants (DOACs) in specific situations, such as renal impairment or suspected overdose, and discusses the challenges and variability in monitoring unfractionated heparin (UFH) therapy. The text provides detailed information on monitoring various anti-coagulant therapies, highlighting the significance of using specific assays for accurate monitoring and addressing potential adverse events associated with these medications. [Extracted from the article]

Simple Summary: Hepatocellular carcinoma (HCC) associated with portal vein thrombosis (PVT) represents an advanced stage of the tumor, with a subsequently poor prognosis and reduced therapeutic perspectives. These patients could present severe complications such as ascites, metastases, an increase in portal hypertension and potentially fatal gastrointestinal bleeding. The intricate molecular patterns at the basis of the development of TVP could also represent possible biomarkers in the early detection of patients at high risk of PVT. Hepatocellular carcinoma (HCC) represents the sixth most diagnosed cancer worldwide and is the second leading cause of cancer-related death in the world. The association of HCC and portal vein thrombosis (PVT) represents an advanced stage of the tumor. PVT has a prevalence of about 25–50% in HCC, determining poor prognosis and a remarkable reduction in therapeutic perspectives in these patients, leading to severe complications such as ascites, metastasis, an increase in portal hypertension and potentially fatal gastrointestinal bleeding. The aim of this review is to evaluate the molecular mechanisms that are at the basis of PVT development, trying to evaluate possible strategies in the early detection of patients at high risk of PVT. [ABSTRACT FROM AUTHOR]

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non‐bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs) comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random‐effects meta‐analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8 years and a mean follow up of 20 days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.16–0.95, 268 participants). However, there was no difference in mortality (RR = 0.90, 95% CI 0.23–3.59, 52 participants) or need for ulcer surgery (RR = 0.48, 95% CI 0.10–2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery. [ABSTRACT FROM AUTHOR]

Background Mechanical assist device indications have changed in recent years. Reduced incidence of complications, better survival, and the third generation of mechanical support devices contributed to this change. In this single-center study, we focused on two time periods that are characterized by the use of different types of mechanical support devices, different patient characteristics, and change in the indications. Methods The data were processed from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). We retrospectively defined two time intervals to reflect changes in ventricular assist device technology (period 1: 2007–2015; period 2: 2016–20222). A total of 181 patients underwent left ventricular assist device implantation. Device utilization was the following: HeartMate II = 52 (76.4%) and HeartWare = 16 (23.6%) in period 1 and HeartMate II = 2 (1.8%), HeartMate 3 = 70 (61:9%), HeartWare = 29 (25.7%), SynCardia TAH = 10 (8.8%), and BerlinHeart EXCOR = 2 (1.8%) in period 2. The outcomes of the time intervals were analyzed and evaluated. Results Survival was significantly higher during the second time period. Multivariate analysis revealed that age and bypass pump time are independent predictors of mortality. Idiopathic cardiomyopathy, bypass time, and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score are independent predictors of adverse events. Furthermore, the first period was noted to be at an increased risk of the following adverse events: pump thrombosis, gastrointestinal bleeding, and bleeding events. Conclusion Despite the higher risk profile of the patients and persistent challenges, during the second period, there was a significant decrease in mortality and morbidity. The use of the HeartMate 3 device may have contributed to this result. [ABSTRACT FROM AUTHOR]

Background: The prognosis comparison between endoscopic therapy + partial splenic embolization (PSE) and Hassab's operation is unclear in the treatment of esophageal variceal bleeding in patients with liver cirrhosis. This study aimed to compare the outcome of endoscopic therapy + PSE (EP) with a combination of splenectomy + pericardial devascularization procedure, known as Hassab's operation (SH) for esophageal variceal bleeding in patients with liver cirrhosis with hypersplenism. Methods: We enrolled 328 patients, including 125 and 203 patients who underwent EP and SH, respectively. Each group consisted of 110 patients after propensity score matching (PSM). Subsequently, we recorded and analyzed bleeding episodes and mortality in 6 months and 1, 2, and 5 years after therapies. Results: The median follow-up time in the EP and SH groups was 53 and 64 months, respectively. Bleeding incidence 6 months after therapies in the EP group was lower than that in the SH group (1.8% vs. 10.0%, P = 0.010). Additionally, complications in the perioperative period were not significantly different (0% vs. 3.6%, P = 0.008). However, the bleeding rate between the two groups was not significantly different at 1, 2, and 5 years after therapies (7.3% vs. 12.7%, P = 0.157; 10.9% vs. 16.4%, P = 0.205; 30.6% vs. 31.8%, P = 0.801), as well as mortality rate (4.5% vs 7.3%, P = 0.571). Conclusion: Compared with SH therapy, the bleeding rate 6 months after EP therapy was lower, but the long-term bleeding rate was similar. [ABSTRACT FROM AUTHOR]

Introduction: Lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. A novel adhesive endoscopic hemostatic powder (UI-EWD/NexpowderTM, Nextbiomedical, Incheon, South Korea) has been developed and recently utilized for LGIB hemostasis. The aim of the current study was to assess the efficacy and safety of UI-EWD as a rescue therapy for the treatment of refractory LGIB. Methods: In this study, a total of 59 consecutive patients with LGIB who experienced initial hemostasis failure with conventional endoscopic therapy were enrolled into this multicenter single-arm study. These patients subsequently underwent UI-EWD application for the refractory LGIB hemostasis. We evaluated the success rate of hemostasis, re-bleeding rate within 30 d, and adverse events related to UI-EWD. Results: UI-EWD was successfully administered to the bleeding sites in all enrolled refractory bleeding patients. Hemostasis was achieved in the entirety of the 59 patients (100%). The cumulative re-bleeding rate within 30 d was 8.5% (5/59). There were no UI-EWD-related adverse events, such as perforation nor embolism. Conclusion: Based on our results, the utilization of UI-EWD demonstrated a remarkable success rate in achieving hemostasis for refractory LGIB, while also exhibiting promising outcomes in reducing the re-bleeding rate within a 30-day period. Particularly, UI-EWD exhibits a favorable safety profile across all segments of the colon in cases of refractory LGIB. [ABSTRACT FROM AUTHOR]

