Introduction

The management of acute lower gastrointestinal bleeding (LGIB) is based on clinical acumen and local protocols that are not underpinned by validated scoring systems. The ABC score is validated to predict 30-day survival in LGIB but not to predict need for therapeutic intervention. Therefore, we retrospectively reviewed the clinical course of inpatients with LGIB at the Aberdeen Royal Infirmary (ARI) to evaluate ABC score performance in decision-making in a period before and during the COVID-19 pandemic as a part of a natural experiment.

Aims & Methods

Consecutive unscheduled admissions to ARI in the 10 months before and after 31/03/2020 with discharge summaries coded with lower or unspecified GIB that warranted investigation or management were identified by electronic patient record search. Patient demographics, investigations, and outcome were analysed with statistical testing by chi-squared and Wilcoxon rank sum tests. General linear models were created within R using a random selection of 80% of the cohort to “train” the model, using the remaining 20% as “validation” of model performance.

Results

The search identified 273 admissions (257 unique patients): 138 (51%) in the pre-pandemic period and 135 (49%) in the pandemic period. There were no significant differences in sex, age, ABC score, or length of stay between these two periods. ABC score was associated with decreased 30-day survival, though most patients with a high ABC score nonetheless survived. Patients with an intermediate ABC score were most likely to be admitted to critical care and those with a low ABC score had the shortest length of stay. ABC score performed very well in predicting 30-day survival (area under the curve [AUC] = 0.97), but not in predicting LGI endoscopy, computed tomography mesenteric angiograms, or deferment to outpatient investigations. Likewise, ABC score did not accurately predict admission to critical care. Half of patients with a high ABC score of 8 or more (15 out of 30) were qualitatively described as too frail for invasive procedures such as endoscopy.

Conclusion

The ABC score to predict 30-day survival in patients with LGIB was very accurate in our retrospective cohort of patients admitted to the ARI, both before and after the start of the COVID-19 pandemic. However, the ABC score was relatively ineffectual in predicting investigations, management, and critical care admission. Higher ABC scores were generally garnered by frailer patients, reflecting the large proportion of points relating to chronic conditions. Accordingly, these are patients in whom invasive management strategies are often not appropriate. Due to limitations in our data, we were unable to compare the performance of the ABC score relative to other scoring systems. The ABC score is unlikely to contribute to clinical decision making in the initial management of LGIB. Therefore, further large-scale studies are required to provide an evidence basis to guide admission to critical care and urgent intervention.

References

Laursen SB, Oakland K, Laine L, Bieber V, Marmo R, Redondo-Cerezo E, Dalton HR, Ngu J, Schultz M, Soncini M, Gralnek I, Jairath V, Murray IA, Stanley AJ. ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study. Gut. 2021 Apr;70(4):707-716.

Introduction

Lower gastrointestinal bleeding (LGIB) is a major medical emergency, and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality that increases with aging.

Aims & Methods

We aimed to describe patient characteristics, interventions and clinical outcomes of LGIB, and to define the impact of LGIB in elderly patients. This was a retrospective multinational cohort study which included adult patients consecutively presenting LGIB at 10 participating centers over a 12-month period. Data relevant to the initial LGIB episode and for up to 30 days afterwards were collected from patient medical records.

Results

Among the 950 patients included at this moment, 53.5% were men. Patients aged ≥ 65 years comprised 79,7% of the cohort (mean age 74 years); in this group, most comorbidities and use of antiplatelet/anticoagulant therapy were more frequent (p<0.001). 22.8% had a previous LGIB bleeding episode. On admission, hemodynamic instability was present in 12.6% (n=120) and almost 50% required red cell transfusion (n=442). Most patients (81.6%) required hospitalization and 6% of them were admitted in an intensive care unit. The risk scores Oakland (p<0.001) and ABC (p=0.003) were higher in patients ≥65 years. Colonoscopy was the most common investigation (63.8%). Hemostatic endoscopy therapy was performed in 20% of patients. Interventional radiology therapy and surgery were necessary in 7 (0.7%) and 24 (2.5%) patients, respectively. Diverticular bleeding (20.5%) was the most common cause of LGIB, followed by anorectal diseases (12.7%) and ischemic proctitis/colitis (10.3%). Median length of stay was 7 days, 12% of patients rebled during hospitalization and readmission with bleeding occurred in 8.4%. In-hospital mortality was 9% (n=86), with 74 deaths attributed to non-bleeding causes. The multivariate analysis showed that older adults required hospitalization (p<0.001) and longer hospital stays (p<0.001) more frequently, while younger patients had higher ICU admission rates (p=0.018). Antiplatelet (p=0.034) or anticoagulant use (p=0.018), ABC score (p<0.001) and Charlson Comorbidity Index (CCI, p<0.001) were independently associated with in-hospital mortality. The CCI, higher in older patients, also correlated with need of blood transfusions (p=0.035), rebleeding (p=0.048), and re-hospitalization (p=0.027). Table 1 summarizes use of healthcare resources and clinical outcomes.

