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Background: Early colonoscopy (within 8–24 h) is recommended in different guidelines for acute lower gastrointestinal bleeding (LGIB). Despite this recommendation, evidence for its effectiveness are conflicting, and early colonoscopy is often not performed. Objectives: We aimed to evaluate the utility of early colonoscopy by examining the findings during the procedure, and by comparing in-hospital and long-term outcomes between patients who did and did not undergo early colonoscopy. Design: This is a retrospective cohort study based on the electronic medical records of a large tertiary hospital in Israel. Methods: All patients hospitalized with acute LGIB to acute wards between 2012 and 2022 were included. First, structured and free-text procedure notes from patients who did undergo early colonoscopy were examined. Second, we compared in-hospital and long-term outcomes between patients who did and did not undergo early colonoscopy while adjusting for possible confounders using multivariable regression of the type appropriate for each outcome. Results: Overall, 953 patients were included, of which 90 underwent early colonoscopy. The majority (54%) were found insufficiently prepared. Common findings were diverticulosis (38%) and colon polyps (20%). The procedure was effective for hemostasis in only 13% of the cases. Early colonoscopy was not significantly associated with increased survival (exponentiated coefficient = 1.19, 95% CI: 0.76, 1.87), decreased length of hospitalization (exponentiated coefficient = 1.08, 95% CI: 0.97, 1.21), or increased blood hemoglobin at discharge (coefficient =−0.27, 95% CI: −0.58, 0.03). Conclusions: Early colonoscopy was often not effective and was not associated with significantly improved outcomes. [ABSTRACT FROM AUTHOR]

Background: Acute gastrointestinal (GI) bleeding is one of the leading causes of emergency department visits and hospital admissions. CT angiography (CTA) has had an expanding role in the evaluation of acute GI bleeding because it is rapidly performed, widely available, reasonably sensitive and provides precise localization when positive. We attempted to identify patient and clinical characteristics that predict CTA results in order to help guide the utilization of this modality in patients with acute GI bleeding. Methods: In this retrospective study, we analyzed all CTAs performed for the evaluation of GI bleeding in the Duke University healthcare system between October 2019 and March 2020. We captured patient characteristics including age, sex, vital signs, hemoglobin, platelets, PT/INR, and anticoagulation status. Study indications were grouped by suspected source of bleeding: upper GI bleeding (hematemesis or coffee-ground emesis) vs small bowel bleeding (melena or "dark stools") vs lower GI bleeding (hematochezia or bright red blood per rectum (BRBPR)). Chi-square, Wilcoxon, t test, and multivariate logistic regression were used to describe and assess the relationship between patient characteristics and study outcomes (Table 1). Table 1 Univariate analysis of patient characteristics by CT angiography outcome Patient Characteristics by Positive CT for GI Bleed No (N = 274) Yes (N = 43) Total (N = 317) p value Gender 0.451 Female 138 (50.4%) 19 (44.2%) 157 (49.5%) Male 136 (49.6%) 24 (55.8%) 160 (50.5%) Age, median (Q1,Q3) 65 (51,75) 70 (62,80) 66 (52, 76) < 0.012 Heart rate, median (Q1,Q3) 86 (74,100) 89 (72,98) 86 (74, 99) 0.782 MAP, mean (SD) 87.32 (15.52) 81.72 (16.53) 86.56 0.033 Shock index, median (Q1,Q3) 0.70 (0.58, 0.85) 0.78 (0.55, 1.00) 0.71 (0.58, 0.85) 0.352 Hemoglobin 0.332 N 273 43 316 Median (Q1, Q3) 8.50 (6.90, 11.00) 7.70 (6.50, 11.30) 8.45 (6.90, 11.00) Baseline hemoglobin 0.202 N 258 39 297 Median (Q1, Q3) 11.20 (9.40, 13.00) 12.00 (9.40, 14.00) 11.20 (9.40, 13.00) Hemoglobin drop from baseline 0.062 N 258 39 297 Median (Q1, Q3) 2.10 (0.60, 3.70) 2.70 (1.20, 4.80) 2.20 (0.70, 3.80) Platelets, median (Q1, Q3) 219.5 (141, 301) 183 (139, 246) 217 (139, 282) 0.102 INR 0.272 N 263 42 305 Median (Q1, Q3) 1.10 (1.00, 1.30) 1.20 (1.00, 1.30) 1.10 (1.00, 1.30) Anticoagulation 0.131 No 155 (56.6%) 19 (44.2%) 174 (54.9%) Yes 119 (43.4%) 24 (55.8%) 143 (45.1%) Upper GI bleeding 0.401 No 251 (91.6%) 41 (95.3%) 292 (92.1%) Yes 23 (8.4%) 2 (4.7%) 25 (7.9%) Small Bowel bleeding 0.761 No 216 (78.8%) 33 (76.7%) 249 (78.5%) Yes 58 (21.2%) 10 (23.3%) 68 (21.5%) Lower GI bleeding 0.091 No 134 (48.9%) 15 (34.9%) 149 (47.0%) Yes 140 (51.1%) 28 (65.1%) 168 (53.0%) 1Chi-Square 2Wilcoxon 3Equal Variance T-Test Results: A total of 317 patients underwent CTA between October 2019 and March 2020. Forty-three patients (13.6%) had a CTA positive for active bleeding. Multivariable logistic regression showed that after controlling for age, mean arterial pressure (MAP) and indication, only a hemoglobin drop from baseline was significantly associated with a positive CTA. For each 1 g / dL drop in hemoglobin from the patient's baseline, the odds of a positive CT increased by 1.17 (OR 1.17 95% CI 1.00 – 1.36, p = 0.04). Age (OR 1.02 95% CI 0.99 – 1.04, p = 0.06) and hematochezia / BRBPR (OR 2.09 95% CI 0.94—4.64, p = 0.07) approached statistical significance. Conclusions: In patients who present to the hospital with GI bleeding, CTA can be a helpful triage tool that is most helpful in older patients with suspected lower GI bleeding with a drop in hemoglobin from baseline. Other clinical factors including MAP and the use of anticoagulants were not predictive of a positive CTA. [ABSTRACT FROM AUTHOR]