An aortoenteric fistula (AEF) is an uncommon cause of gastrointestinal bleeding that requires prompt diagnosis and intervention owing to its high mortality rate. Moreover, iliac aneurysmo-colonic fistula is an exceptionally infrequent presentation. We report a unique case of a 71-year-old male presenting with hematochezia, later diagnosed with a primary fistula between a common iliac artery aneurysm and the sigmoid colon. Initially, the patient was misdiagnosed as having a gastrointestinal stromal tumor, leading to delayed and emergent surgical intervention due to massive bleeding 2 days later. This case is particularly notable for its rarity, misinterpretation of the initial diagnosis, complicated surgical procedures, and development of complications including ischemic myopathy. This case highlights the criticality of accurate diagnosis with a high index of suspicion, significance of consultation with a vascular surgeon for vascular abnormalities, and importance of considering ischemic time in the sequence of surgical treatments to ensure timely and appropriate management. [ABSTRACT FROM AUTHOR]

Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P =.008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk. [ABSTRACT FROM AUTHOR]

This article discusses a case study of a 38-year-old female patient with refractory leukemia who received CAR-T cell therapy. The patient experienced complications, including immune effector cell–associated hemophagocytic lymphohistiocytosis–like syndrome and neurologic manifestations. The article explores the clinical manifestations of major complications, such as cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS). The patient ultimately developed a sudden coma and was found to have a cerebellar hemorrhage. The article emphasizes the need for early involvement of neurointensivists in the evaluation and management of patients receiving CAR-T cell therapy. [Extracted from the article]

Introduction: Patients on nonvitamin K antagonist (NVKA) are usually taking other drugs. Potential interaction may increase the gastrointestinal (GI) bleeding risk associated with NVKA. Methods: Observational cohort study using Medicare data from 2017 to 2020. Participants receiving a NVKA were included. A concomitant overlapping period while on NVKA was assessed for nonsteroidal anti‐inflammatory drugs (NSAIDS), selective serotonin reuptake inhibitors (SSRI), antiplatelets, glucocorticoids, aspirin and proton pump inhibitors (PPI). A logistic regression predicting either any bleeding or GI bleeding was conducted estimating the odds ratio (OR) and 95% confidence interval (CI). Results: A total of 102 531 people on NVKA with mean age 77 years (SD = 9.8) and 55% females (N = 56 671) were included. Previous history of GI bleeding occurred in 2 908 (2.8%) participants, concomitant exposure to PPI occurred in 38 713 (38%), SSRI in 16 487 (16%), clopidogrel in 15 795 (15.4%), NSAIDs in 13 715 (13.4%) and glucocorticoids in 13 715 (13.4%). Risk for any bleeding was shown for clopidogrel (OR: 1.37, 95% CI: 1.30, 1.44), prasugrel/ticagrelor (OR: 1.36, 95% CI: 1.18, 1.58), glucocorticoids (OR: 1.26, 95% CI: 1.19, 1.34), and SSRIs (OR: 1.13, 95% CI: 1.07, 1.19). GI bleeding risk was shown for clopidogrel (OR: 1.44, 95% CI: 1.34, 1.55), prasugrel/ticagrelor (OR: 1.47, 95% CI: 1.20, 1.79), SSRIs (OR: 1.09, 95% CI: 1.01, 1.17) and glucocorticoids (OR: 1.33, 95% CI: 1.23, 1.44). PPI use was correlated with both NSAID (r = 0.07, p ≤ 0.0001) and SSRI use (r = 0.09, p ≤ 0.0001). Conclusion: NVKA concomitantly taken with antiplatelets, glucocorticoids, and SSRIs showed an increased risk for any bleeding and GI bleeding. [ABSTRACT FROM AUTHOR]

This document provides a comprehensive overview of iron deficiency, its diagnosis, and management. It highlights the global prevalence of iron deficiency, with a particular focus on its impact on women. The document explains the classifications and diagnosis of iron deficiency, as well as the causes and investigation of the condition. It also discusses various treatment options, including oral and intravenous iron supplementation, and emphasizes the importance of monitoring response to therapy. The document includes helpful tables outlining recommended serum ferritin levels, the likelihood of different causes of iron deficiency, and the elemental iron content of different oral iron formulations. It also provides information on intravenous iron formulations and their recommended dosages. This resource is a valuable tool for individuals researching iron deficiency and its treatment options. [Extracted from the article]

Objective: Rare disease Background: Heyde syndrome is characterized by anemia due to angiodysplasia, aortic valve stenosis, and acquired von Willebrand syndrome. However, the awareness regarding Heyde syndrome in clinical practice is low. We report the case of an older woman with severe refractory iron-deficiency anemia and severe aortic stenosis who was diagnosed with Heyde syndrome. Case Report: A 70-year-old woman who had been experiencing exertional dyspnea for 3 months prior to presentation was diagnosed with iron-deficiency anemia, with a hemoglobin level of 69 g/L. She did not experience any episodes of bleeding, such as nosebleeds, gum bleeding, abnormal bleeding, or melena. Upper and lower gastrointestinal endoscopy revealed no evidence of bleeding, and oral iron supplementation failed to improve the anemia. Auscultation of the chest identified an ejection systolic murmur. Chest and abdominal computed tomography showed no significant lesions or active bleeding. Capsule endoscopy of the small intestine revealed capillary dilation. Echocardiography detected severe aortic valve stenosis. Blood test results revealed a deficiency in large von Willebrand factor multimers. Therefore, Heyde syndrome was diagnosed. Aortic valve replacement surgery was performed, which resulted in an improvement in anemia and the associated symptoms. Conclusions: In cases of unexplained and treatment-resistant iron-deficiency anemia, especially if careful auscultation detects aortic stenosis, Heyde syndrome should be considered a differential diagnosis. Furthermore, screening for angiodysplasia in the gastrointestinal tract and prompt diagnosis through measurement of large von Willebrand factor multimers are imperative when investigating potential sources of bleeding. [ABSTRACT FROM AUTHOR]

Cardiac embolism plays a very significant role in acute ischemic strokes (AIS), constituting approximately one-third of cases. The origin of these emboli often stems from intracardiac thrombi in the left atrium or left ventricle. Utilizing the National Readmission Database from 2016 to 2019, we investigate the prevalence of cardiac thrombi in AIS patients and explore their potential correlation with endovascular thrombectomy (EVT) utilization, and mortality rates. Among 1,272,456 AIS patients, 0.6% had concurrent cardiac thrombus, with an increasing trend observed over the study period (P value < 0.001). The cardiac thrombus cohort showed a higher prevalence of comorbidities such as congestive heart failure and atrial fibrillation. After propensity-score matching, groups were well-balanced in terms of baseline characteristics. Patients within the cardiac thrombus cohort experienced a longer hospital stay (median 5 days vs. 3 days), but no significant difference in mortality was noted. Importantly, the cardiac thrombus cohort demonstrated a higher frequency of EVT utilization, suggesting a link to larger vessel occlusions. Despite matching based on atrial fibrillation, the EVT utilization in the cardiac thrombus cohort remained high, highlighting a significant association. While 30-day readmission rates were comparable, cardiac thrombus patients faced a higher risk of gastrointestinal bleeding and hemorrhagic stroke, likely attributed to anticoagulation use. Limitations include potential miscoding in the administrative database and a lack of detailed imaging findings. In conclusion, this study highlights the increased likelihood of EVT in AIS patients with cardiac thrombus, possibly indicative of larger vessel occlusion associated with cardiac thrombus. [ABSTRACT FROM AUTHOR]

