Introduction

Acute GI bleeding (GIB) can present significant mortality. Topical Endoscopic Haemostatic Agents (TEHAs) have been added to endoscopic treatment modalities for GIB’s. There is no dedicated international consensus on the role of TEHAs in GIB control. We aimed to develop the first expert led consensus statements to provide international guidance on the use of TEHAs in acute GIB’s.

Aims & Methods

A team of 15 world renowned experts in the field of acute GIB from 8 countries were recruited. All panel members have published extensively and possess significant expertise in the cognitive and endoscopic aspects of GIB management. A first meeting was held to define statements and divide them in 5 subgroups: Indications of therapy, mechanism of action, usage, safety and published evidence. Using the RAND/UCLA appropriateness method, they voted on statements by combining expert collective judgement and best available evidence in a two-round voting process. Extensive literature searches were carried out on each statement to provide the latest evidence base to support decisions. A second meeting was held to discuss the results of the first meeting and refine statements. A second round of voting was conducted to rate refined statements. Statements were rated on a 9-point interval scale (1 to 9). A higher score implied a “more appropriate” statement i.e. an important statement in the management of GIB patients. Four statistical methods were used to delineate statements that satisfied all criteria of appropriateness: 1. mean absolute deviation from the mean, 2. BIOMED concerted action on appropriateness definition, 3. RAND method and 4. inter-percentile range adjusted for symmetry methods. For a statement to be considered appropriate it had to meet all statistical definitions of appropriateness showing consensus agreement.

Results

24 statements were presented in round one. 15 statements met all four statistical definitions of appropriateness and proceeded to round two. Following round two, a list of 11 final consensus statements were scored as appropriate and met all four statistical definitions of appropriateness showing overall consensus being reached (Table 1). There was 100% agreement that TEHAs are effective in achieving haemostasis in malignancy related GIB’s (statement 2), can be used as ‘salvage’ therapy for non-variceal GIB’s (statement 4), and can be used as a bridge to definitive non-endoscopic therapy for persistent GIB’s (statement 5). These represent the most important indications for TEHAs that endoscopists should recognise.

Table 1: Final eleven statements voted as appropriate reaching expert consensus after round two. (Score 1-3 = inappropriate statement, score 4 – 6 = uncertain about statement, score 7 – 9 = appropriate statement), TEHAs = Topical Endoscopic Haemostatic Agents

Conclusion

We present the first dedicated international consensus statements aimed at providing guidance to clinicians on best practice use of TEHAs in patients with acute GIB’s. There was consensus on the need for future trials to compare use of different haemostatic powders in GIB’s.

Introduction

Acute upper gastrointestinal bleeding and timing to endoscopy are a recognised as risk factors for mortality. European Guidelines * suggest that the hemodynamical resuscitation could be performed before the endoscopy, however, indications are lacking about the timing of blood transfusions.

Aims & Methods

The aim of the study is to evaluate the transfusion timing to reduce death risk in patients with upper gastrointestinal bleeding. This is a prospective multicentre cohort study, including all consecutive hospitalized patients with upper gastrointestinal bleeding (UGIB). Clinical, endoscopic source of bleeding, medical and endoscopic treatment, time to endoscopy, and timing to transfusion were collected. We adopted the ESGE* guidelines to define the need for transfusion, timing to endoscopy and mortality. We considered timing to transfusion before or after the endoscopic procedure. Statistics: multivariate backward logistic regression was used to estimate the adjusted odds ratio death risk for variables with main clinical relevance or highly statistical significance at univariate analyses. Variables identified by the logistic regression were used into the propensity-score matching to compare the death risk between the two groups.

Results

2,017 out of 3324 patients received a transfusion and were included in the analysis; the mean age was 69.7 [±15.1], male was 1,365 (67.7%); the source of bleeding was non-variceal in 1634 patients (81 %), 178 patients died (8.8%); 69 out of 700 (9.9 %) died in the group transfusion before endoscopy; 109 out 1317 (8.3 %) in the group transfusion after endoscopy with an OR 1.2 (C.I. 95% .86 to 1.68) p<= 0.23. Mortality between the two groups did not significantly differ when haemoglobin levels at admission were considered, nor after adjustment for potential confounding variables, including ASA score, in-hospital bleeding, haematemesis at presentation, shock at admission, altered mental status and timing to endoscopy. Propensity score matching analysis indicated that among patients who received a transfusion, the risk of death decreased when the transfusion was administered before the endoscopy and the haemoglobin level was below 7 g/dL (coefficient = -0.06, p = 0.06; see Table).

