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The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Sengupta, Neil; Kastenberg, David M; Bruining, David H; Latorre, Melissa; Leighton, Jonathan A; Brook, Olga R; Wells, Michael L; Guglielmo, Flavius F; Naringrekar, Haresh V; Gee, Michael S; Soto, Jorge A; Park, Seong Ho; Yoo, Don C; Ramalingam, Vijay; Huete, Alvaro; Khandelwal, Ashish; Gupta, Avneesh; Allen, Brian C; Anderson, Mark A; Dane, Bari R; Sokhandon, Farnoosh; Grand, David J; Tse, Justin R; Fidler, Jeff L
Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.
PMID: 38441091
ISSN: 1527-1315
CID: 5637502

A National Survey of the Infrastructure and Scope of Practice for Gastroenterology Hospitalists

Wan, David W; Latorre, Melissa; Sun, Edward; Hughes, Michelle L; Buckholz, Adam; Li, Darrick K
BACKGROUND:Hospital-based specialty-trained physicians have become more prevalent with emerging data suggesting benefit in consult and procedure volume, reduced complication rates, and increased practice productivity. Interest in gastroenterology (GI) hospitalist programs has increased in recent years. However, little is known regarding the types of GI hospitalist models that currently exist. AIMS/OBJECTIVE:To characterize the infrastructure of GI hospitalist models across the USA. METHODS:A 50-question survey was distributed to the GI Hospitalist Special Interest Group of the American Society for Gastrointestinal Endoscopy. Information on demographics, hospital infrastructure, and compensation were collected. RESULTS:31 of 33 (94%) GI hospitalists completed the questionnaire. Respondents were mostly male (65%), white (48%) or Asian (42%). Most GI hospitalists spent at least half of their clinical time dedicated to the inpatient consultation service (73%), during which they had no other clinical duties. Most services had endoscopy suites with dedicated inpatient endoscopy rooms (66%), over 4 h allotted for procedures (83%), and were available on weekends (62%). Over half of GI hospitalists reported having outpatient duties, the most common being performance of direct access endoscopy (69%). Outside of clinical responsibilities, GI hospitalists were most frequently involved in clinical education or fellowship program leadership (48%). Most GI hospitalists were salaried with an incentive-based bonus based on work relative value units. CONCLUSION/CONCLUSIONS:GI hospitalist programs are varied throughout the USA but key commonalities exist between most programs.
PMID: 36797510
ISSN: 1573-2568
CID: 5432222

Outcomes in Non-Variceal Upper Gastrointestinal Bleeding With Use of the Endoscopic Over-the-Scope-Clip Device Deployed by General Gastroenterologists and Trainees: Experience From a Large Academic Medical Center [Meeting Abstract]

Laljee, S; Dong, S; Cheng, K; Burkhard, P; Latorre, M
Introduction: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalization and is associated with an up to 30% incidence of rebleeding. Data increasingly suggests the over-thescope clip (OTSC) is an effective and safe tool in hemostasis specifically for rebleeding, severe hemorrhage or large ulcers not amenable to standard therapy. Nevertheless, this tool remains underutilized in general gastroenterology (GI) practice and training. We seek to show our outcomes in hemostasis for NVUGIB after competency training of general GI attendings and trainees by our GI hospitalist.
Method(s): We performed a retrospective chart review of patients with NVUGIB who received treatment with OTSC by general GI faculty and trainees at a large quaternary care academic center between July 2019 and May 2022. Procedures were supervised by 6 attendings. Demographics are shown in Table. The primary outcome was 30-day rebleeding at the site of initial hemostasis, defined as clinical signs of bleeding with need for repeat endoscopic intervention or angiography.
Result(s): We identified 52 patients hospitalized for NVUGIB who underwent upper endoscopy with use of the OTSC by general GI attendings and trainees. Of these cases, we observed a 30-day rebleeding rate of 13.5% (n = 7). We observed that patients who rebled had higher readmission rates (71.4% vs 13.3%, p < 0.05). No significant differences were observed in demographics, medical history, presenting labs, ulcer features, or length of stay between the two cohorts (Table). We observed that a majority of lesions were found within the duodenum (69.2%, n = 36), and a majority of these ulcers were large >10mm in size (82.7%, n = 43) in both groups. Of patients undergoing OTSC use for primary hemostasis versus secondary hemostasis, rebleeding rate was 15.6% (n = 5) and 10% (n = 2), respectively. Of patients who rebled, 3 underwent repeat endoscopy alone, and 2 underwent EGD & angiography, and 2 underwent angiography alone. No patients required surgery. There were no complications from OTSC placement.
Conclusion(s): The OTSC is a highly effective tool in the management of NVUGIB specifically in cases of rebleeding, severe hemorrhage, and large ulcers not amenable to standard treatment. The OTSC can be safely and successfully deployed by general gastroenterologists and trainees. Education and competency in OTSC should be encouraged in physicians who treat NVUGIB. (Table Presented)
ISSN: 1572-0241
CID: 5514912

