Introduction

It has been reported that diverticulum hemorrhage has a high spontaneous hemostasis rate of 70 to 90% and rarely leads to hemorrhagic shock, so emergency colonoscopy is not widely performed. However, there is a report that the identification rate of stigmata of recent hemorrhage increases with early colonoscopy administration, so we have performed many emergency colonoscopy within 24 hours after the ER visit.

Aims & Methods

We retrospectively examined 68 cases of diverticulum bleeding who visited our hospital from April 2011 to October 2016; 38 cases in the emergency group who underwent colonoscopy within 24 hours and 30 cases in the elective group who underwent colonoscopy after 24 hours.

Results

The age was 73 ± 11 in the emergency group and 72 ± 12 in the elective group. The blood Hb concentration at the first ER visit was 10.0 ± 3.0 g / dL in the emergency group and 10.5 ± 2.4 in the elective group, showing no significant difference. There were no significant differences in blood pressure or pulse rate at the first ER visit. The oral antiplatelet drug use was 39% in the emergency group, which was higher than that in the elective group 23%, but there was no significant difference in the oral anticoagulant and NSAIDS use. The length of hospital stay was 8.0 ± 6.1 days in the emergency group, 8.0 ± 4.6 days in the elective group, and the blood transfusion rate was 53% in the emergency group and 46% in the elective group, showing no significant differences. A significant difference was observed in the rate of identifying bleeding sources. In 26% of the emergency group and 10% of the elective group, stigmata of recent hemorrhage was identified and hemostatic treatment was performed (p<0.05). No major complications such as intestine perforation was observed in the two group.

Conclusion

Emergency colonoscopy for diverticulum bleeding does not reduce blood transfusion during hospital stay, but it identifies bleeding sources and may lead to effective treatment.

Clinical Case Summary

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. There is limited data regarding the use of liver transplantation for biliary trauma and criteria for liver transplantation in the setting of secondary biliary cirrhosis are not well established.
A 14-year-old male was evacuated to Portugal due to biliary injury after abdominal trauma, after failure of cholecystectomy. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Four years later he presented with obstructive jaundice (total bilirubin of 22 mg/dL), pruritus and physical signs of chronic liver disease. A magnetic resonance cholangiopancreatography showed an anastomotic stricture with marked dilation of the intrahepatic biliary tree. Endoscopic resolution of the stricture was not feasible. A percutaneous transhepatic biliary drainage was performed with immediate efficacy, but the procedure failed to resolve cholestasis, with subsequent referral to a liver transplantation center. Abdominal imaging revealed a cirrhotic liver and dilation of the biliary tract. At the age of 19 years old, an orthotopic liver transplant was performed. Piggy-back technique was used along with a continuous hepaticojejunostomy. Two years post-transplant the patient is asymptomatic and with a markedly improved quality of life.
Management of extrahepatic biliary tree injury can be extremely demanding. Even after clinically successful treatment, the quality of life may be impaired. Some complicated cases culminate in refractory and intractable stenosis of the hepaticojejunostomy with secondary biliary cirrhosis. Timely referral to a tertiary center is essential. Liver transplantation is the last line of treatment, but an earlier referral for this treatment may be needed in order to improve outcomes in severe, complicated or intractable cases.

References

- Thomas MN, Stippel DL. Management of bile duct injuries [Management von Gallengangsverletzungen]. Chirurg 2020;91(1):18-22;
- Krawczyk M, Grat M, Adam R, et al. Liver Transplantation for Hepatic Trauma: A Study From the European Liver Transplant Registry. Transplantation 2016;100(11):2372-2381;
- Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:56;
- Schreuder AM, Busch OR, Besselink MG, et al. Long-Term Impact of Iatrogenic Bile Duct Injury. Dig Surg 2020;37(1):10–21;
- LeBedis CA, Bates DDB, Soto JA. Iatrogenic, blunt, and penetrating trauma to the biliary tract. Abdom Radiology 2017;42(1):28-45;
- Romine MM, White J. Role of Transplant in Biliary Disease. Surg Clin North Am. 2019;99(2):387-401;
- Pereira R, Vo T, Slater K. Extrahepatic bile duct injury in blunt trauma: A systematic review. J Trauma Acute Care Surg 2019;86(5):896-901.Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15(1):24.