Conclusion

Red pack cell transfusions before or after endoscopy did not modify the death risk in patients with acute upper gastrointestinal bleeding; the death risk was less frequent in patients transfused before endoscopy and with a haemoglobin value lower than 7 gr/l. However, this risk increased in those patients transfused before endoscopy and with a haemoglobin value > 8 gr/l.

References

* Ian M. Gralnek et al. Endoscopy 2021; 53: 300–332

Introduction

Individuals with Lynch syndrome (LS) are predisposed to different tumors, including gastric (GC) and duodenal (DC) cancer, especially those with specific mutations or familial aggregation. However, the role of esophagogastroduodenoscopy (EGD) in these patients is still uncertain, with heterogeneous recommendations among different guidelines.

Aims & Methods

To estimate the overall incidence of GC and DC in individuals with LS, to determine the incidence of GC and DC in higher-risk subgroups within these patients, as well as to clarify the usefulness of screening or surveillance by EGD.

Systematic search of Pubmed and Embase for cohort studies and clinical trials from inception to April 2024. Incidences of GC and DC were calculated, as well as the relative risk (RR) and their respective 95% confidence intervals in those studies comparing patients under surveillance with EGD vs without. A meta-analysis was performed using a random-effects model. Heterogeneity was assessed with the I² statistic.

Results

A total of 584 studies were obtained, of which 30 were finally included, with a total of 31264 patients with LS. The overall incidence of GC was 2.04% (95%CI 1.63-2.45). The incidence of GC was 2.60% (95%CI 1.61-3.60) in MLH1 carriers and 2.91% (95%CI 1.63-2.45) in MSH2 carriers. In those with LS and family history, the incidence of GC was 25.94% (95%CI 15.01-36.87). The incidence of DC was 1.61% (95%CI 1.21-2.00).
Only 3 studies compared patients with LS in follow-up with EGD vs those without follow-up, evidencing a protective effect of EGD for GC [RR 0.31 (95%CI 0.14-0.69)], but not for DC [RR 0.65 (95%CI 0.22-1.32)].

Conclusion

The incidence of GC and DC in patients with LS is higher than that of the general population, especially in those patients with MLH1, MSH2 mutations or family aggregation. Surveillance with EGD could help to reduce this incidence through the diagnosis of premalignant lesions.

Clinical Case Summary

A 19-year-old man with a long-standing history of recurrent abdominal pain and a recent episode of melena of unknown origin. He presented to the emergency department (ED) with hematochezia and asthenia, with a drop in hemoglobin to 8.9 g/dL. Upper and lower endoscopy were inconclusive. Capsule enteroscopy revealed a double-lumen sign and mildly erythematous mucosa, raising suspicion of Meckel’s diverticulum. A technetium-99m pertechnetate (Tc-99m) scan confirmed the presence of ectopic gastric mucosa. The patient subsequently underwent enterectomy, and histological analysis confirmed gastric mucosal heterotopia.
A 13-year-old man with a history of iron-deficiency anaemia requiring transfusion at 7 years old, and previous episodes of abdominal pain due to ileo-ileal intussusception. He had
undergone an inconclusive exploratory laparoscopy. He was admitted to the ED with melena and hypogastric pain. Blood tests revealed hemoglobin of 12.9 g/dL. Abdominal ultrasound showed thickening of the distal ileum over 11 cm, without signs of intussusception. Capsule enteroscopy revealed a segment of circumferential edema and erythema in the ileum, with absence of a clear villous pattern and an appearance suggestive of gastric mucosa. A Tc-99m scan confirmed the presence of ectopic gastric mucosa. Exploratory laparoscopy identified a 10–15 cm segment with gastric fold-like appearance within otherwise normal small intestinal mucosa, in the absence of a diverticulum. Histological analysis confirmed gastric mucosal heterotopia.
Gastric heterotopia is an important differential diagnosis in patients with gastrointestinal bleeding and can occur independently of the presence of Meckel’s diverticulum. The authors highlight the role of capsule enteroscopy in the diagnostic algorithm.

Introduction

The neutrophil-lymphocyte ratio (NLR) has been used as a predictor of survival in critically ill patients. However, there are scarce studies that evaluate the relationship between NLR and alcoholic hepatitis.

Aims & Methods

Objectives: To determine the association between NLR with mortality and the degree of acute-on-chronic liver failure (ACLF).
A longitudinal, retrospective, observational and descriptive cohort study was conducted. The subjects met criteria for alcohol hepatitis established by the National Institute on Alcohol Abuse and Alcoholism. Patients with concomitant infections or conditions that could alter the NLR were excluded.
Statistical analysis was performed with the Jamovi program. To compare clinical values, Student's T-test or Mann Whitney U test were performed according to the distribution of the data. The association analysis between NLR and 30-day mortality, as well as the association between NLR and ACLF degrees, were carried out using a point-biserial correlation. An ROC curve was performed using GraphPad Prism version 10.2.3 and Microsoft Excel software to establish the cutoff point of the neutrophil-lymphocyte ratio, as well as determine the sensitivity and specificity of the model to predict 28-day mortality.