Conclusion

This study analyzed the epidemiological data of LGIB in a large representative sample of the European population. Despite more accurate diagnostic/therapeutic methods and likely earlier detection, higher use of healthcare resources and worse outcomes have increased which may reflect a higher burden of comorbidities in a progressively aged population. Besides higher prevalence, comorbidities and risk factors in elderly patients, the present study demonstrates that there are several differences in the management of LGIB patients across Europe.

References

1. Abraham NS, Noseworthy PA, Inselman J, et al. Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age. Clin Gastroenterol Hepatol. 2020;18:337–346 e19.
2. Triantafyllou K, Gkolfakis P, Gralnek IM, et al. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021 Aug;53(8):850-868.
3. Sengupta N, Feuerstein JD, Jairath V, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol. 2023 Feb 1;118(2):208-231.
4. Oakland K, Guy R, Uberoi R, et al; UK Lower GI Bleeding Collaborative. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit. Gut. 2018 Apr;67(4):654-662.
   

Introduction

Lower gastrointestinal bleeding (LGIB) is a frequent clinical challenge, particularly in elderly patients and those on anticoagulants. While anticoagulants are known to increase bleeding risk, their impact on LGIB outcomes remains uncertain.

Aims & Methods

To assess whether anticoagulant use is independently associated with adverse outcomes in patients hospitalized with acute LGIB, using robust propensity score-based methods to adjust for confounding.
Methods: This study was a post-hoc analysis of prospectively collected data from a multicenter, international cohort of 1911 patients hospitalized for LGIB. Propensity score matching (PSM) was performed using a logistic regression model, incorporating key covariates including demographics, comorbidities, comedications (antiplatelets, nonsteroidal anti-inflammatory drugs), prior history of LGIB, bleeding presentation (melena or hematochezia, hemodynamic instability) and care setting (inpatient vs. outpatient). Patients on anticoagulants were matched 1:1 with controls using nearest-neighbor matching (caliper=0.2). Covariate balance after adjustment was assessed using standardised mean differences (SMDs), with all variables achieving an SMD<0.2. Primary outcomes were in-hospital death and rebleeding. Secondary outcomes included red blood cell (RBC) transfusion and surgery. McNemar’s test was used for outcome comparisons between anticoagulant users and matched controls. Subgroups analysis to compare DOACs vs. VKAs was conducted using chi-squared and Mann–Whitney U tests, as appropriate.

Results

Among the original cohort of 1911 patients (mean age 77 years, IQR 66-84; 54.2% male), 610 (31.9%) were on anticoagulants (310 direct oral anticoagulant [DOACs], 188 vitamin K antagonists [VKAs], 89 low-molecular-weight or unfractionated heparin, and 23 unspecified). Overall, in-hospital death occurred in 72 (3.8%), rebleeding in 166 (8.7%), surgery in 104 (5.4%), and RBC transfusion in 836 (43.7%) patients. The matched cohort included 980 patients (490 per group). Anticoagulant use was not significantly associated with higher in-hospital mortality (OR 1.16, 95% CI 0.63-2.14), rebleeding (OR 1.42, 95% CI 0.90-2.25), or surgery (OR 0.75, 95% CI 0.43-1.32). However, it was related with higher RBC transfusion rates (OR 1.66, 95% CI 1.28-2.14). In the subgroup analysis, outcomes were comparable between DOACs and VKAs.

Conclusion

In patients hospitalized with LGIB, anticoagulant use is not associated with increased mortality, rebleeding, or surgical intervention but is linked to a higher need for RBC transfusion.

References

Oakland K., et al., Re-bleeding and Mortality After Lower Gastrointestinal Bleeding in Patients Taking Anti-platelets or Anti-coagulants, Clin Gastroenterol Hepatol, 2019
Radaelli F., et al., Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study, Dig Liver Dis, 2021
Dajti E., et al., In-hospital Mortality in Patients with Lower Gastrointestinal Bleeding: Development and Validation of a Prediction Score, Endoscopy, 2025

Disclosure

Emanuele Rondonotti and Franco Radaelli have received speaker honoraria from Fujifilm Co. The other authors have no disclosures.