Background: Community-acquired pneumonia (CAP) is a common infectious disease characterized by inflammation of the lung parenchyma in individuals who have not recently been hospitalized. It remains a significant cause of morbidity and mortality worldwide. Aspirin is a widely used drug, often administered to CAP patients. However, the benefits of aspirin remain controversial. Objective: We sought to determine whether aspirin treatment has a protective effect on the outcomes of CAP patients. Methods: We selected patients with CAP from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Propensity score matching (PSM) balanced baseline differences. A multivariate Cox regression model assessed the relationship between aspirin treatment and 28-day mortality. Results: A total of 3,595 patients were included, with 2,261 receiving aspirin and 1,334 not. After PSM, 1,219 pairswerematched. The 28-day mortality rate for aspirin users was 20.46%, lower than non-users. Multivariate Cox regression indicated aspirin use was associated with decreased 28-day mortality (HR 0.75, 95% CI 0.63-0.88, p < 0.001). No significant differences were found between 325 mg/day and 81 mg/day aspirin treatments in terms of 28-day mortality, hospital mortality, 90-day mortality, gastrointestinal hemorrhage, and thrombocytopenia. However, intensive care unit (ICU) stay was longer for the 325 mg/day group compared to the 81 mg/day group (4.22 vs. 3.57 days, p = 0.031). Conclusion: Aspirin is associated with reduced 28-day mortality in CAP patients. However, 325 mg/day aspirin does not provide extra benefits over 81 mg/day and may lead to longer ICU stays. [ABSTRACT FROM AUTHOR]

With the recent development of interventional endoscopic ultrasound (EUS), EUS‐guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension‐related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS‐guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS‐guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to characterize the safety profiles of rivaroxabanassociated suspected adverse events by mining the Food and Drug Administration Adverse Event Reporting System (FAERS). Methods: A disproportionality analysis of spontaneously reported suspected adverse drug reactions (ADRs) was conducted. The reports in FAERS from 2014 to 2024 were compiled. Frequentist and Bayesian statistics were both applied to calculate drug-AE combinations in system organ classes and preferred-term levels. Reporting odds ratio (ROR), proportional reporting ratio (PRR), the Medicines and Healthcare products Regulatory Agency (MHRA), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS) methods were analyzed and used to compare the suspected AEs. Results: Of 77,384 ADR reports, 66,705 (86.20%) were serious rivaroxaban AE reports. The most common age group was above 65 years. The suspected adverse effects of rivaroxaban emerging for system organ classes (SOCs) primarily included "Gastrointestinal disorders"; "Injury, poisoning, and procedural complications", "Nervous system disorders" and "Vascular disorders". Ranked by EBGM, the top signal strength of suspected AE signals of rivaroxaban under ROR algorithm at the preferred-term (PT) level were "Haemorrhagic arteriovenous malformation" (N = 571, ROR = 756.520, PRR = 754.029, Information Component (IC) = 7.197, Empirical Bayesian Geometric Mean (EBGM) = 146.725), "Gastrointestinal vascular malformation haemorrhagic" (N = 197, ROR = 211.138, PRR = 210.950, IC = 6.614, EBGM = 97.923), and "Diverticulum intestinal haemorrhagic" (N = 722, ROR = 169.898, PRR = 169.210, IC = 6.458, EBGM = 97.920). Moreover, uncommon but significantly suspected AE signals, such as "Coagulation factor X level increased", "Basal ganglia haematoma", and "Proctitis haemorrhagic" were observed. Notably, "Gastrointestinal haemorrhage" (N = 13,436, ROR = 80.477, PRR = 74.460, IC = 5.729, EBGM = 53.042), "Upper gastrointestinal haemorrhage"(N = 2,872, ROR = 73.978, PRR = 72.797, IC = 5.706, EBGM = 52.198) and "Internal haemorrhage" (N = 2,368, ROR = 91.979, PRR = 80.899, IC = 5.813, EBGM = 56.212) exhibited relatively high occurrence rates and signal strengths. From 2014 to 2024, the IC values of rivaroxaban-associated suspected AEs for "Surgical and medical procedures" and "Cardiac disorders" showed an annual increasing trend in the time-span analysis. Based on the various visulization plots, a key discovery is that "Gastrointestinal hemorrhage" emerged as the most significant suspected AE across five algorithms. The exciting finding was that the MGPS algorithm revealed a higher risk of suspected AEs under the "Investigations" category. However, the results of the analyses of the other algorithms at the SOC level were not akin to this. Moreover, the results of signal mining for the three main types of indication populations with adverse drug reactions (ADRs), including Atrial fibrillation, Cerebrovascular accident prophylaxis, and Deep vein thrombosis were shown that "Gastrointestinal haemorrhage", "Epistaxis", "Haematuria", "Rectal haemorrhage", and "Upper gastrointestinal haemorrhage" were detected as the most common and significant signals of suspected adverse events. Conclusion: Rivaroxaban has risks of various suspected adverse reactions while providing therapeutic effects and being used widely. Our pharmacovigilance study may provide valuable hints that practitioners should closely monitor occurrences of "Gastrointestinal disorders", "Injury, poisoning, and procedural complications" and "Nervous system disorders", and other events in clinical applications. Consequently, it remains to persist in monitoring rivaroxaban, assessing the associated risks in the future. [ABSTRACT FROM AUTHOR]