Background: Angioembolization is a useful therapeutic tool for lower gastrointestinal bleeding (LGIB) however is only available at centres with specialist interventional radiology departments. Delay in angioembolization of greater than 120–150 minutes is associated with higher rates of non‐therapeutic angioembolization. Methods: This retrospective review analysed the impact of interhospital transfer on timing and success of angioembolization in adults with LGIB. Results: Of the 121 patients who underwent CTMA at a peripheral hospital for LGIB, only 20.7% had positive CTMA (n = 25). Of the 24 patients who were transferred for the purpose of angioembolization, only five ultimately had successful embolisation (20.1%). Patients who had unsuccessful angioembolization had a significantly longer mean time from arrival at the tertiary hospital to angioembolization compared to patients who had successful angioembolization (mean 375 versus 175 min, P = 0.001). There was no association of patient haemodynamics, use of anticoagulant or antiplatelet therapy, and transfusion requirement with success of angioembolization. Conclusion: Interhospital transfer is associated with delay in angioembolization. Delay after arrival at the receiving hospital is associated with unsuccessful angioembolization. [ABSTRACT FROM AUTHOR]

Background and study aims Despite the common occurrence of non-neoplastic findings (NNFs) in individuals with a positive fecal immunochemical test (FIT), few studies have reported on these findings. The aim of this cross-sectional study was to determine the prevalence of colonic NNFs in three cohorts of Danish clinical trial participants who underwent colon capsule endoscopy (CCE). Patients and methods Retrospectively collecting NNFs from CCE reports of three Danish trials, we classified them into five categories: diverticula, vascular abnormalities, inflammation, erosions/ulcerations, and others. The statistical analysis included 516 participants from three trials, with a mean age ranging from 59.2 to 63.9 years. The participants in the three trials were FIT-positive screening or symptomatic individuals. Results NNFs were reported in more than half of the CCE procedures (50.6% to 77.9%), with colonic diverticula being the most common NNF appearing in 40.9% to 66.9% of the CCE reports. Vascular abnormalities and erosions/ulcerations were also common depending on the specific trial. Conclusions NNFs are common and may be an indicator of more widespread disease. Furthermore, NNFs may develop into clinically significant conditions despite their benign appearance. This paper expands on the limited literature about prevalence of NNFs and underscores the additional value of CCE video recordings beyond detecting polyps., Competing Interests: Conflict of Interest Sebastian Radic Eskemose, Lasse Kaalby Møller, and Ulrik Deding have no conflicts of interest or financial ties to disclose. Anastasios Koulaouzidis has received consultancy fees from Jinshan Science and Technology (Group) Co. Ltd. (Jinshan Group) and Corporate Health International, received honoraria from Jinshan Group and Medtronic, received travel support by Jinshan Group, has issued a patent with AJM Med-i-Caps Ltd., and has equity interest in iCERV Ltd. and AJM Med-i-Caps Ltd. Thomas Bjørsum-Meyer has received consulting fees from Medtronic. The funders had no role in the design of the paper; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and study aims Topical hemostatic agents emerged as a new treatment modality for gastrointestinal bleeding. The aim of this study was to assess the safety and efficacy of PuraStat for control of active bleeding and for prevention of bleeding after different operative endoscopy procedures. Patients and methods A national, multicenter, observational registry was established to collect data from ten Italian centers from June 2021 to February 2023. Demographics, type of application (active gastrointestinal bleeding or prevention after endoscopic procedures, site, amount of gel used, completeness of