Results

Eighty-nine patients were included, 86 (96%) men and 3 (4%) women. There was significant difference between patients who died within 28 days compared with those who survived (Table 1). The mean NLR value in patients who survived was approximately four times the value presented in patients who died within 28 days (p < 0.001). A gradual increase in severity-dependent NLR was identified based on the CLIF-C ACLF SCORE. The cutoff point of the neutrophil-lymphocyte ratio was >12.9 (AUC 0.986), with a p value <0.0001, sensitivity 92.7% and specificity 94.1% (95% CI).

Conclusion

The association between high NLR levels and mortality within 28 days is confirmed. Furthermore, there is an association between NLR and the severity of ACLF. Therefore, the NLR could be a useful prognostic factor in the clinical practice for alcoholic hepatitis.

References

Forrest, E. H., Storey, N., Sinha, R., Atkinson, S. R., Vergis, N., Richardson, P., Masson, S., Ryder, S., Thursz, M. R., Allison, M., Fraser, A., Austin, A., McCune, A., Dhanda, A., Katarey, D., Potts, J., Verma, S., Parker, R., Hayes, P. C., & Group, =STOPAH N L R. (2019). Baseline neutrophil-to-lymphocyte ratio predicts response to corticosteroids and is associated with infection and renal dysfunction in alcoholic hepatitis. Alimentary Pharmacology &amp; Therapeutics, 50(4), 442–453. https://doi.org/10.1111/apt.15335
Velarde-Ruiz Velasco, J. A., Higuera-de la Tijera, M. F., Castro-Narro, G. E., Zamarripa-Dorsey, F., Abdo-Francis, J. M., Aiza Haddad, I., Aldana Ledesma, J. M., Bielsa-Fernández, M. v, Cerda-Reyes, E., Cisneros-Garza, L. E., Contreras-Omaña, R., Reyes-Dorantes, A., Fernández-Pérez, N. J., García-Jiménez, E. S., Icaza-Chávez, M. E., Kershenobich-Stalnikowitz, D., Lira-Pedrín, M. A., Moreno-Alcántar, R., Pérez-Hernández, J. L., … Torre-Delgadillo, A. (2020). Consenso Mexicano de hepatitis alcohólica. Revista de Gastroenterología de México, 85(3), 332–353. https://doi.org/https://doi.org/10.1016/j.rgmx.2020.04.002

Disclosure

No conflict of interest.

Clinical Case Summary

Introduction: Intra-abdominal sepsis from colonic perforation is a surgical emergency with high mortality. While diverticulitis is a common cause in older adults, its presence in young, healthy individuals suggests additional etiologies. Parasitic infestations such as Ascaris lumbricoides, though rare in developed regions, can complicate outcomes.
Case presentation: A 35-year-old previously healthy male presented with 3 days of severe abdominal pain and vomiting. CT scan revealed pneumoperitoneum. Emergency laparotomy showed perforated sigmoid diverticulitis with fecal peritonitis. A Hartmann’s procedure was performed with an open abdomen due to gross contamination. Despite surgery, the patient developed persistent sepsis, requiring seven relook laparotomies. During the fourth, live Ascaris worms were seen emerging from the bowel during ileostomy creation, prompting Albendazole treatment. Histopathology confirmed diverticulitis with perforation. Recovery was complicated by multidrug-resistant infections, anemia, malnutrition, and thrombotic events, prolonging ICU stay.
Discussion: This case highlights how unrecognized parasitic infestation can worsen intra-abdominal sepsis. Ascaris may contribute to mucosal damage, obstruction, and inflammation, exacerbating outcomes. Early hypoalbuminemia might have reflected chronic enteric loss or parasite burden.
Conclusion: In endemic areas, chronic helminthic infections should be considered in young patients with unusual presentations or poor postoperative progress. Timely recognition may impact treatment and recovery.

References

Figure 1: CT Abdomen with Contrast showing Moderate Pneumoperitoneum
Figure 2: Worm coming out of iliostomy
Figure 3: acsaris
Figure 4 : CT Chest showing bilateral moderate pleural effusion more on the right side with underlying lung consolidation collapse.
Figure 5 : US Neck showing Left internal jugular vein central line with echogenic thrombus not completely occluding the lumen.