Objectives: To identify independent predictors of late recurrence of atrial fibrillation (AF) after surgical ablation in patients undergoing rheumatic valve surgery. Methods: A total of 258 patients who underwent surgical ablation for AF with rheumatic heart disease at our hospital between January 2019 and June 2022 were retrospectively included. The patients were followed up for 12 months. Late recurrence was defined as any AF recurrence longer than 30 s between 3 and 12 months. Patients with or without late recurrence were divided into non-recurrence and recurrence groups. Univariate and multivariate analyses were performed to identify the predictors of late recurrence. Results: The in-hospital mortality rate was 0.8% (2/258), and the late recurrence rate of AF was 38.4%, including 152 and 95 cases in the non-recurrent and recurrent groups respectively, with a follow-up completion rate of 96.5% (247/256). There were no deaths during follow-up, two patients (0.8%) experienced a stroke, and one patient (0.4%) experienced gastrointestinal hemorrhage. The results of the univariate and multivariate analyses of the preoperative risk factors for late recurrence showed a left atrial (LA) anteroposterior diameter ≥ 52.9 mm (odds ratio [OR] = 2.366, 95% confidence interval [CI] = 1.089–5.138, P = 0.030], ratio of the superoinferior to the anteroposterior diameters of LA (S-AR) < 1.19 (OR = 4.639, 95% CI = 2.181–9.865, P < 0.001), and AF duration ≥ 39 months (OR = 6.152, 95% CI = 2.897–13.061, P < 0.001), and cardiothoracic ratio ≥ 0.63 (OR = 2.716, 95% CI = 1.314–5.612, P = 0.007) were the most significant independent risk factors. Conclusions: LA anteroposterior diameter ≥ 52.9 mm, S-AR < 1.19, and AF duration ≥ 36 months and cardiothoracic ratio ≥ 0.63 are independent predictors for late recurrence of AF after surgical ablation in patients undergoing rheumatic valve surgery. [ABSTRACT FROM AUTHOR]

Introduction: Upper gastrointestinal bleeding (UGIB) is among the most common causes of morbidity and mortality worldwide, accounting for major resource allocation and increasing incidence. This study aimed to evaluate the severity of non-variceal bleeding in patients at risk of bleeding through the use of NSAIDs, oral anticoagulants, and antiplatelet therapy. Material and Method: The study included 296 patients admitted in the Gastroenterology Department of the Municipal County Emergency University Hospital, Timisoara, between 01.01.2018 and 01.04.2020, and diagnosed via gastroscopy with non-variceal gastrointestinal bleeding. The patients were divided among four groups based on their use of different drugs known to induce UGIB, i.e., aspirin and clopidogrel, NOACs, NSAIDs, and anti-vitamin K drugs, respectively. Statistical analyses were performed based on ANOVA one-way tests for continuous variables and Chi-square tests for categorical variables with pairwise comparisons based on Bonferroni adjusted significance tests. Results: The results showed several parameters having statistical significance among the different groups of patients. Patients on NOACs had statistically significant lower hemoglobin levels, lower hematocrit values, lower erythrocytes, lower RDW and higher fibrinogen levels compared to patients on VKA. Discussion: Surprisingly, the results from our study suggest that the use of NOACs was associated with a higher risk of bleeding when compared to VKA, which differs from the existing literature. Conclusions: One of the important factors causing upper non-variceal bleeding can be iatrogenic, either due to antiplatelet drugs or anticoagulants, to which NSAID treatment is additionally associated for various reasons. In our study, the use of NOACs seemed to have a more severe bleeding spectrum with higher morbidity compared to VKA. [ABSTRACT FROM AUTHOR]

Background: The use of durable left ventricular assist devices (LVADs) for advanced heart failure is increasing and a growing number of patients will require anesthesia for non-cardiac procedures (NCPs). The goal of this study was to describe our experience with NCPs for LVAD patients. Methods: All anesthetic procedures performed in LVAD patients at a single center were reviewed from 2014 to 2023. Perioperative management data and complications were assessed. Results: In total, 16 patients had an LVAD implanted and 9 (56.3%) patients underwent anesthesia for a total of 22 NCPs. Most of the procedures took place outside of the operating room, mainly in the endoscopy unit, as gastrointestinal endoscopy was the most common procedure (13, 59.2%). Sedation was provided in 17 procedures (77.3%). Standard monitoring was used in all cases, and invasive monitoring was applied just in cases of major surgeries. There were no intraoperative complications reported. Postoperative complications were recorded after eight (36.4%) of the procedures, consisting mainly of lower gastrointestinal bleeding after lower endoscopy, which increased the length of hospital stay. All procedures were performed by non-cardiac anesthesiologists. Conclusions: Our data suggest that, in most cases, adherence to standard anesthesia practices can be suitable for NCPs in LVAD patients. [ABSTRACT FROM AUTHOR]

Summary: Background: The incidence of major gastrointestinal bleeding (GIB) in patients on low‐dose direct‐acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking. Aims: To assess GIB incidence and predictors from RCT data of patients on aspirin, low‐dose rivaroxaban, or both. Methods: This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures. Results: Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53–6.82 for ≥75 vs. 55–64), peptic ulcer disease (PUD, OR 1.57, 1.01–2.44), liver disease (OR 2.09, 1.01–4.33), hypertension (OR 1.42, 1.04–1.94), and smoking (OR 1.85, 1.26–2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12–2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88–7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64–4.84) than upper GIB (OR 1.86, 1.18–2.92). Conclusions: We established incidences and identified risk factors for GIB in users of low‐dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggest that low-molecular-weight heparin (LMWH) may play a role in mitigating the severity of acute pancreatitis (AP). This systematic review and meta-analysis aims to synthesise existing evidence on the effectiveness and safety of LMWH in the treatment of moderately-severe and severe AP. Methods: This systematic review and meta-analysis was conducted in accordance with the 2020 update of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The systematic search was conducted in MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, and EMBASE, covering studies published up to February 2024. Randomised controlled trials (RCTs) and observational studies (n-RCTs) that reported the differences in the outcomes of AP for patients receiving LMWH in addition to the standard treatment (Intervention), compared to patients managed by standard treatment without LMWH (Control) were eligible. A random-effects model was used to calculate the pooled relative risk (RR) and mean differences (MD) with the corresponding 95% CI. Results: Thirteen studies were included in the meta-analysis, all published between 2004 and 2022. Eight studies were RCTs, and five were n-RCTs. Data from 13,709 patients (6.971 Interventions and 6.738 Controls) were analysed. The comparison of Intervention and Control groups showed the superiority of LMWH to standard treatments in terms of overall mortality (RR = 0.44, 95% CI = 0.31; 0.64, P < 0.0001, I2 = 51%), acute necrotic collections (RR = 0.24, 95% CI = 0.09; 0.62, P = 0.003, I2 = 0%), and organ failure (RR = 0.67, 95% CI = 0.48; 0.93, P = 0.02, I2 = 78%). The Intervention group showed superior outcomes compared with the Control group for gastrointestinal bleeding (RR = 0.64, 95% CI = 0.44; 0.94, P = 0.02, I2 = 0%), length of hospital stay (MD= − 6.08, 95% CI = − 10.08; − 2.07, P = 0.003, I2 = 98%), need for operative interventions (RR = 0.50, 95% CI = 0.29; 0.87, P = 0.01, I2 = 61%), and vascular thrombosis (RR = 0.43, 95% CI = 0.31; 0.61, P < 0.00001, I2 = 0%). Conclusions: Moderate to high-quality evidence suggests that early intervention with LMWH could improve the prognosis of non-mild AP in terms of mortality, organ failure, and decreased incidence of vascular thrombosis. In light of our findings, integrating LMWH into the treatment regimen for moderate-severe to severe AP is advocated. [ABSTRACT FROM AUTHOR]