coverage of the treated area), outcomes (rates of intraprocedural hemostasis and bleeding events during 30-day follow-up), and adverse events (AEs) were prospectively analyzed. Results Four hundred and one patients were treated for active gastrointestinal bleeding or as a preventive measure after different types of operative endoscopy procedures. Ninety-one treatments for active bleeding and 310 preventive applications were included. In 174 of 401 cases (43.4%), PuraStat was the primary treatment modality. Complete coverage was possible in 330 of 401 (82.3%) with difficulty in application in seven of 401 cases (1.7%). Hemostasis of active bleedings was achieved in 90 of 91 patients (98.9%). In 30-day follow-up 3.9% patients in whom PuraStat was used for prophylaxis had a bleeding event compared with 7.7% after hemostasis. No AEs related to the use of PuraStat were reported. Conclusions PuraStat is a safe and effective hemostat both for bleeding control and for bleeding prevention after different operative endoscopy procedures. Our results suggest that the possible applications for the use of PuraStat may be wider compared with current indications., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: Lower gastrointestinal bleeding (LGIB) is one of the most common indications for hospital admission. The current standard of care for patients admitted with LGIB includes colonoscopy. The aims of this study are to define the rate of readmission in patients with LGIB and to determine whether early colonoscopy within the first 24 h after admission impacts the rate of readmission in these patients. Methods: We performed a retrospective cohort study on data obtained from the Nationwide Readmission Database and identified patients admitted with lower GI bleed using ICD-10 codes. The primary outcome was 30-day all-cause readmission, and one of our secondary outcomes was the impact of early colonoscopy on 30-day readmission. Results: We analyzed data from 35,790,513 patients who were admitted for LGIB in 2017. A total of 16.4% of these patients were readmitted within 30 days of discharge, with diverticular bleeding most common diagnosis for readmission. Overall, in-hospital mortality was 1.18% for index admission and 4.44% for readmission. Early colonoscopy did not impact the rate of readmission within 30 days of discharge. Conclusion: LGIB remains a commonly encountered in clinical practice with a high readmission rate. Mortality is significantly higher during readmission compared to index admission. Early colonoscopy did not impact the 30-day readmission rate. [ABSTRACT FROM AUTHOR]

Aortoenteric fistulae (AEF) is a rare but life-threatening condition. They can be classified as primary (spontaneous, PAEF) or secondary (after aortic reconstructions). Most of the PAEFs involve the duodenum and the small bowel. Because of their rareness, the diagnosis is difficult and can sometimes be missed, with lethal consequences. In fact, PAEFs overall mortality reaches 50% and remains dramatically high even after intervention 30–40%. We report a case of 68-year old man, admitted to Emergency Department for abdominal pain and rectal bleeding. An intravenous contrast-enhanced abdomen CT scan reported an infrarenal and left iliac aneurysm with a replenished hematoma which displaced the sigmoid colon and a fluid collection in the left psoas muscles. He underwent a percutaneous EVAR procedure and a later CT angiography showed a suspected communication between the sigmoid colon and the hematoma. Thus, we performed Hartmann's procedure with debridement of the abdominal cavity. The literature review reported 19 cases of aortic or iliac-sigmoid fistula. Six patients were treated by endovascular means. Regardless of care, eight patients died during the operation or in the early post-operative phase. Open surgery remains the gold standard of the treatment for PAEFs, however bridge endovascular approach should be considered as lifesaving strategy in non-elective setting.

Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.