Use of an Endoscopic Doppler Probe by General Gastroenterologists and Trainees to Guide Hemostasis in Non-Variceal Upper Gastrointestinal Bleeding (NVUGIB): Outcomes of a Large Academic Medical Center [Meeting Abstract]

Dong, S; Laljee, S; Cheng, K; Burkhard, P; Latorre, M
Introduction: Visual assessment of stigmata of hemorrhage in NVUGIB is the cornerstone of endoscopic therapy. Nevertheless, rebleeding occurs in up to 30% of patients. The endoscopic doppler probe (EDP) is a novel device that can help guide hemostasis by assessing for arterial blood flow (ABF) within an ulcer base despite its visual appearance. It is most helpful when there is ambiguous stigmata or discordance between the stigmata and clinical picture. Ulcers with residual ABF flow following treatment have been associated with higher rates of rebleeding. The use of EDP to confirm eradication of ABF improves rebleeding. Use of the EDP has not been widely adopted. We seek to evaluate the outcomes in hemostasis with use of EDP after competency training of general gastroenterology (GI) attendings and trainees by our GI hospitalist.
Method(s): We performed a retrospective study of patients admitted to a large quaternary care academic medical center with NVUGIB for whom EDP was used during endoscopy (EGD) before and/or after endoscopic treatment. Procedures were performed between January 2021 and May 2022 and were supervised by 4 gastroenterology attendings. Patient demographics and outcomes are listed in Table. The primary outcome was 30-day rebleeding rate, defined as clinical evidence of bleeding plus need for repeat endoscopy or other therapeutic intervention at the location of initial hemostasis as guided by EDP.
Result(s): We identified 37 patients who underwent EGD with EDP. We found a 30-day rebleeding rate of 13.5% (n = 5). Patients who rebled were more likely to be of Hispanic heritage and previously treated with bipolar cautery (p< 0.05). There were no other significant differences (Table). Most ulcers were located within the duodenum (67.6%, n = 25), and most were large (> 10mm in size; 75.7%, n = 28). In 4 patients use of the EDP did not lead to additional endoscopic treatment. None of these patients had rebleeding. For the patients with rebleeding 1 patient required EGD and angiography; 2 patients required repeat EGD only and 2 patients underwent angiography only. No patients required surgery. No intraprocedural complications were identified.
Conclusion(s): The EDP is a highly effective tool in the management of NVUGIB and can be safely and successfully used by general GI attendings and trainees. The EDP provides a treat-to-target approach to hemostasis and improves upon standard visual assessment of stigmata of hemorrhage. Training in EDP should be encouraged in physicians who treat NVUGIB. (Figure Presented)
ISSN: 1572-0241
CID: 5514982

The Impact of the GI Hospitalist Model on Hospital Metrics and Outcomes: Experience of a Large Academic Medical Center [Meeting Abstract]

Klein, S; Zenger, C; Latorre, M
Introduction: Within internal medicine the implementation of a hospitalist care model has shown an improvement in hospital outcomes (length-of-stay and readmissions), quality metrics (in-hospital mortality) and cost savings. The hospitalist model has been increasingly adopted by subspecialities including gastroenterology (GI) given its benefits and the growing need to have physicians onsite for inpatient emergencies. A GI hospitalist is a physician who spends the majority of their clinical time overseeing the care of hospitalized patients with gastrointestinal disorders. Additionally, they may be involved in coordinating and executing endoscopic procedures when indicated. Limited data exists on the impact of a GI hospitalist on inpatient care. In this study we evaluate the impact of hiring a GI hospitalist on hospital metrics at a large quaternary care academic medical center.
Method(s): We performed a retrospective single center study of patients who received inpatient endoscopic general GI procedures (endoscopy, colonoscopy, and enteroscopy) at an academic quaternary care medical center in the fiscal year before and after hiring a GI hospitalist (September 2016 through August 2018).We compared patient outcomes of interest including mean observed-to-expected length of stay (O: E LOS), discharge before noon (
ISSN: 1572-0241
CID: 5515282