Introduction

Although the incidence of acute lower gastrointestinal bleeding (LGB) is increasing, the predictors of outcomes are not as well studied and defined as for acute upper gastrointestinal bleeding. Scores in gastrointestinal bleeding contain common variables. The most frequently repeated are 4: heart rate, hemoglobin, systolic blood pressure and age.

Aims & Methods

We hypothesized that a new score containing the common variables might perform as well as other scoring systems in predicting lower GI bleeding outcomes. The aim of this study was to compare the accuracy of score with common variables (CVS) with 4 available risk scores (Strate, Oakland, Glasgow-Blachford (GBS) and Pre-endoscopic Rockall) for predicting: 1.- Severe bleeding, 2.- Rebleeding, 3.- Transfusion, 4.- Treatment (endoscopic therapy, vascular embolization, surgery), 5.- Safe discharge and. 6.- Clinical intervention. Retrospective study in university tertiary care hospital. They were collected consecutively for 5 years. Patients with acute LGB were identified using the International Classification of Diseases (10th Revision) and Clinical Modification codes for admission diagnosis. Scores were retrospectively calculated according to the clinical reports data. Area under the receiver operating characteristic curve (AUC) analysis was used to compare the scores. AUROC s were compared with the DeLong method by using STATA 14.1 software (StataCorp.2015).

Results

A total of 406 consecutive patients admitted with LGB were identified. The mean age was 76.6 years (range 23-97), 277 (68.1%) of patients were older than 70 years, 219 (53.8%) were men. 119 (29.2%) with severe bleeding, 35 (8.6%) rebleeding, 109 (26.8%) received transfusion, 52 (12.5%) received treatment (48 endoscopic, 4 embolization ), 136 (33.5%) underwent clinical intervention; in 40 patients (9.8%) it was possible to be safely discharged and 6 (1.5%) died, The most frequent etiology of bleeding was diverticular disease present in 115 patients (28.3%). The CVS was better than Strate , Rockall pre-endoscopic index and GBS in predicting severe bleeding and transfusion (AUROC>0.8). CVS was the same as the other indices to predict treatment and recurrence (AUROC<0.8). GBS and Oakland obtained ROC curves similar to CVS to predict safe discharge and need for clinical intervention. All prognostic indices are more accurate in determining the need for transfusion than severe bleeding or clinical intervention. (Table 1)

Conclusion

The CVS is useful for predicting results in LGB and with a smaller number of variables than the other indices, which makes it an easier score to calculate.

References

Tapaskar N, Jones B, Mei S, Sengupta N. Comparison of clinicalpredictiontools and identification of riskfactorsfor adverse outcomes in acutelower GI bleeding.GastrointestEndosc. 2019 May;89(5):1005-1013
Majed Almaghrabi, Mandark Gandhi, Leonardo Guizzettiet al. Comparison of Risk Scores for Lower Gastrointestinal Bleeding. A Systematic Review and Meta-analysis. JAMA Netw Open. 2022 May 2;5(5)

Clinical Case Summary

Introduction: Heterotopic gastric mucosa (HGM) is not uncommon throughout the gastrointestinal (GI) tract, nevertheless its presence in the lower GI is considered as a rare entity. The purpose of this study is to report a clinical case of HGM located in the rectum, which was presented with intermittent bleeding. The medical history of the patient and the way was treated are presented.
Case presentation: A 40-year-old male patient with an unremarkable medical history presented to the outpatient clinic suffering from anal pain, accompanied with intermittent rectal bleeding. At colonoscopy, a solitary flat elevated lesion with central depression, approximately 2 cm in size, was identified in the lower part of the rectum. Histological examination of the biopsy specimen showed heterotopic gastric mucosa while Giemsa stain was positive for Helicobacter Pylori (HP). First-line treatment for HP eradication including a 14-day course of proton pump inhibitor (PPI), amoxicillin, clarithromycin and metronidazole was administered. One month after therapy was completed, the patient underwent a Urea Breath Test (UBT) and an HP antigen stool examination, which were both negative. Meanwhile, the symptoms had been resolved. Unfortunately, the patient never returned to follow the standard procedure of proper clinical and endoscopic re-evaluation.
Conclusion: HGM can be either congenital, as a result of an error in the differentiation of the endodermal stem cells during organogenesis, or acquired, as a metaplasia during the repair of damaged epithelium. When located in rectum, HGM can be presented with symptoms such as bleeding, abdominal or anal pain. Moreover, complications such as ulcer and even adenocarcinoma have been reported. Although endoscopic or surgical resection is considered as the radical therapy of the HGM in rectum, administration of PPIs, inhibitors of histamine-receptors or HP eradication treatment, in cases HP is present, is effective in short-term symptoms relief.