Objective: To determine the prevalence of the common causes of lower gastrointestinal bleeding by Colonoscopy as a diagnostic modality in patients with gastrointestinal bleeding. Study Design: Cross Sectional Descriptive study. Setting: Department of Gastroenterology, Liaquat University of Medical and Health Sciences, Jamshoro. Period: March 2021 to August 2021. Material & Methods: This study was performed in Liaquat University of Medical and Health Sciences, Jamshoro in patients presenting with lower gastrointestinal bleeding. History, examination and investigations were carried out. After stabilizing the patient lower gastrointestinal endoscopy was performed. Results: Total 139 patients were included in this study. Intermittent bleeding per rectum was the main presenting complaint followed by continuous bleeding per rectum. The average age of the patients was 45.61 ±16.40 years. Out of 139 patients, 94(67.6%) males and 45(32.4%) females. Bleeding related to internal hemorrhoids was present in 40(28.8 %) patients 30(21.6%) male and 10(7.2%) females as the most common cause of lower GI bleed followed by rectal ulcers 14(10.1%) and polyps in 9(6.5%) patients. infective colitis, proctitis and colonic ulcers were noted in 8(5.8%), 6(4.3%) and 5(3.6%) patients respectively. Malignant lesions in colon and rectum were noted in 8(5.8%) and 3(2.2%) patients while ulcerative colitis, crhon's and diverticular disease were noted in 5(3.6%), 1(1.4%), 2(0.7%) patients respectively. 29(%) had normal clonoscopic examination. Conclusion: In our population hemorrhoid bleed is the leading cause of lower gastrointestinal bleeding followed by bleeding due to rectal ulcer and polyps. [ABSTRACT FROM AUTHOR]

Abstract Background/Aims Although colonic diverticular bleeding (CDB) is common, few reports have described the effects of antithrombotic agents (ATs) on CDB. This study aimed to clarify the risk factors of re‐bleeding within a year in CDB patients. Methods We retrospectively analyzed the risk of re‐bleeding in CDB patients. Among 324 patients who were hospitalized for acute lower gastrointestinal bleeding at our institution during the period from 2015 to 2019, we used 76 patients who were diagnosed as CDB. Risk factors for re‐bleeding were determined by Cox proportional hazard models. Results Of 76 patients analyzed, 32 were taking ATs, nine of whom were taking multiple agents. Twenty‐six patients re‐bled within a year. Compared with the patients without re‐bleeding, patients with re‐bleeding within a year had been treated by antithrombotic therapy more frequently (62% vs. 32%, p = 0.013). Cox proportional hazard model revealed that treatment with ATs (hazard ratio 3.89, 95% confidence interval 1.53–10.74, p = 0.004) was an independent risk factor for re‐bleeding within a year. Conclusion ATs were found to be an independent risk factor related to re‐bleeding within a year in patients with CDB.

Incidence of lower gastrointestinal (GI) bleeding (LGIB) is increasing over time. It can be seen in all age group patients, commonly associated with pre-existing comorbidities and is one of the common indications of colonoscopy. This study was done to identify common causes of LGIB in eastern part of India, because there is no previous study from Eastern India to identify the common causes of lower GI bleeding diagnosed by colonoscopy in different age group patients. Consecutive 64 patients with LGIB were included in this study from June 2018 to March 2019. We divided our study population into three groups, such as group A (20 years to 40 years), group B (41 years to 60 years), and group C (more than 60 years). Data were entered into Excel and then transferred into SPSS version 22 for statistical analysis. Mean age of study population was 49.83 ± 19.06 years. Normal colonoscopic finding was seen in 7 patients (10.9%). Most common colonoscopic findings of our study population were hemorrhoids (n=32; 50%), anal fissure (n=11; 17.2%) and isolated rectal ulcer (n=9; 14.1%). Colorectal growth was seen in 6 patients (9.4%), among them female patients were more commonly affected than male patients. Therefore, most common causes of LGIB in eastern part of India are hemorrhoids, anal fissure and isolated rectal ulcer. Male individuals are more commonly affected by LGIB.

