Team reports innovations in defining sources of GI bleeding

A team of physicians at LSU Health New Orleans has found that endoscopy combined with the administration of antiplatelet or anticoagulant agents is a safe and effective technique for identifying hidden sources of gastrointestinal bleeding. The work is published online in Gastrointestinal Endoscopy (GIE), available here and reviewed in New England Journal of Medicine Journal Watch in October 2016.

"This is the first case series to evaluate the benefit and safety of provocative testing combined with endoscopy to be reported in the literature," notes Dr. Daniel Raines, Chief of the Section of Gastroenterology at LSU Health New Orleans School of Medicine, and lead author of the paper.

According to the Agency for Healthcare Research and Quality, GI bleeding results in more than 500,000 hospitalizations each year. In some cases, the source cannot be defined despite exhaustive testing resulting in the need for repeated transfusions, repeated hospitalizations and sometimes death.

The LSU Health New Orleans team developed a novel technique to find the leak —giving these patients blood thinners to stimulate or provoke bleeding before endoscopy because some sources are only visible when actively bleeding.

To define the effectiveness of this practice, they reviewed their large database of endoscopic procedures to identify 27 patients with refractory bleeding who were treated with medical provocation combined with endoscopy. Provocative procedures were divided into three groups depending upon the method by which the provocative agent was selected and administered. All of the patients in this study had transfusion-dependent, iron-deficiency anemia and/or persistent bleeding. Provocative testing was successful in 15 patients (56%).

"The decision to attempt provocation of bleeding in patients with an unknown bleeding source should not be taken lightly, particularly when the provocative agent is not otherwise indicated," says Dr. Raines. "Our study demonstrates that provocative endoscopy can be performed safely and successfully, and it may be a justifiable intervention in highly selected cases where death associated with recurrent bleeding justifies the risk."

Other members of the team included Dr. Kellen Jex and Mark Nicaud at LSU Health New Orleans and Dr. Douglas Adler at the University of Utah.