Introduction

Cardiorespiratory arrest is a recognized complication of endoscopic procedures, particularly when sedation is administered. Hospitalized patients, especially those with a prescribed Do Not Resuscitate (DNR) order, are more likely to have severe underlying illness, and consequently a higher risk of cardiorespiratory complications. Additionally, the request for endoscopic exams, especially urgent ones, in this group of patients is becoming increasingly common.

Aims & Methods

The aim of this study was to asses the current clinical practices, as well as the beliefs of gastroenterologists in Portugal regarding the management of the code status in hospitalized patients with prescribed DNR undergoing endoscopic procedures.
Self-reported data was obtained through a voluntary and anonymous survey of gastroenterologists and gastroenterology trainees in Portugal.

Results

One hundred and forty five gastroenterologists, of which 26 (17.9%) were trainees, responded to the survey, with an average age of 42 years (27-83 years), and 59.3% female. The majority are aware of the patient's code status prior to the endoscopic procedure (73.1%, n=106). However, DNR is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n=97) or attending physician (58.6%, n=85). In patients with prescribed DNR, the rate of reversal prior to the procedure is rarely performed (reversal in all or almost all in 8,3%, n=12). Most respondents are unaware of the procedures necessary for DNR prescription (81.3%, n=118), as well as existing national/international recommendations on DNR reversal (96.5%, n=140). Regarding personal beliefs, the majority consider that in these patients DNR should be reversed to an intermediate option that includes limited resuscitation maneuvers according to the patient's preference (62.1%, n=90). They also believe that the urgency of a procedure should not influence the decision to reverse DNR (n=89, 61.4%), and that if DNR is reversed, it should be done by the attending physician who initially prescribed it (91.7%, n=133). Finally, respondents are divided when asked if they would perform an endoscopic procedure on a patient with prescribed DNR that has not been previously reversed: 49.7% answered yes (n=72), 22.1% no (n=32), and 28.3% have no formed opinion (n=41). There is a consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n=142).

Conclusion

The majority of Gastroenterologists rarely reverse DNR before endoscopic procedures, however, it is mostly advocated that limited resuscitation maneuvers should be offered according to patient preference. Most are unaware of the existence of institutional, national, or international policies regarding DNR. These findings suggest considerable variation in knowledge and approach to hospitalized patients with DNR, highlighting the need for specific recommendations for Gastroenterology in this area.

References

H. Carneiro A, Carneiro R. DNR A Decisão de Não Reanimar. Revista Portuguesa de Medicina Interna [Internet]. 5 de Dezembro de 2021
Braga I, Dutschmann L, Fiuza T, Almeida H, Gil V, Brandão T. Implementação da Ordem de Não Reanimar. Revista Ordem Médicos. 2012;133:20-23.
Wada K, Szego MJ. Revisiting code status in patients undergoing GI endoscopy with a "do not resuscitate" order. Gastrointest Endosc. 2019 Feb;89(2):380-382.
Feld LD, Mergener K, Rubin DT, Rao VL. Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists. Gastrointest Endosc. 2021 Jul;94(1):172-177.e2.

Introduction

Abdominal pain is the cardinal symptom of acute pancreatitis (AP), often requiring opioid therapy. We aimed to investigate the dose-response relationship between exposure to opioids and the development of moderately severe and severe AP.

Aims & Methods

This was a post-hoc analysis of the prospective PAINAP database, which recruited patients with first-time AP from 118 centres across 27 countries between April 1 and June 30, 2022. From this database, we extracted baseline patient characteristics, post-pancreatitis outcomes and information regarding the dosage of opioid treatment. The morphine-equivalent doses (MEDs) of each opioid administered were calculated based on daily doses and duration of treatment and subsequently summarized into total cumulative MEDs for each patient. Using multivariable regression analysis, we identified risk factors for developing moderately severe or severe AP.

Results

The final cohort for this post-hoc analysis consisted of 1,030 AP patients receiving various doses of opioids (51% male; median age 54 (IQR, 40-69) years). The median pain severity on admission was 7 (IQR, 6-8), and in 504 (50%) patients, the pre-admission duration of pain was more than 24 hours. Most patients (78%) had mild AP, whereas 14% and 8% of patients developed moderately severe and severe AP. On multivariable analysis, a high burden of comorbidity (CCI>2), alcohol aetiology, pre-admission pain duration >24 hours and higher pain severity on admission were independent risk factors for moderately severe or severe AP. There was a significant increase in the risk of moderately severe or severe AP, per mg MED (OR 1.00 (95% CI, 1.00-1.00), P=0.039). Accordingly, receiving >40 mg MED (compared to <10 mg MED) increased the risk of moderately severe or severe AP (OR, 3.51 (95% CI, 2.09-5.93), P<0.001).