There is limited evidence on the efficacy of hemostatic powders in the management of lower gastrointestinal bleeding. to revise our series of patients with lower gastrointestinal bleeding treated with hemostatic powders and to provide a pooled estimate of their efficacy based on the current literature. Sixty-five patients underwent topical endoscopic application of hemostatic powder between 2016 and 2020. The primary endpoint was treatment success, with 7- and 30-day rebleeding rate, adverse events and mortality as secondary outcomes. Literature review was based on computerized bibliographic search on the main databases through December 2020. Pooled effects were calculated using a random-effects model. Overall, the powder was applied as monotherapy in 37 patients (56.9%), as combination therapy in 15 patients (23.4%), and as rescue therapy in 13 cases (19.9%). Hemostasis was achieved in 100% of patients. Rebleeding rate at 7- and 30-day was 7.7% and 9.2%, respectively. A total of 10 studies with 259 patients were included in the meta-analysis. Immediate hemostasis was achieved in 96.3% (93.4%-99.2%) patients, whereas pooled 7- and 30-day rebleeding rates were 9.6% (4.5%-14.6%) and 12.9% (7.2%-18.5%), respectively. Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Background: Bleeding of the gastrointestinal tract (BGIT) is a common gastrointestinal emergency. There is no consensus whether this condition should be admitted to medical or surgical discipline. Timing of presentation may also impact patient outcomes due to differences in healthcare resource availability. This study thus aims to investigate the impact of admitting discipline and timing of admission on patient outcomes in BGIT. Methods: A 2‐year tertiary institution database was retrospectively reviewed. Outcome measures included 30‐day mortality, 30‐day readmissions and rebleeding requiring repeat endoscopic, angiographic or surgical interventions. Secondary outcome measures included time to endoscopy, percutaneous angiographic interventions and surgery. The effect of admission discipline (medical versus surgical) and time of admission (office‐hours versus after office‐hours) were analysed using a propensity‐score‐adjusted estimate. Results: A total of 1384 patients were included for analysis, medical (n = 853), surgical (n = 530); during office‐hours (n = 785) and after office‐hours (n = 595). After propensity‐score‐adjusted analysis, no significant differences in mortality or readmissions were noted between medical or surgical admissions. Patients admitted under surgery were less likely to sustain rebleeding (P = 0.004) for lower BGIT and had an earlier time to endoscopy for upper BGIT (P = 0.04). Patients admitted after office‐hours had similar outcomes with those admitted during office hours apart from a delay in time to endoscopy (P = 0.02). Conclusion: For BGIT patients, admission to a surgical discipline compared to a medical discipline appeared to have at least equivalent patient outcomes. Patients presenting with BGIT after office‐hours were more likely to experience a delay to endoscopy, although it did not affect patient mortality. [ABSTRACT FROM AUTHOR]

Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management. Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded. Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5–4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients. Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT 04364412]. [ABSTRACT FROM AUTHOR]