Diagnostic yield of inpatient capsule endoscopy

Levine, Irving; Hong, Soonwook; Bhakta, Dimpal; McNeill, Matthew B; Gross, Seth A; Latorre, Melissa
BACKGROUND:Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2 METHODS: We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE. RESULTS:131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE. CONCLUSIONS:Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.
PMID: 35550029
ISSN: 1471-230x
CID: 5214652

Upper gastrointestinal bleeding in a lung transplant recipient

Sivasailam, Barathi; Rudym, Darya; Latorre, Melissa; Mehta, Sapna A
PMID: 35373524
ISSN: 1600-6143
CID: 5201562

Use of a Novel Attachment Device to Aid in Endoscopic Food Impaction Removal [Meeting Abstract]

Lawrence, Zoe; Dornblaser, David; Hasbun, Johann; Sivasailam, Barathi; Latorre, Melissa
ISSN: 0002-9270
CID: 5526532

Hemostatic powder TC-325 treatment of malignancy-related upper gastrointestinal bleeds: International registry outcomes

Hussein, Mohamed; Alzoubaidi, Durayd; O'Donnell, Michael; de la Serna, Alvaro; Bassett, Paul; Varbobitis, Ioannis; Hengehold, Tricia; Ortiz Fernandez-Sordo, Jacobo; Rey, Johannes W; Hayee, Bu'Hussain; Despott, Edward J; Murino, Alberto; Graham, David; Latorre, Melissa; Moreea, Sulleman; Boger, Phillip; Dunn, Jason; Mainie, Inder; Mullady, Daniel; Early, Dayna; Ragunath, Krish; Anderson, John; Bhandari, Pradeep; Goetz, Martin; Kiesslich, Ralf; Coron, Emmanuel; Rodriguez de Santiago, Enrique; Gonda, Tamas; Gross, Seth A; Lovat, Laurence B; Haidry, Rehan
BACKGROUND AND AIM/OBJECTIVE:Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. METHODS:Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. RESULTS:One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7-12). The median Rockall score was 8 (IQR, 7-9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient. CONCLUSIONS:Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor-related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor.
PMID: 34132412
ISSN: 1440-1746
CID: 4925582

The role of hemospray as a monotherapy treatment of gastrointestinal bleeds [Meeting Abstract]

Hussein, M; Alzoubaidi, D; O'Donnell, M; De, la Serna A; Varbobitis, I; Hengehold, T; Fernandez-Sordo, J O; W, Rey J; Hayee, B; Despott, E; Murino, A; Moreea, S; Boger, P; Dunn, J; Mainie, I; Graham, D; Mullady, D; Early, D; Latorre, M; Ragunath, K; Anderson, J; Bhandari, P; Goetz, M; Keisslich, R; Coron, E; De, Santiago E R; Gonda, T; Gross, S; Lovat, L; Haidry, R
Introduction Dual endoscopic therapy has been considered the standard of care for endoscopic management of GI bleeding. We aimed to look at the outcomes of Hemospray as a monotherapy treatment for GI bleeds. Methods Data was collected on patients with GI bleeds treated with Hemospray monotherapy in 18 centres. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 62 patients with peptic ulcer bleeds were treated. There was an immediate haemostasis of 90% (56/62), re-bleed rate of 16% (7/44) (Table 1). 69% were Forrest 1a/1b ulcers. 72 patients with malignancy related bleeds. There was a haemostasis rate of 100% and a re-bleed rate of 18% (11/63). There was a haemostasis rate of 100% with post endoscopic therapy bleeds. 48% were post endoscopic mucosal resection. 22 patients with lower GI bleeds were treated. 36% secondary to colonic tumours. There was a haemostasis rate of 96% (21/22) and re-bleed of 26% (5/19). A 100% haemostasis was achieved in 5 patients treated for gastric angiodysplasia with one re-bleed. Conclusions Results show high haemostasis and comparable rebleed rates with Hemospray monotherapy treatment. It may play a potential role in actively bleeding peptic ulcers in difficult anatomical positions to help bridge towards definitive therapy. These data may represent the evolution of new treatment paradigms as experience with haemostatic powders increases
ISSN: 1468-3288
CID: 5082952