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Dieulafoy's lesion (DL) is a dilated aberrant submucosal vessel that erodes through the overlying epithelium in the absence of a primary ulcer. It is a known cause of gastrointestinal (GI) bleeding and commonly located in the lesser curvature of the stomach, but it is rare in the anal canal. We report a unique case of a middle-aged man presenting with lower GI bleeding secondary to an anal DL diagnosed by colonoscopy, managed successfully with endoscopic hemoclips.

Background and study aims Hemostatic powders have been introduced to improve the management of gastrointestinal (GI) bleeding and to extend the variety of tools available for emergency endoscopy. The aim of the present pilot study was to evaluate the indication profiles and the short-term outcome of EndoClot. Patients, materials and methods In a prospective observational pilot study patients with acute nonvariceal GI bleeding were included. Primary or secondary application of EndoClot was assessed. Hemoglobin, prothrombine time and platelets were documented before and after hemostasis. The efficacy of EndoClot was assessed 72 hours and 1 week after application. Results Seventy patients with acute GI bleeding were recruited into the study. Eighty-three percent (58/70) of the patients had upper and 17% (12/70) had lower GI bleeding. In the upper GI tract treatment success was achieved in 64% (30/47, 95% confidence interval, 50%-76%) after primary use and in all patients, when used after established techniques had failed (95% confidence interval, 70%-100%). In lower GI bleeding hemostasis was achieved in 83% of cases (10/12, 95% confidence interval 54%-97%). Rebleeding occurred in 11% (8/70), in 10% EndoClot served as a bridge to surgery (7/70). Conclusions EndoClot expanded the therapeutic options in the management of GI bleeding. It was applicable as a monotherapy or in combination with other techniques from oozing bleeding type or lower. It was most effective in diffuse or extensive bleeding activity or when access to the bleeding vessel was difficult. EndoClot can be applied as a bridge to surgery when classical methods of hemostasis have failed.

Choriocarcinoma, a nonseminomatous germ cell tumor, is a rare type of testicular malignancy that tends to occur in young males. It is, however, exceedingly rare for choriocarcinoma to involve the GI tract. In this article, we present a rare case of a 31-year-old male, diagnosed with choriocarcinoma of the left testes, along with several metastases to distant sites. The patient presented with headaches and severe lower GI bleeding due to metastases to the GI tract, which was eventually controlled with systemic chemotherapy, while requiring several units of packed RBCs during his admission to the hospital. An extensive literature review found very few cases of the occurrence of GI bleeding as a consequence of choriocarcinoma due to metastases to the GI tract.

Background and Aims Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospitalization potentially requiring urgent intervention, which may not be readily available at weekends and off-hours. The aim of this study was to examine the association between weekend admission for LGIB and mortality, time to colonoscopy, length of stay, and hospital charges. Methods The 2016 U.S. National Inpatient Sample (NIS) dataset was queried for admissions with a primary diagnosis of LGIB. Outcomes for weekend versus weekday admissions were compared using survey-adjusted chi-squared or bivariate correlation. Multivariable regression was then used to compare primary outcomes adjusting for the Elixhauser mortality score (a validated measure of comorbidities), colonoscopy, transfusion, shock, and hospital type. Results An estimated 124,620 patients were admitted for LGIB in 2016. Comparing weekend with weekday admissions, there was no difference in unadjusted mortality (0.9% vs 1.0%, P = .636). Colonoscopy within the first day (28.6% vs 23.0%, P Conclusions Early colonoscopy (within the first day) is more common for weekday admissions, but overall outcomes are not affected by weekend admission for LGIB compared with weekday admissions.

Introduction Gastrointestinal (GI) bleeding is becoming more common with an aging population. Lower GI bleeding is less common than its upper GI bleed counterpart. Incidence of bleeding is increasing because more patients are on anticoagulation medication. Abnormal coagulation can lead to this life-threatening condition requiring rapid diagnosis and treatment by a skilled medical provider. Simulation can be used to practice recognition of this disease process and work through treatment algorithms. Methods This simulation case used a high-fidelity simulator to teach emergency medicine providers how to manage lower GI bleeding in a patient with abnormal coagulation secondary to intentional ingestion of rodenticide. The case simulated a 58-year-old female with history of bipolar disorder presenting with brisk rectal bleeding. Residents were expected to identify the type of GI bleed, leading to recognition that the patient was in hemorrhagic shock; they then had to appropriately reverse the anticoagulation and resuscitate with blood products. Afterward, learners were given a short survey to evaluate the case and debriefing process. Results The case was performed at the University of Pennsylvania Simulation Center as part of the Emergency Medicine Resident Simulation Curriculum. Twenty-eight learners took part; of these, 20 (71%) found the simulation realistic, and 24 (86%) agreed or strongly agreed that the simulation was useful. Discussion Main learning points include management of lower GI bleeding and reversal of abnormal anticoagulation. This simulation case is straightforward to run, requires minimal resources, and has been well received by learners at our institution.