INTRODUCTION The lower gastrointestinal bleeding (LGIB) is an alarming symptom and common disease with annual admission of 0.15% with mortality rate of 5-10%. LGIB is caused by neoplastic and non-neoplastic lesions. For accurate diagnosis of various colorectal lesions, colonoscopy is gold standard, convenient and cost effective procedure. It is the investigation of choice in LGIB and helps in early diagnosis of colorectal carcinoma. This study was aimed to scrutinize the clinical and colonoscopic findings in patients with LGIB in Universal College of Medical Sciences-Teaching Hospital (UCMS-TH). MATERIAL AND METHODS This was a hospital based prospective observational study conducted after taking permission from institutional review committee in January 2017 at UCMS-TH from 15 January 2017 to 15 January 2018. All patients presenting with LGIB who fulfilled inclusion and exclusion criteria and gave written consent were included. RESULTS Total 88 patients were included in the study. The mean age of our patients was 48 ±17 years with age range from 17-81 years. Majority were in the age group 50-60 years (25%) (n=22). Colonoscopy detected abnormality in 73.8% cases. The common non-neoplastic were haemorrhoids and non-specific colitis (14.5% each) followed by 12.5% of neoplastic cases. The higher frequency of colorectal lesions was observed in males comprising 72.7% (n=64) patients. The most commonly diagnosed etiologies of LGIB were haemorrhoid and nonspecific colitis respectively. CONCLUSION Colonoscopy detected abnormality in 75% of cases. The common causes of LGIB were haemorrhoids and non-specific colitis followed by neoplastic lesion. A careful history, physical and colonoscopic examination with or without biopsy makes significant impact for early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Introduction Cytomegalovirus (CMV) is the most common viral pathogen affecting patients undergoing solid organ transplantation. It is often the most important infection for patients who have undergone kidney transplantation. Clinical presentations of cytomegalovirus infection range from asymptomatic infection to organ-specific involvement. This study aimed to determine the frequency of cytomegalovirus-associated colitis in kidney transplant recipients (KTRs) presenting with lower gastrointestinal bleeding. Methods After the approval of the ethical review committee of the Sindh Institute of Urology and Transplantation (ERC-SIUT), this cross-sectional study was conducted at the Department of Hepatogastroenterology at the Sindh Institute of Urology and Transplantation from January 2021 to December 2021. All the KTRs (six months after the transplantation) of either gender and aged between 18 and 65 years, presenting with lower gastrointestinal (GI) bleeding as per the operational definition, were enrolled in the study. Those patients who were either unfit for the endoscopy or refused to give consent were excluded from the study. Colonic biopsies were reviewed by a consultant histopathologist for the features of CMV infection. Results A total of 95 renal transplant recipients of either gender or age above 18 to 65 years with lower GI bleeding were included in the study. Among them, 84 (88.4%) were males, while 11 (11.6%) were females. The mean age of the patients included in the study was 37±11 years. The most common presenting complaint was fresh bleeding per rectum, which was observed in 73 (76.8%). The most common findings observed on colonoscopy in KTRs with bleeding per rectum were colonic ulcers and erosions noted in 41 (43.1%) and 36 (37.3%) patients, respectively. On histopathology, CMV colitis was noted in 21 (22.1%) patients. On comparison of different baseline variables, the presence of fresh bleeding per rectum and the presence of both ulcers and erosions on colonoscopy were the factors significantly associated with CMV colitis in KTRs. Conclusion CMV colitis is a prevalent condition in KTRs, presenting with lower GI bleeding. Despite the significant occurrence, the levels of CMV viremia were not associated with CMV colitis, suggesting that diagnosis should rely on histopathological confirmation. Prophylaxis during periods of high immunosuppression is crucial to reducing the incidence of CMV infections and improving both graft function and patient survival., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethical review committee-Sindh Institute of Urology and Transplantation issued approval 241. Dear Dr. Arz Muhammad, Thank you for submitting the above-referenced protocol to the SIUT-Ethical Review Committee (ERC). Your application was reviewed and this protocol raises no ethical concerns. An approval is being granted and you may commence your research at this time. . Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Muhammad et al.)

Background and study aims Capsule endoscopy (CE) is commonly used as the initial exam for suspected mid-gastrointestinal bleeding after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detecting upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a convolutional neural network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE. Patients and methods A multicentric AI model development study was based on 1022 CE exams. Our group used 34655 frames from seven types of CE devices, of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, and the latter was used to evaluate the model's performance. At the time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and an area under the precision-recall curve (AUC-PR). Results Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second. Conclusions This is the first proof-of-concept artificial intelligence deep learning model developed for pan-endoscopic automatic detection of vascular lesions during CE. The diagnostic performance of this CNN in multi-brand devices addresses an essential issue of technological interoperability, allowing it to be replicated in multiple technological settings., Competing Interests: Conflict of Interest João Ferreira is a paid employee of DigestAID. The remaining authors have no conflict of interest to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Small bowel bleeding can be overt or occult. Despite advances in imaging and endoscopy, the diagnosis and treatment of small bowel bleeding remain challenging due to its length and location. Diagnostic procedures such as push enteroscopy, capsule endoscopy and intraoperative enteroscopy are recommended to identify the source of bleeding. A 33-year-old female with no prior history of bleeding diathesis presented with massive lower GI bleeding. Although she was in hypovolemic shock from bleeding, physical exam, splanchnic angiography and colonoscopy were unable to localize the source of bleeding. The patient continued to bleed and deteriorate despite transfusions. Exploratory laparotomy was done but localizing the source with manual palpation of small bowel was difficult. Intraoperative enteroscopy was done and showed a 2 by 1 cm ulcerative lesion at mid jejunum. Part of jejunum containing the ulcer was resected and anastomosis done. The patient did well postoperatively and on follow up. A bleeding primary jejunal ulcer is rare clinical scenario difficult to diagnose. Intraoperative enteroscopy is useful in cases where initial diagnostic workups are inconclusive. It can be performed using various types of endoscopes, such as a standard or pediatric colonoscope, push enteroscope, or a sonde enteroscope, during laparotomy. Primary jejunal ulcer is a rare cause of massive lower GI bleeding. Although minimally invasive deep endoscopic techniques to diagnose small bowel ulcers are evolving, intraoperative enteroscopy remains to be technically easy and helpful tool to make a diagnosis and guide intervention especially in a patient undergoing laparotomy for bleeding small bowel ulcer. • Primary jejunal ulcer with massive lower GI bleeding is a rare scenario • The diagnosis and treatment of small bowel bleeding remain challenging. • Intraoperative enteroscopy plays major role in diagnosis and guiding therapy for small bowel bleeds • If a diagnosis of primary jejunal ulcer is made, segmental resection of small bowel with anastomosis should be performed. [ABSTRACT FROM AUTHOR]

