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Lower Gastrointestinal Bleeding

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Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study.
Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, Murphy MF, Collins GS.
Lancet Gastroenterol Hepatol. 2017 Sep;2(9):635-643.

Rationale for Inclusion: Large prospective study used to develop and validate a novel clinical prediction model with good discriminative performance in identifying patients with lower gastrointestinal bleeding who are candidates for safe outpatient management, yielding important resource and economic implications..

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Diagnosis of lower gastrointestinal bleeding by multi-slice CT angiography: a meta-analysis.
He B, Yang J, Xiao J, Gu J, Chen F, Wang L, Zhao C, Qian J, Gong S.
Eur J Radiol. 2017 Aug;93:40-45.

Rationale for Inclusion: A total of 14 articles with 549 patients were included in the meta-analysis.  The study showed multi-slice spiral CTA has high value (sensitivity 90% and specificity 92%) in the diagnosis of lower gastrointestinal bleeding and should be considered an adjunct in the clinical treatment of lower GI bleeds.

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Neural network prediction of severe lower intestinal bleeding and the need for surgical intervention.
Loftus TJ, Brakenridge SC, Croft CA, Smith RS, Efron PA, Moore FA, Mohr AM, Jordan JR.
J Surg Res. 2017 May 15;212:42-47.

Rationale for Inclusion: Artificial neural network (ANN) models have outperformed scoring systems based on regression models in predicting severe bleeding.  This study compared ANNs to the Strate model in predicting acute lower intestinal bleed (ALIB). The Strate model was less accurate than an ANN featuring six variables present on admission: hemoglobin, systolic blood pressure, outpatient prescription for Aspirin 325 mg daily, Charlson comorbidity index, base deficit, and international normalized ratio. A similar ANN predicted the need for surgery by integrating two additional parameters: hemoglobin nadir and the occurrence of a 20% decrease in hematocrit. The optimal approach to clinical prognostication may incorporate the efficiency and pragmatism regression-based risk calculators and the accuracy of ANNs.

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ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding.
Strate LL, Gralnek IM.
Am J Gastroenterol. 2016 May;111(5):755.

Rationale for inclusion: This article provides a nice summary of management of lower GI bleeding.

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Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy.
Nagata N, Niikura R, Aoki T, Moriyasu S, Sakurai T, Shimbo T, Shinozaki M, Sekine K, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N.
J Gastroenterol. 2015 Dec;50(12):1162-72.

Rationale for inclusion: This is a small study but addresses one of the dilemmas with LGIB; to scan or to perform endoscopy. In a small cohort of patients, the authors demonstrate some benefit with contrast-enhanced multidetector computed tomography for acute LGIB in localizing the lesion.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants.
Lanas Á, Carrera-Lasfuentes P, Arguedas Y, García S, Bujanda L, Calvet X, Ponce J, Perez-Aísa Á, Castro M, Muñoz M, Sostres C, García-Rodríguez LA.
Clin Gastroenterol Hepatol. 2015 May;13(5):906-12.e2.

Rationale for inclusion: The common use of NSAIDS and oral anticoagulants necessitate an understanding of the risks associated with their use. This study confirms that GI bleeds are increased when these agents are used.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding.
Laine L, Shah A.
Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642.

Rationale for inclusion: this study confirmed the importance of performing upper endoscopy in patients with clinically significant lower GI bleeding with hemodynamic instability; 15% had an upper GI source of bleeding.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study.
Kim CY, Suhocki PV, Miller MJ Jr, Khan M, Janus G, Smith TP.
J Vasc Interv Radiol. 2010 Apr;21(4):477-83.

Rationale for inclusion: this study that provoking bleeding by intra-arterial injection of a vasodilator and tissue plasminogen activator successfully uncovered the source of bleeding in about one-third of patients with occult lower GI bleeding.  Complication rates were low and the rates of hemorrhage control (after provocation) were high.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center.
Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, Sugawa C.
Surgery. 2009 Oct;146(4):600-6; discussion 606-7.

Rationale for inclusion: this large retrospective review demonstrates that the most common causes of acute lower GI bleeding are diverticulosis, hemorrhoids, and carcinoma, and that colonoscopy was effective in diagnosis and treatment.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage.
Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, Wilmer A.
Am J Gastroenterol. 2009 Aug;104(8):2042-6.

Rationale for inclusion: this study demonstrates high effectiveness and low complication rates associated with transcatheter angioembolism for lower GI bleeding.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated?
Plummer JM, Gibson TN, Mitchell DI, Herbert J, Henry T.
Int J Clin Pract. 2009 Jun;63(6):865-8.

Rationale for inclusion: this study reports that sub-total colectomy is the preferred treatment for unrelenting massive lower GI bleeding.  Because most mortalities were secondary to sepsis from anastomotic leak, end ileostomy is recommended.

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The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding.
Ell C, Remke S, May A, Helou L, Henrich R, Mayer G.
Endoscopy. 2002 Sep;34(9):685-9.

Rationale for inclusion: this study demonstrates the utility of wireless capsule endoscopy in identifying occult GI bleeding and its superiority over push enteroscopy.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline.
Ryan JM, Key SM, Dumbleton SA, Smith TP.
J Vasc Interv Radiol. 2001 Nov;12(11):1273-7.

Rationale for inclusion: this is another provocative mesenteric angiography study demonstrating a similar one-third success rate.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Total colectomy versus limited colonic resection for acute lower gastrointestinal bleeding.
Farner R, Lichliter W, Kuhn J, Fisher T.
Am J Surg. 1999 Dec;178(6):587-91.

Rationale for inclusion: this study supports the practice of total colectomy for the treatment of ongoing lower GI bleeding.  Compared to limited colonic resection, the rebleeding rate was much lower (4% vs. 18%).

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Bleeding colonic diverticula. A reappraisal of natural history and management.
McGuire HH Jr.
Ann Surg. 1994 Nov;220(5):653-6.

Rationale for inclusion: this study has two main clinical pearls: 1) most (75%) bleeding stops spontaneously, and 2) “blind” colon resection is unsafe.

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Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding.
Hunter JM, Pezim ME.
Am J Surg. 1990 May;159(5):504-6.

Rationale for inclusion: this study demonstrates the limited utility of nuclear imaging (technetium scintigraphy) for localizing the source of lower GI bleeding.  Performing resection based on results of scintigraphy resulted in surgical error 42% of the time!

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

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