Symptoms of lower gastrointestinal (GI) disease are common and frequently trigger consultation in primary and secondary care. Diarrhoea, abdominal pain and constipation are presentations of a wide range of different underlying pathologies, from chronic, benign, functional conditions to acutely life-threatening emergencies. Lower GI bleeding is often due to serious pathology and requires rational investigation based on a systematic clinical assessment. Extra-intestinal manifestations of lower GI disease can often give a clue to the underlying diagnosis. In this contribution, we review the aetiology, clinical features, investigations and management for a range of lower GI symptoms, namely diarrhoea, constipation, lower GI bleeding, bloating and abdominal pain.

Introduction. We aimed to assess the efficacy and safety of digital subtraction angiography (DSA) and super-selective mesenteric artery embolization (SMAE) in managing lower GI bleeding (LGIB). Method. A retrospective case series of patients with LGIB treated with SMAE in our health service. Patients with confirmed active LGIB, on either radionuclide scintigraphy (RS) or contrast-enhanced multidetector CT angiography (CE-MDCT), were referred for DSA +/− SMAE. Data collected included patient characteristics, screening modality, bleeding territory, embolization technique, technical and clinical success, short-term to medium-term complications, 30-day mortality, and progression to surgery related to procedural failure or complications. Results. There were fifty-five hospital admissions with acute unstable lower gastrointestinal bleeding which were demonstrable on CE-MDCT or RS over a 31-month period. Eighteen patients proceed to embolization, with immediate success in all. Eight patients (44%) had clinical rebleeding after intervention, warranting repeated imaging. Only one case (5.6%) demonstrated radiological rebleeding and was reembolized. Complication rate was excellent: no bowel ischaemia, ischaemic stricture, progression to surgery, or 30-day mortality. Conclusion. SMAE is a viable, safe, and effective first-line management for localised LGIB. Our results overall compare favourably with the published experiences of other institutions. It is now accepted practice at our institution to manage localised LGIB with embolization.

Risk assessment is widely used in upper gastrointestinal bleeding (UGIB) however no score accurately predicts all important clinical outcomes. This review discusses the performance of the Rockall score, pre-endsocopy Rockall score, Glasgow-Blatchford score, AIMS-65 and newer scores such as Progetto Nazionale Emorragia Digestiva and CANUKA scores. The quality of external validation varies considerably for each score. There is a relative lack of risk scores available for use in lower GI bleeding (LGIB) but recent developments have focussed on the identification of low risk patients. The BLEED, NOBLADS, Strate and Sengupta scores have been developed to predict severe bleeding or death, each with varying performance. The Oakland score has been developed to identify patients at low risk of adverse outcomes who may be suitable for outpatient management. The comparative performance of the LGIB scores and Rockall, Glasgow-Blatchford and AIMS-65 in the prediction of outcomes in LGIB is also discussed.

In response to the recently published national guideline on lower GI bleeding written by Oakland et al ,1 we have audited our practice at the Queen Elizabeth Hospital, Birmingham (QEHB). We were most interested by the general recommendation for CT angiography and for the use of ‘Shock Index’ to select patients for CT angiography, with the aim to identify the source of bleeding. When retrospectively analysing 4 years of admissions (905) for lower GI bleeding, we found that 74 patients underwent CT angiography, with a total of 91 scans. This 8% rate is higher than the national 5.9%.1 Our most interesting finding was the identification of bleeding points …

We are writing with regard to the recently published British Society of Gastroenterology (BSG) lower GI bleeding (LGIB) guidelines.1 We have significant concerns about some of the recommendations. The quick reference flowchart suggests that patients with stable LGIB (shock index