Objectives: Use of proton pump inhibitors (PPIs) is a mainstay in treating upper gastrointestinal bleeding (UGIB). However, the beneficial effects of PPIs are not anticipated to extend beyond the duodenum and may actually contribute to the risk of lower gastrointestinal bleeding (LGIB). However, in practice, PPIs are often used for inpatients with LGIB where no benefit exists., Methods: A retrospective chart review was performed on inpatients during a 2-year period at an urban academic teaching hospital. Inpatients with consults to the gastroenterology (GI) service with confirmed or highly suspected LGIB were included. Outcomes regarding PPI use and the GI consulting service recommendations in these 225 patients were evaluated., Results: About 37.8% of patients were started on a PPI during their inpatient course. Of those, 46% patients started on a PPI had no indication for PPI and 85% had no recommendation by the GI consultants to start a PPI. Of the 85 patients started on PPI, the GI consultants recommended stopping it in two (2.3%) patients. Lastly, 20 patients (9%) were discharged on PPI without an indication for PPI., Conclusion: To our knowledge, this is the first study that looked at the inappropriate utilization of PPIs in patients admitted for LGIBs utilizing GI consultant recommendations. Given the large proportion of patients started on PPI without a clinical indication and continued at discharge and the paucity of GI recommendations to discontinue inappropriate use, we found that clinical care may be improved with formal GI recommendations regarding use of PPI.

Angiodysplasia of the gastrointestinal (GI) tract is recognized as an important cause of lower GI bleeding in elderly. It usually involves the cecum and right colon in adults. Unlike the adult group, there has been little experience with the pediatric population. Methods: From July 2004 to October 2008, patients presenting at the Mackay Memorial Hospital with GI hemorrhage diagnosed as angiodysplasia by helical computed tomographic angiography were reviewed. Results: Eighteen patients (14 boys and 4 girls) with mean age of 7.1 years (range, 1 month to 17 years) were diagnosed. The time from initial clinical onset to diagnosis of angiodysplasia ranged from 1 week to 11 years, most around 1–2 weeks. All patients except one had anemia and an average hemoglobin level of 7.9±2.1 g/dL. The most commonly involved areas were ascending colon and terminal ileum. Four patients received surgery treatment with resection of affected segments. Conclusions: In pediatric patients, angiodysplasia is a rare cause of GI bleeding and may be delayed in diagnosis. This diagnosis should be considered when patients have recurrent GI bleeding. In this study, the final surgical and pathological diagnosis was made in 6 of 18 patients. In six patients, computed tomographic angiography had 66% diagnostic accuracy for angiodysplasia (four of six patients who received operation were compatible with angiodysplasia by confirmation of histology).

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.

Lower gastrointestinal bleeding (LGIB) along with intestinal perforation is a well-known complication of typhoid fever. Reports of colonoscopic appearance and intervention of typhoid perforation involve only few cases. This series reports the colonoscopic findings and the role of colonoscopic hemostatic interventions in controlling the bleeding ileocolonic lesions. During the typhoid fever outbreak in Sulaymaniyah City in Iraqi Kurdistan Region, we received 52 patients with LGIB manifesting as fresh bleeding per rectum or melena. We performed total colonoscopy with ileal intubation for all cases. The findings were recorded and endoscopic hemostatic intervention with adrenaline-saline injection and argon plasma coagulation was applied to actively bleeding lesion. These patients were young, 11-30 years of age, with female preponderance. Blood culture was positive in 50 %. Colonoscopic findings were mostly located in the ileocecal region, although other areas of the colon were involved in many cases. Twenty-four percent of the cases required endoscopic hemostatic intervention by adrenaline injection with argon plasma coagulation which was effective in all patients except one who died in spite of surgical intervention in addition of endoscopic hemostasis. Dual endoscopic hemostatic intervention can be a safe and effective management option for patients with LGIB due to typhoid fever. [ABSTRACT FROM AUTHOR]