References

1) Iacopini F, Gotoda T, Elisei W, Rigato P, Montagnese F, Saito Y, Costamagna G, Iacopini G. Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review. Gastroenterol Rep (Oxf). 2016 Aug;4(3):196-205. doi: 10.1093/gastro/gow006. Epub 2016 Apr 21. PMID: 27103738; PMCID: PMC4976682.
2) Devereaux CE, Devereaux RG. Heterotopic gastric mucosa of the rectum with a review of the literature. J Clin Gastroenterol. 1994 Jul;19(1):41-5. doi: 10.1097/00004836-199407000-00011. PMID: 7930432.
3) Chrysanthos, N. & Anagnostopoulou, Evagelia & Daskalaki, Anna & Patsavela, Stamatia. (2015). Images of the Month. The American journal of gastroenterology. 110. 498. 10.1038/ajg.2014.251.
4) Chen WG, Zhu HT, Yang M, Xu GQ, Chen LH, Chen HT. Large heterotopic gastric mucosa and a concomitant diverticulum in the rectum: Clinical experience and endoscopic management. World J Gastroenterol 2018; 24(30): 3462-3468 [PMID: 30122884 DOI: 10.3748/wjg.v24.i30.3462]

Introduction

Nowadays one of the biggest healthcare burdens is the diseases of the gastrointestinal tract (GIT). Taking into consideration, that the human gut harbors more than 10¹⁴ CFU of bacteria, through the years scientists have linked those diseases to bacteria species like: Bacteroides fragilis, Fusobacterium nucleatum, Escherichia coli, and Helicobacter pylori. Nevertheless, according to World Health Organisation (WHO), Klebsiella pneumoniae is the priority pathogen with the main bacterial pool in the gastrointestinal tract and is easily transmitted between patients, leading to nosocomial outbreaks. Therefore, scientific research with dependable murine models of Klebsiella pneumoniae infection in GIT is highly required.

Aims & Methods

Within the frames of this study, we aimed to develop a dependable mice model for gastrointestinal tract infection of K. pneumoniae as a method for testing novel antimicrobial therapies. Three different study design settings, overall, six experimental groups, and two bacterial strains (ATCC12657, ATCC43816) were used to test the most effective approach for Klebsiella pneumoniae infection: Control groups (10⁸ CFU: G1 - K. pneumoniae ATCC12657; G4 - K. pneumoniae ATCC43816); antibiotics (penicillin 2000 U/ml, streptomycin 2 mg/ml) pre-treated groups with ampicillin therapy (125 mg/l) (10⁸ CFU: G2 - K. pneumoniae ATCC12657; G3, G5, G6 - K. pneumoniae ATCC43816). Real-time PCR for khe (specific K. pneumoniae gene) and 16S rRNA gene sequencing was performed on DNA extracted from faecal samples of the study animals.

Results

The gastrointestinal K. pneumoniae colonization was detected in the antibiotic pre-treated mice group followed by the introduction of K. pneumoniae in all study groups. The control groups of just K. pneumoniae inoculation for three continuous days resulted in (G1) 2,1 x 10⁸ CFU/50mg and (G4) 6.39 x 10⁸ CFU/50mg (p=0,008). To disrupt the host microbiota, the antibiotic pre-treatment in drinking water (streptomycin and penicillin) for three continuous days and low dose ampicillin afterward, were used in two study groups (G2) 6,67 x 10⁸ CFU/50 mg; (G3) 8,24 x 10⁸ CFU/50 mg (p=0,03). Because of sufficient colonization results using three days of antibiotic pre-treatment, one study group was tested with a singular dose of streptomycin and penicillin before bacterial inoculation ((G5) 6,24 x 10⁸ CFU/50 mg) and another one with additional ampicillin therapy ((G6) 9,01 x 10⁸CFU/50 mg) (p=0,31). Analysis of the gastrointestinal tract colonization with K. pneumoniae proved effective with or without antibiotic pre-treatment. The effectiveness and differences in microbiota using two bacterial species were also confirmed by 16S rRNA gene sequencing. All above-mentioned results are statistically significant considering p<0.05 with ±95% confidence intervals.