Purpose: To determine the ability of CO2-enhanced angiography to detect active diverticular bleeding that is not detected by iodinated contrast medium (ICM)-enhanced angiography and its impact on clinical outcomes when used to confirm embolization, particularly the risks of rebleeding and ischemic complications. Materials and methods: We retrospectively identified a cohort of patients with colonic diverticular bleeding who underwent catheter angiography between August 2008 and May 2023 at our institution. We divided them according to whether they underwent CO2 angiography following a negative ICM angiography study or to confirm hemostasis post-embolization (the CO2 angiography group) or ICM angiography alone in the absence of active bleeding or for confirmation of hemostasis post-embolization (the ICM angiography group). The ability to detect active colonic diverticular bleeding and clinical outcomes were compared between the two groups. Results: There were 31 patients in the ICM angiography group and 29 in the CO2 angiography group. The rate of detection of active bleeding by CO2 angiography that was not identified by ICM angiography was 48%. The rebleeding rate was 23% in the ICM angiography group and 6.9% in the CO2 angiography group. Among the patients who underwent TAE, the ischemic complications rate was 7.1% in the ICM angiography group and 4.5% in the CO2 angiography group. Conclusions: CO2 angiography may detect active diverticular bleeding that is not detectable by ICM angiography and appears to be associated with a lower rebleeding rate. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%–90%. However, 10%–20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments. [ABSTRACT FROM AUTHOR]

Background and Objectives Materials and Methods Results Conclusion To develop key performance indicators (KPI) for use in quality assessment of our institutional goal‐directed massive transfusion (GDMT).A team comprising our transfusion and emergency medicine departments carried out a cross‐sectional data analysis of GDMT in adult patients from January 2021 to December 2022. The study was rooted in the Define, Measure, Analyse, Improve, Control (DMAIC) approach. Features of KPIs were (a) importance, (b) scientific soundness and (c) feasibility. Study parameters were defined and analysed using measures of central tendencies and benchmark comparison.Ninety‐two massive transfusion events occurred and 1405 blood components were used. Trauma was the leading cause, followed by postpartum haemorrhage and upper gastrointestinal bleeding. Appropriate GDMT activation was observed only in 43.47% of events. The turnaround time (TAT) was within the benchmark in 85.8% of events with an average of 16 ± 10 min. The average utilization of blood components was 20.5 (interquartile range [IQR] = 11.3) in the appropriate group and 5.5 (IQR = 4.25) in the inappropriate group with a wastage rate of 3.5%. Duration of activation was 6.19 ± 4.59 h, and the adherence to thromboelastography was 66.3%. Overall mortality was 45.65%, and the average duration of hospital stay was 6.1 ± 5.9 days.The KPIs developed were easy to capture, and the analysis provided a comprehensive approach to the quality improvement of the GDMT protocol. [ABSTRACT FROM AUTHOR]

The first article discusses a rare oesophageal lesion called oesophageal submucosal gland duct adenoma (ESGDA). It is typically diagnosed in males aged 50-80 and can cause abdominal pain. Less than 20 cases have been reported, with some cases also involving other types of cancer. The article emphasizes the importance of considering ESGDA in the differential diagnosis of oesophageal submucosal lesions and highlights the need for complete endoscopic mucosal resection.The second article focuses on colonoscopy in octogenarians and older patients for colorectal cancer (CRC) detection. The study evaluates the effectiveness and safety of a contemporary bowel preparation method called 1L polyethylene glycol plus ascorbic acid (1L PEG+ASC) in this population. The results show that 1L PEG+ASC was highly effective and had a good safety profile, with over half of the patients achieving high-quality colon cleansing. [Extracted from the article]

This document includes summaries of three articles from the Journal of Gastroenterology & Hepatology. The first article discusses the safety, efficacy, and tolerability of an ultra-low volume bowel preparation called NER1006. The study found that NER1006 was a safe and effective option for bowel preparation, with high scores on the Boston Bowel Preparation Scale and positive quality indicators for colonoscopy. The second article focuses on the recurrence of gastroesophageal reflux disease (GERD) symptoms after cessation of vonoprazan therapy. The study found that the presence of a hiatal hernia was a significant predictor for symptomatic recurrence of GERD. The third article discusses the establishment of a tertiary faecal microbiota transplant (FMT) service and its outcomes. The study found that FMT was effective in treating recurrent Clostridium difficile infection (CDI) and had a high rate of primary response and cure. [Extracted from the article]

Purpose To analyze the appropriateness of triple-antithrombotic therapy based on the 2020 American College of Cardiology (ACC) consensus statement while evaluating safety outcomes for patients with respect to adverse events. Methods A single-center, retrospective chart review was conducted using electronic medical records from December 18, 2020, to August 31, 2022. The primary endpoint was the rate of appropriateness for triple-antithrombotic therapy in patients discharged from Ochsner LSU Health Shreveport. Appropriateness was a composite endpoint extrapolated from the 2020 ACC consensus statement. For therapy to be defined as appropriate, patients had to have had the correct therapy indication, medications, dosing, and 30-day duration. Secondary safety endpoints included the percentage of patients rehospitalized at 14 and 30 days, the rate of major bleeding events, and the percentage of patients on gastrointestinal prophylaxis while on triple-antithrombotic therapy. Results A total of 93 patients were included in the study, of whom 31 (33%) received appropriate triple-antithrombotic therapy. Prolonged duration of triple-antithrombotic therapy was the most common reason that therapy did not meet the primary endpoint. The readmission rate due to bleeding was 2.2% at 14 days and 6.5% at 30 days. Within 30 days of initiation of triple therapy, 4.3% of patients endured major bleeding as defined by the International Society on Thrombosis and Hemostasis and 2 patients died. Conclusion In this single-center study, triple-antithrombotic therapy appropriately adhered to the 2020 ACC consensus statement for one-third of patients discharged on this therapy. [ABSTRACT FROM AUTHOR]

