Retrospective Observational Study of Patients Admitted with Acute Upper GI Bleed

Abstracts

337

The Reliability of Ultra-Thin Endoscope for Diagnosis of Milder

Form of Esophagitis Compared to Standard EndoscopeYoshio Hoshihara, Naohisa Yahagi, Michio HongoBackgroud: Minimal change esophagitis is defined as Grade M in the modified LosAngeles Grading System in Japan. However, inter-observer agreement of grade M isnot high. To clarify the vagueness of definition on minimal change esophagitis, wedivided Grade M into Grade MW as white blurring of the mucosa and Grade MR asredness or erythema of the mucosa. Ultra-thin endoscopes are getting popular inpractice, but thought to be less in image quality. It is not clear that milder form ofesophagitis are diagnosed reliably with such ultra-thin endoscopes. Aim: Toevaluate the diagnostic reliability of new definition for milder form of esophagitis,and the diagnostic reliability of ultra-thin endoscope compared to standardendoscope. Method: A total of 614 subjects in the program of health checks havingEGD from April 2005 to March 2006 participated to this study. Single experiencedendoscopist (YH) performed unsedated peroral endoscopy in all subjects, andevaluated the severity of esophagitis under deep inspiration, prospectively. Severityof esophagitis was evaluated by modified LA system; adding Grade N (normalmucosa), Grade MW and Grade MR to the original LA system. Subjects were askedto choose either ultra-thin videoendoscope (o.d. 5.9mm) or standard endoscope(o.d. 9.6mm or 10.2mm) after informing the merits and the demerits of each scope.Results: Two hundreds fifty-nine subjects (M 189, F 70) chose the ultra-thin scope,while 355 subjects (M 267, F 88) chose the standard scope. No statistical differenceswere identified between the groups in the gender ratio, age and the prevalence ofGI symptoms. Distribution of the patients to each grades of esophageal mucosalfinding were not statistically different between the scopes used, as shown in theTable. Conclusion: This study shows good reproducibility of the evaluation ofendoscopic grading of minimal change regardless the types of the scope, constantdiagnosability of grades MW and MR. The observation under deep inspirationduring endoscopy might be an important condition for the reliable evaluation ofthe milder form of esophagitis. As the unsedated ultra-thin endoscope, eithertransnasal or peroral, could be well tolerated, observation of esophageal mucosa atdeep inspiration using ultra-thin scope could become a new standard for the milderform of esophagitis, and our new classification, grades MW and MR, may benefitfurther understanding of GERD pathophysiology.Distribution of the patients to each grades of esophageal mucosal finding

Grading N MW MR A B C

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Ultra-thin scope

432

Prospective Evaluation of the Upper and Lower Gastrointestinal

Tract in Young Patients with Iron Deficiency AnemiaBani Chander, Edmund J. BiniBackground: Although gastrointestinal (GI) endoscopy is standard of care toevaluate iron deficiency anemia (IDA) in patients who are R50 years old, theapproach to younger patients with IDA remains unclear. The aims of this study wereto describe the frequency, type, and distribution of clinically important GI lesions inyoung patients with IDA. Methods: Consecutive patients who were referred for theevaluation of IDA were prospectively enrolled at a single medical center. Patientswere interviewed by a research assistant who obtained detailed demographic andclinical data, and all subjects had same-day EGD and colonoscopy. Iron deficiencywas defined as a transferrin saturation of !15% and a ferritin of !20 ug/L, whereasanemia was defined as a hemoglobin of !13 g/dL in men and !12 g/dL in women.Lesions were classified as clinically important according to predeterminedstandardized criteria. Patients were stratified into 3 groups according to age: !50years, 50 - 69 years, and R70 years of age. Results: A total of 1,432 patients with IDAwere enrolled, including 272 !50 years old, 463 ages 50 - 69, and 697 patients R70years of age. There were no differences in sex or race/ethnicity between the 3groups. The prevalence of one or more clinically important lesions anywhere in theGI tract was lower in younger subjects (49.6% vs. 65.0% vs. 63.6%, p Z 0.001). Theprevalence of clinically important lesions in the lower GI tract (31.3% vs. 41.7% vs.48.1%, p Z 0.003), the proportion of subjects with colonic lesions proximal to thesplenic flexure (18.8% vs. 22.9% vs. 28.1%, p Z 0.001), and the frequency ofsynchronous lesions in the upper and lower GI tract (10.3% vs. 13.2% vs. 19.7%,p !0.001) all increased with age. In contrast, the frequency of lesions in the upperGI tract did not increase significantly with age (28.7% vs. 36.5% vs. 35.2%, p Z0.13). As age increased, there was an increase in the prevalence of colonicadenomas R1 cm (20.2% vs. 25.3% vs. 29.3%, p Z 0.003), colorectal cancer (6.3%vs. 12.1% vs. 12.8%, p Z 0.009), colonic vascular ectasias (2.2% vs. 4.1% vs. 7.6%,p !0.001), esophageal adenocarcinoma (0.0% vs. 0.4% vs. 1.1%, p Z 0.04), gastricadenocarcinoma (1.1% vs. 1.1%, vs. 3.0%, p Z 0.02), and vascular ectasias in theupper GI tract (1.5% vs. 4.8% vs. 5.0%, p Z 0.03). Conclusions: Although theprevalence of clinically important GI lesions increases with age in patients with IDA,young patients have clinically important lesions, including colorectal and gastriccancers, identified by endoscopy. These findings suggest that all patients with IDAshould undergo a thorough endoscopic evaluation of the GI tract, regardless of age.