Conclusion

The association between opioid exposure and severity of AP was dose dependent. Further studies are warranted to explore this association as this may have clinical implications for pain management in AP.

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure

Introduction

Upper gastrointestinal bleeding (UGIB) is one of the main potentially life-threatening emergencies encountered in gastroenterology that requires prompt management. For this reason, numerous prognostic scores have been developed to predict the level of risk in patients. However, there are few studies in the literature comparing these scores.

Aims & Methods

The main objective of this study was to compare the performance of the pre-endoscopic scores Glasgow-Blatchford Score (GBS), Rockall Score (pRS), and quick Sequential Organ Failure Assessment (qSOFA) in predicting the severity of UGIB according to predefined criteria.
Methods: This is a retrospective descriptive and analytical study of 102 patients who presented with upper gastrointestinal bleeding at the International University Hospital Cheikh Khalifa over a period of 1 year between October 2021 and October 2022. Scores were calculated for each patient with complete medical records. The data was analyzed using the Jamovi 2.2.5 software. The accuracy of each risk score in predicting clinical criteria was evaluated by the area under the receiver operating characteristic curve (AUROC). A p-value less than 0.05 was considered statistically significant.

Results

The included patients had a mean age of 57.1 years with a slight female predominance (53.9%). GBS was found to be more predictive of the risk of admission to the Intensive care Unit (ICU) and the need for blood transfusion than pRS and qSOFA with an AUROC of 0.914 for these two criteria. GBS was also more predictive of the risk of therapeutic intervention (AUROC 0.882) compared to pRS (AUROC 0.788) and qSOFA (AUROC 0.676). Regarding endoscopic intervention, pRS and GBS were equally able to predict this criterion with moderate power (AUROC pRS 0.721) (AUROC GBS 0.747). qSOFA showed no significant performance, especially in its preferred domain of admission to the ICU (AUROC 0.735) (Table). None of the 3 scores was able to predict the need for surgical intervention.

Table: Comparison of AUC, sensitivity, specificity, PPV and NPV along with cut-off value of Glasgow-Blatchford Score, pre-Rockall, and Quick-Sofa scores to predict the clinical outcomes

Conclusion

At the end of this study, the use of GBS and pRS in daily clinical practice in emergency departments is strongly recommended to predict the need for therapeutic intervention, hospitalization, or re-bleeding episodes. However, it would be interesting to study the usefulness of these prognostic scores, especially qSOFA, through larger prospective studies.

References

1. Cúrdia Gonçalves T, Barbosa M, Xavier S, et al. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE Port J Gastroenterol. nov 2018;25(6):299‑307.
2. Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol. déc 2019;13(12):1161‑7.
3. Aquarius M, Smeets FGM, Konijn HW, et al. Prospective multicenter validation of the Glasgow Blatchford bleeding score in the management of patients with upper gastrointestinal hemorrhage presenting at an emergency department. Eur J Gastroenterol Hepatol. sept 2015;27(9):1011‑6.
4. Li Y, Lu Q, Song M, Wu K, Ou X. Comparisons of six endoscopy independent scoring systems for the prediction of clinical outcomes for elderly and younger patients with upper gastrointestinal bleeding. BMC Gastroenterol. 13 avr 2022;22(1):187
5. Renukaprasad AK, Narayanaswamy S, R V. A Comparative Analysis of Risk Scoring Systems in Predicting Clinical Outcomes in Upper Gastrointestinal Bleed. Cureus. juill 2022;14(7):e26669
6. Taslidere B, Sonmez E, Özcan AB, Mehmetaj L, Keskin EB, Gulen B. Comparison of the quick SOFA score with Glasgow-Blatchford and Rockall scores in predicting severity in patients with upper gastrointestinal bleeding. Am J Emerg Med. juill 2021;45:29‑36

Disclosure

All co-authors have seen and agree with the contents of the manuscript and there is no conflict of interest.