Pseudoaneurysm of the splenic artery is a rare vascular complication of chronic pancreatitis, with a high mortality rate. Haemorrhage and abdominal pain are the most common manifestations, and so far there are no literature reviews on the rare complication of splenic artery pseudoaneurysm due to chronic pancreatitis. Therefore, we describe a male patient with worsening haemochezia and upper abdominal pain, who had been hospitalized repeatedly for 'pancreatitis' 1 year ago, and relevant investigations confirmed a pseudoaneurysm of the splenic artery, which was successfully treated by transarterial embolization, and a literature review is also presented. [ABSTRACT FROM AUTHOR]

This article provides information on the emergency care of patients who have undergone metabolic bariatric surgery. It emphasizes that patients may present with few symptoms and little pain, but still be critically unwell. The article discusses common clinical signs of surgical complications and the importance of transferring patients to specialist bariatric centers when necessary. It also provides information on side effects and complications of different bariatric procedures, highlighting the need for prompt diagnosis and appropriate management to minimize morbidity and mortality. The document emphasizes the importance of specialized care in bariatric centers and collaboration with bariatric surgeons for optimal outcomes. [Extracted from the article]

The role of the liver in drug metabolism makes individuals with hepatic dysfunction more susceptible to adverse drug reactions, necessitating careful consideration in analgesic selection and dosing. Acetaminophen, despite being a common cause of liver failure, is considered safe within recommended dosages. Nonsteroidal antiinflammatory drugs (NSAIDs), while effective, pose risks in cirrhosis due to complications like renal failure and gastrointestinal bleeding. Cyclooxygenase-2 inhibitors have limited data, and their use is discouraged due to cardiovascular concerns. Opiates, though potent, require cautious use in cirrhosis due to altered metabolism, potential adverse effects, and the risk of addiction. Tricyclic antidepressants like nortriptyline and desipramine can be utilized for neuropathic pain, while SSRIs and SNRIs are not recommended. Anticonvulsants such as gabapentin and pregabalin are preferred for neuropathic pain, with gabapentin being the first-line choice. Topical analgesics, including NSAIDs, lidocaine, and rubefacients, are deemed safe for use in cirrhosis, offering localized relief with minimal systemic effects. Nonpharmacological approaches addressing medical, psychological, and socio-economic factors are crucial adjuvants to analgesic therapy in advanced liver diseases. Physiotherapy, psychotherapy, behavioral therapy, relaxation techniques, acupuncture, and traditional practices like yoga and massage, as well as novel modalities, contribute to a holistic pain management strategy. This review provides healthcare professionals with valuable insights into the complex landscape of analgesic therapy in cirrhosis. Meticulous consideration of drug metabolism, hepatic safety, and individual patient factors is paramount in optimizing pain management strategies for this challenging patient population. [ABSTRACT FROM AUTHOR]

This document provides a summary of a study on the long-term surveillance of gastric varices (GV) in patients with non-cirrhotic portal hypertension (NCPH). The study found that repeat secondary prophylactic interventions for GV rarely occur beyond four years, and rebleeding can still occur despite endoscopic ultrasound (EUS) surveillance and treatment. However, late rebleeding may have a good prognosis. The study suggests that larger prospective cohorts would be valuable to confirm these findings. The document also includes supplementary materials related to the article and information about conflicts of interest and funding. [Extracted from the article]

Background/Aims: Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis. Methods: Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival. Results: The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20-220 days) and 66.5 days (range, 31-220 days), respectively. Conclusions: Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life. [ABSTRACT FROM AUTHOR]

Background/Aims: Few multicenter studies have investigated the efficacy of hemostatic powders in gastrointestinal (GI) bleeding. We aimed to investigate the clinical outcomes of hemostatic powder therapy and the independent factors affecting rebleeding rates. Methods: We retrospectively recruited patients who underwent a new hemostatic adhesive powder (UI-EWD; Next-Biomedical) treatment for upper and lower GI bleeding between January 1, 2020 and March 1, 2023. We collected patients' medical records and bleeding lesions. The primary outcomes were clinical and technical success rates, and the secondary outcomes were early and delayed bleeding rates refractory bleeding rate, mortality rate, and factors affecting early rebleeding rates. Results: This study enrolled 135 patients (age: 67.7±13.6 years, male: 74.1%) from five hospitals. Indications for UI-EWD were peptic ulcers (51.1%), post-procedure-related bleeding (23.0%), and tumor bleeding (19.3%). The clinical and technical success rates were both 97%. The early, delayed, and refractory rebleeding rates were 19.3%, 11.1%, and 12.8%, respectively. Initially elevated blood urea nitrogen (BUN) levels (p=0.014) and Forrest classification IA or IB compared with IIA or IIB (p=0.036) were factors affecting early rebleeding. Conclusions: UI-EWD showed high clinical and technical success rates; however, rebleeding after UI-EWD therapy in patients with initially high BUN levels and active bleeding, according to the Forrest classification, should be considered. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Cystic artery pseudoaneurysm is a rare phenomenon associated with cholecystitis. We describe the successful management of angioembolisation and cholecystectomy. Cystic artery pseudoaneurysm (CAP) is a rare but clinically significant condition with various etiological factors. Cholecystitis is a prominent cause, often leading to inflammation‐induced arterial wall erosion and pseudoaneurysm formation. CAP can present with a range of symptoms, including hemobilia, upper GI bleeding, and jaundice. Despite its rarity, CAP warrants attention in emergency care due to its potential for life‐threatening arterial bleeding. Timely diagnosis is crucial, with imaging techniques playing a key role. Depending on the clinical context, management options include endovascular embolization and surgical intervention. Due to the limited cases, standard protocols remain elusive. A 64‐year‐old woman presented with abdominal pain, anorexia, and weight loss, prompting an evaluation for possible gallbladder cancer. She experienced sudden abdominal pain and upper gastrointestinal bleeding (hematemesis). Laboratory findings revealed leukocytosis, anemia, and abnormal liver function tests. Imaging showed gallbladder wall thickening, luminal contraction, and a pseudoaneurysm in the cystic artery. The patient underwent angioembolization followed by cholecystectomy, confirming acute cholecystitis and CAP with thrombosis. This case underscores the importance of early recognition and appropriate management in CAP, particularly when accompanied by acute cholecystitis. [ABSTRACT FROM AUTHOR]