Low-dose aspirin (LDA) is now broadly administered for the prevention of cardiovascular and cerebrovascular diseases. However, aspirin, even at a low dose, induces adverse effects on both the upper and lower gastrointestinal tracts, which precludes patient adherence to the continuous administration of aspirin. A preventive strategy for LDA-induced upper GI tract injury is being established, and the risk factors include histories of peptic ulcer diseases and concomitant intake of nonsteroidal anti-inflammatory drugs, antiplatelet agents, anticoagulants, and oral steroids. Patients with these risk factors should be coadministered gastroprotective drugs, such as proton pump inhibitors, to prevent upper GI adverse events. By contrast, a preventive strategy for LDA-induced lower GI tract injury remains to be established, although new endoscopic techniques, such as capsule endoscopy and double balloon endoscopy, yield images of small intestinal injury induced by LDA. Because lower GI bleeding has increased in LDA users, whereas upper bleeding has decreased, a preventive strategy for LDA-induced lower GI tract injury must be urgently established.

Endoscopic therapy is the primary modality for hemostasis of both upper and lower gastrointestinal (GI) bleeding. Some technical differences exist, however, with regard to the application of hemostasis in the lower GI tract relative to the upper gut. A working knowledge of the techniques and hemostatic devices available for the treatment of particular bleeding lesions in the lower GI tract is necessary for the safe and effective use of these modalities. Herein, the specifics of endoscopic techniques for hemostasis of lower GI bleeding will be highlighted, in addition to the role of the interventional radiologist and surgeon when colonoscopic management fails or is not feasible.

To date, absent inferior mesenteric vein (IMV) has not been reported in the literature as a cause of or being associated with lower gastrointestinal (GI) bleeding. We describe a case of 13 year-old girl who presented with hematochezia and was subsequently found to have widespread colonic varices involving the ascending, transverse and proximal descending colon. The upper GI tract, small bowel, and rectum were not involved. Delayed venous phase of mesenteric angiography revealed an absent inferior mesenteric vein. The patient underwent laparoscopic extended right hemicolectomy with ileosigmoid anastomosis. No bleeding from recurrent varices occurred during a 1-year period of follow up. We conclude that extended right hemicolectomy is a potential curative surgical option in patients presenting with lower GI bleeding from colonic varices caused by absent IMV. Upper GI and small intestinal involvement should be excluded to prevent future bleeding from missed varices these sites.

We sought to determine, in patients with serious hematochezia, the proportion who have an upper gastrointestinal (GI) source and whether urgent colonoscopy improves outcomes as compared with elective colonoscopy in those without an upper source.Patients with hematochezia were eligible if they also had heart rate100, systolic blood pressure100, orthostatic change in heart rate or blood pressure20, hemoglobin drop ≥ 1.5 g/dl, or blood transfusion. Patients had upper endoscopy within 6 h. Those without an upper source were randomized to urgent (≤ 12 h) or elective (36-60 h after presentation) colonoscopy. The primary end point was further bleeding. Patients were followed for the duration of hospitalization.Eighty-five eligible patients had urgent upper endoscopy; 13 (15%) had an upper source. The remaining 72 were randomized to urgent (N=36) or elective (N=36) colonoscopy. Further bleeding occurred in 8 (22%) vs. 5 (14%) of the urgent vs. elective groups (difference=8%, 95% confidence interval (CI)=-9 to 26%). Units of blood (1.5 vs. 0.7), hospital days (5.2 vs. 4.8), subsequent diagnostic or therapeutic interventions for bleeding (36% vs. 33%), and hospital charges ($27,590 vs. $26,633) also were not lower in the urgent group. A major limitation is that the study was terminated before reaching the prespecified sample size.Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious lower GI bleeding showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

Symptoms of lower gastrointestinal (GI) disease are common and frequently trigger consultation in primary and secondary care. Diarrhoea, abdominal pain and constipation are presentations of a wide range of different underlying pathologies, from chronic, benign, functional conditions to acutely life-threatening emergencies. Lower GI bleeding is often due to serious pathology and requires rational investigation based on a systematic clinical assessment. Extra-intestinal manifestations of lower GI disease can often give a clue to the underlying diagnosis. In this contribution, we review the aetiology, clinical features, investigations and management for a range of lower GI symptoms, namely diarrhoea, constipation, lower GI bleeding, bloating and abdominal pain.