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433

Localization, Efficacy of Therapy, and Outcomes of Dieulafoy

Lesions of the GI Tract - The UT Southwestern GI Bleed Team

ExperienceLuis F. Lara, Jayaprakash Sreenarasimhaiah, Shou Jiang Tang,Bianca B. Afonso, Don C. RockeyIntroduction: Dieulafoy lesions (DL) are an often overlooked cause of GI bleedingthat can happen anywhere in the GI tract. Endoscopic therapy for DL is standard ofcare, with primary hemostasis rates reportedly similar to ulcer disease. Wehypothesized that DL exhibit a unique epidemiology and clinical pattern and aimedto understand the features of DL at our institution. Methods: In this cohort study,patients were identified retrospectively (using ICD-9 codes from 1/03 to 12/05) andprospectively (by registry in the UT Southwestern GI Bleed database from 1/06 to10/07). Clinical and outcome data were abstracted, and Rockall scores calculated.Results: 54 patients with DL were identified (40 retrospectively, 14 prospectively).The prospective incidence of DL was 14/522 (3%), and 14/316 (4.5%) of upper GIbleed (UGIB). The mean age was 57 years (23 to 91). 26 patients presented withhematemesis (13 hematemesis alone), 17 with melena (melena alone 14), 6hematochezia (alone 4), and interestingly 2 had iron deficiency anemia only, andnot reported in three patients. 18 patients had hypertension, 10 DM, 6 renal failure,10 cirrhosis, 3 chronic pancreatitis, and 2 hepatitis, 8 smoked and 11 abusedalcohol. Mean HCT was 26.7%, mean blood transfusions were 3.9 units. The meanRockall score was 5.3 (1 to 9). Four were on warfarin, 9 on ASA (6 on a PPI), and 15on ASA þ NSAID. Rockall scores were higher for those on ASA/NSAID 5.9 vs 5 othermedication (p Z 0.06). Locations were esophagus (1), EG junction (3), cardia/fundus (9), body (11), lesser curve (7), antrum (4), duodenum (13), jejunum (1),and colon in 5 (9%) patients (rectum 4, transverse colon 1). Endoscopy wasperformed in ! 12 hours in 43 patients (79%). Therapy was reported in 49patients: heater probe (HP) alone in 8, epinephrine (epi)/HP in 11 patients,hemoclip (HC) alone in 9, HC/epi injection in 7, epi alone in 7, multipolarelectrocoagulation (BiCap)/epi in 2, BiCap in 1, APC in 1, banding in 1, banding/epiin 1. One patient was not treated. One patient rebled, and rescue hemostasistherapy with HC was successful. In comparison, 13/112 patients with DU or GUbleeding over the same prospective time period rebled (p Z 0.04). There were 5deaths - only one attributable to DL bleeding. Conclusions: DL are not uncommonin patients with upper GI bleeding. 9% were in the colon. There was a trend towarda higher Rockall score in patients on combination ASA/NSAID, suggesting a possibletemporal relationship. Endoscopic therapy was generally very successful, perhapsbecause it was performed in ! 12 hours in 73% of patients. Outcomes weresignificantly better than patients with UGIB due to DU or GU.

434

Retrospective Observational Study of Patients Admitted with

Acute Upper GI BleedKhurum H. Khan, Steven R. Kinnear, Grant CaddyBackground: Current evidence suggests that pre-endoscopy treatment with protonpump inhibitors (PPIs) reduces the length of hospital stay and may reduce re-bleeding, upper gastrointestinal surgery, and mortality in patients admitted withacute upper gastrointestinal bleeding (AUGIB). However, little is known about theoutcome of patients admitted with AUGIB already established on oral PPIs prior toadmission. We sought to establish if there was a difference in severity of bleedbetween patients on and patients not on, pre-admission PPI. A secondary outcomewas to establish if the severity of bleed, as determined by the clinical (pre-endoscopy) and overall Rockall Score, correlated with length of stay. Methods: 400consecutive patients were identified over a 4 year period (2004-2007), using ICD-10diagnostic codes for haematemesis and malaena. Preliminary data has so far beencollected from 80 sets of notes and includes the presence or absence of PPI onadmission, and data to enable a clinical Rockall score to be calculated. Data was alsocollected from the EGD endoscopy record to enable calculation of the overallRockall scores. The Rockall score looks at the age, co-morbidities, admission BP,Pulse and endoscopic stigmatas of GI bleed patients. Differences in the 2 groupswere analysed using students t-test and correlation detected using Pearsoncorrelation. Findings: The mean Overall Rockall Score for patients on pre-admissionPPI was 1.94 vs 3.52 for patients not on PPI (p ! 0.05). A scatter plot of Length ofStay against Overall Rockall Score indicated a trend in that the higher the OverallRockall Score the longer the Length of Stay. The correlation between the twovariables was highly significant (p ! 0.001). Additionally a scatter plot of Length ofStay against Pre-Clinical Rockall Score indicated that the higher the Pre-ClinicalRockall Score the longer the stay. The Pearson Correlation showed this to be highlysignificant (p ! 0.001). The median hospital stay was 5 days (interquartile range 7days). Conclusion: Those patients on pre-admission PPI therapy who have AUGIBhave less severe bleeds than patients who are not taking PPI therapy as calculatedby both the clinical and overall Rockall score. The clinical Rockall Score can becalculated on admission and used to predict the length of stay. It can thereforeinform the Estimated Date of Discharge and contribute to discharge planning. MostGI bleed patients can be expected to remain in hospital for 5 days with a range of 2-9 days. Those patients on pre-admission PPI have less severe bleeds as reflected byOverall Rockall score and subsequently shorter length of stay in the hospital.

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