Introduction: There are a lack of data describing outcomes and follow-up after hospital discharge for patients with newly diagnosed cirrhosis with complication on index admission. This study examines factors that influence outcomes such as readmission, follow-up, and mortality for patients with newly diagnosed cirrhosis. Methods: We conducted a single-center retrospective chart review study of 230 patients with newly diagnosed cirrhosis from January 1st, 2020 through December 31st, 2021. We obtained demographics, clinical diagnoses, admission, and discharge MELD-Na, disposition, mortality, appointment requests rate, appointment show rate, and readmission. Results: The primary complications on admission were GI bleed (27%), ascites (25.7%), and hepatic encephalopathy (HE) (10.4%). Overall, the median length of stay (LOS) was 6 days, and the readmission rate was 27%. Out of 230 patients, 25 (10.9%) patients died while hospitalized while another 43 (18.6%) died after initial discharge within the two-year study period. Although there was a significant reduction of the MELD-Na from admission to discharge (p < 0.05), admission MELD-Na did not correlate with LOS and discharge MELD-Na did not predict readmission. Patients with HE had the highest median LOS, while patients with ascites had the highest readmission rate. The median time to an appointment was 32 days. When comparing discharge destinations, most patients were discharged to home (63%), to facilities (13.9%), or expired (10.9%). The average appointment show rate was 38.5%, although 70% of patients had appointment requests. Readmission rate and mortality did not differ based on appointment requests. No significant differences in outcomes were observed based on race, sex, or insurance status. Conclusion: New diagnosis of decompensated was found to have high mortality and high readmission rates. Higher MELD-Na score was seen in patients who died within 30 days. Routine appointment requests did not significantly improve readmission, mortality, increase appointment show rate, or decrease time to appointment. A comprehensive and specialized hepatology-specific program may have great benefits after cirrhotic decompensation, especially for those with newly diagnosed cirrhosis. [ABSTRACT FROM AUTHOR]

Background: A GI hospitalist (GIH) is a physician who practices in the inpatient setting performing consultations and endoscopic procedures. Obscure small bowel bleeding is a common inpatient diagnosis that is difficult to manage and associated with longer hospitalizations. Having an onsite GIH physician with expertise in video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) has the potential to improve patient outcomes. Aims: This study will be the first to explore how implementing a GIH model and providing a GIH with training in DBE can affect the outcomes of patients with small bowel pathology. Methods: We performed a retrospective study of patients who received an inpatient DBE at an academic medical center before and after initiation of a GIH model and credentialing of a GIH in DBE. We compared outcomes, including procedure volumes, diagnostic and therapeutic yields, procedure duration, time to procedure, and length of stay. Results: There was a 46.5% increase in the number of DBEs performed by the GIH. The diagnostic yield increased from 56.3 to 74.0% (OR 2.2, 95% CI 1.2–4.2), and the proportion of DBEs with a therapeutic intervention increased from 38.0 to 65.4% (OR 3.1, 95% CI 1.4–7.0). The total procedure time increased from 77.8 to 96.4 min (p < 0.05) with a GIH. Conclusion: Having a GIH perform inpatient DBEs was associated with an increased number of procedures, duration of procedures, diagnostic yield, and therapeutic interventions. The onsite presence of a GIH with competency in DBE improves the care of hospitalized patients with small bowel pathology. [ABSTRACT FROM AUTHOR]

Background: Rectal indomethacin reduces pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, there is insufficient evidence regarding its added benefits in patients already receiving prophylactic pancreatic stenting. Our goal was to evaluate the impact of indomethacin in high-risk patients undergoing pancreatic stenting. Methods: A cohort study was conducted on all patients who underwent the rescue cannulation technique for challenging bile duct cannulation (selected high-risk patients). Patients were split into two groups based on the prophylaxis method for post-ERCP pancreatitis (PEP): one receiving a combination of indomethacin and pancreatic stenting, while the other received pancreatic stenting alone. Comparative analyses were carried out on PEP, hyperamylasemia, gastrointestinal bleeding, and postoperative hospital stay among post-ERCP pancreatitis patients. Results: Between November 2017 and May 2023, a total of 607 patients with native papillae were enrolled, with 140 grouped into the indomethacin plus stent group and 467 into the stent alone group. The overall PEP rate was 4.4% in the entire cohort, with no statistical differences observed between the groups in terms of PEP rates (P = 0.407), mild PEP (P = 0.340), moderate to severe PEP (P = 1.000), hyperamylasemia (P = 0.543), gastrointestinal bleeding (P = 0.392), and postoperative hospital stay (P = 0.521). Furthermore, sensitivity analysis using multivariable analysis also validated these findings. Conclusions: Indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement. Therefore, the additional administration of rectal indomethacin to further mitigate PEP appears to be not necessary. [ABSTRACT FROM AUTHOR]

This document, published in the American Journal of Gastroenterology, provides a comprehensive overview of quality indicators for gastrointestinal endoscopic procedures. The authors emphasize the importance of following these indicators to ensure high-quality care and improve patient outcomes. The document covers various aspects of the procedure, including preprocedure, intraprocedure, and postprocedure quality indicators, as well as the standardization of endoscopic reports. It also includes research on open-access endoscopy, guidelines for informed consent and sedation, preoperative fasting, antibiotic prophylaxis, complications and adverse events, and specimen labeling and reporting. The information provided aims to enhance the quality and safety of gastrointestinal endoscopy procedures. [Extracted from the article]

