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The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

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 healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance 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.
PMID: 38857483
ISSN: 1572-0241
CID: 5668892

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

Hemospray® (hemostatic powder TC-325) as monotherapy for acute gastrointestinal bleeding: a multicenter prospective study

Papaefthymiou, Apostolis; Aslam, Nasar; Hussein, Mohamed; Alzoubaidi, Durayd; Gross, Seth A; Serna, Alvaro De La; Varbobitis, Ioannis; Hengehold, Tricia A; López, Miguel Fraile; Fernández-Sordo, Jacobo Ortiz; Rey, Johannes W; Hayee, Bu; Despott, Edward J; Murino, Alberto; Moreea, Sulleman; Boger, Phil; Dunn, Jason M; Mainie, Inder; Mullady, Daniel; Early, Dayna; Latorre, Melissa; Ragunath, Krish; Anderson, John T; Bhandari, Pradeep; Goetz, Martin; Kiesslich, Ralf; Coron, Emmanuel; Santiago, Enrique Rodríguez De; Gonda, Tamas A; O'Donnell, Michael; Norton, Benjamin; Telese, Andrea; Simons-Linares, Roberto; Haidry, Rehan
BACKGROUND/UNASSIGNED:Hemostatic powders are used as second-line treatment in acute gastrointestinal (GI) bleeding (AGIB). Increasing evidence supports the use of TC-325 as monotherapy in specific scenarios. This prospective, multicenter study evaluated the performance of TC-325 as monotherapy for AGIB. METHODS/UNASSIGNED:Eighteen centers across Europe and USA contributed to a registry between 2016 and 2022. Adults with AGIB were eligible, unless TC-325 was part of combined hemostasis. The primary endpoint was immediate hemostasis. Secondary outcomes were rebleeding and mortality. Associations with risk factors were investigated (statistical significance at P≤0.05). RESULTS/UNASSIGNED:One hundred ninety patients were included (age 51-81 years, male: female 2:1), with peptic ulcer (n=48), upper GI malignancy (n=79), post-endoscopic treatment hemorrhage (n=37), and lower GI lesions (n=26). The primary outcome was recorded in 96.3% (95% confidence interval [CI]: 92.6-98.5) with rebleeding in 17.4% (95%CI 11.9-24.1); 9.9% (95%CI 5.8-15.6) died within 7 days, and 21.7% (95%CI 15.6-28.9) within 30 days. Regarding peptic ulcer, immediate hemostasis was achieved in 88% (95%CI 75-95), while 26% (95%CI 13-43) rebled. Higher ASA score was associated with mortality (OR 23.5, 95%CI 1.60-345; P=0.02). Immediate hemostasis was achieved in 100% of cases with malignancy and post-intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received TC-325 for lower GI bleeding, and in all but one the primary outcome was achieved. CONCLUSIONS/UNASSIGNED:TC-325 monotherapy is safe and effective, especially in malignancy or post-endoscopic intervention bleeding. In patients with peptic ulcer, it could be helpful when the primary treatment is unfeasible, as bridge to definite therapy.
PMCID:11226744
PMID: 38974074
ISSN: 1108-7471
CID: 5732192

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)
EMBASE:641287192
ISSN: 1572-0241
CID: 5514912

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 (
EMBASE:641284712
ISSN: 1572-0241
CID: 5515282

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)
EMBASE:641286974
ISSN: 1572-0241
CID: 5514982

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.
PMCID:9101917
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
ISI:000897916000367
ISSN: 0002-9270
CID: 5526532