Conclusion

Our study demonstrates that colonization of mice intestinal tract by K. pneumoniae can be achieved with or without eradicating resident gut microbiota. Nevertheless, any of the six murine models can be used in further studies of GIT diseases.

References

1. Kaur, Christina Parvinder, et al. “Impact of Klebsiella Pneumoniaein Lower Gastrointestinal Tract Diseases.” Journal of Digestive Diseases, vol. 19, no. 5, 2018, pp.262–271., https://doi.org/10.1111/1751-2980.12595.
2. Zhou, Bolun, et al. “Intestinal Flora and Disease Mutually Shape the Regional Immune System in the Intestinal Tract.” Frontiers in Immunology, vol. 11, 2020, https://doi.org/10.3389/fimmu.2020.00575.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB). In a recent Japanese multicenter retrospective cohort study, 63.6% of patients with ALGIB were ultimately diagnosed with CDB [1]. It has also been reported that CDB in ALGIB is reportedly more severe than in other entities [2, 3]. However, few reports have demonstrated the efficacy and safety of bowel preparation for patients undergoing urgent colonoscopy.

Aims & Methods

We aim to clarify choice a of bowel preparation for urgent colonoscopy in patients with colonic diverticular bleeding. In a multicenter retrospective cohort study at 10 institutions, we analyzed the endoscopic findings and clinical course of patients diagnosed with CDB who underwent urgent colonoscopy within 24 hours after admission. Bowel preparation consisted of oral consumption of 1 to 2 L of polyethylene glycol lavage (PEL); enemas were not used. We compared those CDB patients who underwent PEL (PEL group) with a control group who did not undergo PEL (non-PEL group) before and after propensity score matching. For the matching, we selected variables known at the time of hospital admission (i.e. age, sex, comorbidities, medications, performance status, and laboratory data). The primary endpoint of the study was length of hospital stay, and secondary endpoints included blood transfusion requirements, rebleeding rates, endoscopic findings, and complications.

Results

242 patients were enrolled in this study. The median age was 76 years, and 60.7% of patients were men (n = 147). Approximately half of the patients underwent bowel preparation with PEL prior to urgent colonoscopy (n = 129). We compared with clinical findings between the PEL and non-PEL groups. The length of hospital stay was shorter in the PEL group (8.0 ± 5.1 days vs 10.9 ± 5.8 days; mean ± SD; P < 0.001). Further, the PEL group was significantly younger (72.2 ± 12.1 vs 75.4 ± 13.1; mean ± SD; P = 0.036), had fewer patients with hypertension (62.0% vs 75.2%; P = 0.027) and malignant neoplasm (1.6% vs 10.6%; P = 0.002), and had better performance statuses (86.1% vs 76.1%; P = 0.047). Patients in the PEL group received fewer blood transfusions (25.6% vs 44.3%; P = 0.002), had a higher rate of cecal completion (88.3% vs 49.6%; P < 0.001), and shorter endoscopic observation times (20.8 ± 16.2 min vs 29.9 ± 24.8 min; mean ± SD; P = 0.006). After propensity score matching, there were 91 patients each in PEL group and in non-PEL group. PEL group had a significantly shorter hospital stay (7.9 ± 4.6 days vs 10.7 ± 5.8 days; mean ± SD; P < 0.001), a higher cecum completion rate (87.8% vs 48.3%; P < 0.001), and a shorter endoscopic observation time (20.7 ± 16.8 min vs 28.9 ± 24.1 min; mean ± SD; P = 0.031) than non-PEL group. There were no significant differences in blood transfusion requirements, rebleeding rates, identification of SRH, need for endoscopic hemostatic treatment, or complication rates.

Conclusion

In patients with CDB, urgent colonoscopy under PEL resulted in shorter hospital stays, higher cecal completion rates, and shorter endoscopic observation time in urgent colonoscopy. The safety of urgent colonoscopy with PEL was comparable to colonoscopy without PEL. These results suggest that PEL is preferrable for urgent colonoscopy in patients with CDB.

References

1. Nagata N, Kobayashi K, Yamauchi A, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study. Am J Gastroenterol 2021; 116: 2222-2234.
2. Aoki T, Nagata N, Shimbo T, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2.
3. Xavier SA, Machado FJ, Magalhães JT, et al. Acute lower gastrointestinal bleeding: are STRATE and BLEED scores valid in clinical practice? Colorectal Dis 2019; 21: 357-364.