(1) Background: Proton pump inhibitors (PPIs) are commonly prescribed for gastric disorders. In patients with liver cirrhosis, PPI use is associated with an increased risk of spontaneous bacterial peritonitis and increased mortality rates; therefore, they should be used with caution. This study aims to evaluate the appropriateness of PPI prescriptions in hospitalized cirrhotic patients against current clinical guidelines to identify patterns of misuse and guide better prescribing practices. (2) Methods: A retrospective study was conducted on liver cirrhosis inpatients in an internal medicine department from January 2022 to May 2023. The primary measure was the proportion of PPI prescriptions aligned with clinical guidelines. Medical files were entirely reviewed by researchers to assess the appropriateness of PPI prescriptions using the current guidelines. Outcomes included the identification of common reasons for PPI prescription and the rate of inappropriate PPI use among the study population. (3) Results: The study included 189 cirrhotic patients, with PPIs prescribed to 95 (50.2%) patients during hospitalization and 75 (39.7%) patients at discharge. Among those, 47.4% of the inpatients and 34.7% at discharge had no valid indication for PPI administration. The most common reason for PPI prescription during hospital stays was gastritis, followed by antiplatelet use in high-risk patients, ulcers, and upper gastrointestinal bleeding. The most common inappropriate indication was portal hypertensive gastropathy (PHG), followed by treatment with corticosteroids and anticoagulants alone. We did not find an association between PPI administration during hospital stays and infections. Only in 4% of cases patients should have received PPIs and did not. (4) Conclusions: There is a concerning overprescription of PPIs in cirrhotic patients, often deviating from established guidelines. It subjects patients to unnecessary risks. There is an urgent need for increased awareness and adherence to clinical guidelines regarding PPI prescriptions in cirrhotic patients. [ABSTRACT FROM AUTHOR]

Background/Aims: The incidence of acute gastrointestinal bleeding (GIB) increases with the utilization of anticoagulant and nonsteroidal anti-inflammatory drugs (NSAIDs). This study aimed to compare the risk of GIB between anticoagulant and NSAIDs combotherapy and anticoagulant monotherapy in real-world practice. Methods: We investigated the relative risk of GIB in individuals newly prescribed anticoagulant and NSAIDs combination therapy and that in individuals newly prescribed anticoagulant monotherapy at three hospitals using “common data model.” Cox proportional hazard models and Kaplan-Meier estimation were employed for risk comparison after propensity score matching. Results: A comprehensive analysis of 2,951 matched pairs showed that patients who received anticoagulant and NSAIDs combousers exhibited a significantly higher risk of GIB than those who received anticoagulant monousers (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.30 to 2.12; p<0.001). The risk of GIB associated with anticoagulant and NSAIDs combination therapy was also significantly higher than that associated with anticoagulant monotherapy in patients aged >65 years (HR, 1.53; 95% CI, 1.15 to 2.03; p=0.003) and >75 years (HR, 1.89; 95% CI, 1.23 to 2.90; p=0.003). We also found that the risk of GIB was significantly higher in the patients who received anticoagulant and NSAIDs combousers than that in patients who received anticoagulant monousers in both male (p=0.016) and female cohorts (p=0.010). Conclusions: The risk of GIB is significantly higher in patients who receive anticoagulant and NSAIDs combotherapy than that in patients who receive anticoagulant monotherapy. In addition, the risk of GIB associated with anticoagulant and NSAIDs combotherapy was much higher in individuals aged >75 years. Therefore, physicians should be more aware of pay more attention to the risk of GIB when they prescribe anticoagulant and NSAIDs. [ABSTRACT FROM AUTHOR]

Background/Aims: Early studies on direct oral anticoagulants (DOACs) reported a higher risk of gastrointestinal bleeding (GIB) compared with warfarin; however, recent studies have reported a reduced risk. Therefore, this study was designed to evaluate the risk of GIB in users of DOAC and warfarin. Methods: Using a common data model, we investigated the comparative risk of GIB in subjects from eight hospitals who were newly prescribed DOACs or warfarin. We excluded subjects who had a prior history of GIB or had been prescribed both medications. After propensity score matching, we analyzed 3,347 matched pairs of new DOAC and new warfarin users. Results: The risk of GIB in new DOAC users was comparable to that in new warfarin users (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.65 to 1.40; p=0.808). New DOAC users had a similar risk of GIB to new warfarin users among older patients >65 years (HR, 1.00; 95% CI, 0.69 to 1.52; p=0.997) and in older patients >75 years (HR, 1.21; 95% CI, 0.68 to 2.10; p=0.509). In addition, the risk of GIB was not significantly different between two groups according to sex. We also found that the risk of GIB in DOAC users was 26% lower in edoxaban or apixaban subgroups compared to rivaroxaban or dabigatran subgroups (HR, 0.74; 95% CI, 0.69 to 1.00; p=0.049). Conclusions: In real-world practice, the risk of GIB in new DOAC users is comparable to that in new warfarin users. In DOAC users, the risk of GIB was lower in edoxaban or apixaban subgroups than rivaroxaban or dabigatran subgroups. [ABSTRACT FROM AUTHOR]

Introduction: Transcatheter arterial embolization is a minimally invasive technique which is a safe, fast and effective alternative to surgery, and is now considered the first-line therapy for upper GI bleeding, refractory to endoscopic management. Aim & Objectives: The initial treatment modality of any case presenting with upper GI bleed is endoscopic hemostasis. However, this article highlights those cases who are refractory to initial endoscopic therapy and are the candidates for surgery or interventional embolization therapy. Material and Methods: This case report highlights a middle-aged male presenting with endoscopic refractory GI bleed, to a tertiary care center in North- West India. Conclusion: Transcatheter arterial embolization is typically guided by CT angiography which localizes the site of the bleeding vessel. However, in cases where no active bleeding vessel can be identified, a blind procedure is performed in which the suspected vessel is targeted for embolic therapy. In this article we discuss a case where the blind transarterial technique of vascular bed embolization has been utilized which has revolutionized the management of refractory upper GI bleed. [ABSTRACT FROM AUTHOR]

Background: Cavernous hemangioma of the small intestine is rarein adults. Obscure Overt Gastrointestinal bleeding (OOGIB) caused by smallbowel hemangioma is extremely rare. According to the size of the affected vessels, hemangiomas are histologically classified into cavernous, capillary, and mixed-type tumors, with the cavernous type being the most common and racemose being very rare in the clinic.Owing to the rarity of gastrointestinal hemangiomas and the lack of specific manifestations and diagnostic methodsthe source of GI bleeding could not be initially identified despite the use of numerous diagnostic modalities. Case Summary: We report the case of a 40-year-old female presenting with painless melena and postprandial bloating. Laboratory investigations revealed recurrent and prominent anemia. DBE (Double-balloon endoscopy) revealed subepithelial lesion in the distal jejunum. Segmental resection of the lesion in the jejunum was performed, and cavernous hemangioma was diagnosed based on histopathological analysis. Segmental resection of the ileal lesion was performed surgically, and the final pathologicalresults revealed a diagnosis of cavernous hemangioma. At present the patient is symptom free and doing fine. Conclusion: The current report will increase our understanding of the diagnosis and treatment of gastrointestinal hemangiomas and provide a review of the related literature. [ABSTRACT FROM AUTHOR]