A Retrospective Review of Upper Gastrointestinal Bleed Outcomes During Hospital Admission While on Oral Anticoagulation.

Introduction Direct-acting oral anticoagulants (DOACs) are approved for stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. Most recent guidelines recommend DOACs over warfarin for most diagnoses given their predictable pharmacodynamics, lack of required monitoring, and safety profile. Specific outcomes such as shock, acute renal failure, and blood transfusion requirement while on oral anticoagulation compared to no anticoagulation remain unknown in patients with upper gastrointestinal (GI) bleeds.  Methods This retrospective study used the HCA Healthcare Enterprise Data Warehouse (EDW) to analyze 13,440 patients aged >18 years that were admitted with an upper GI bleed from January 2017 to December 2019. The patients were categorized based on oral anticoagulant (i.e. rivaroxaban, apixaban, dabigatran and warfarin). The control group was patients admitted with an upper GI bleed not on oral anticoagulation. We evaluated the severity of upper GI bleeds while on oral anticoagulation based on the outcomes: mortality rate, length of stay, acute renal failure, shock, and need for packed red blood cell transfusions (pRBC). Comorbid conditions assessed were coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), heart failure (HF), atrial fibrillation (AF), venous thromboembolism (VTE), peripheral vascular disease (PVD), tobacco abuse, alcohol abuse, and chronic kidney disease (CKD). Home use of proton pump inhibitors (PPI), aspirin, and P2Y12 inhibitors were also evaluated.  Results Patients on a DOAC without home PPI have a mortality odds ratio of 3.066 with a confidence interval (CI) greater than 95% (1.48-6.26, p<0.05) compared to patients on a DOAC and home PPI. Patients on warfarin and no home PPI have a mortality odds ratio of 5.55 (95% CI (1.02-30.35), p<0.05) compared to those on warfarin with home PPI use. In the no anticoagulation group, those not on PPI have an odds ratio of 3.28 (95% CI (2.54-4.24), p<0.05) of death compared to home PPI use. There was no statistical difference in mortality between each DOAC and warfarin.  There was no difference in the presence of acute renal failure or shock when comparing each DOAC, warfarin, and no medication. For patients presenting with GI bleed, 0.8414 units of pRBC were transfused. Patients not on oral anticoagulation were found to have statistically significant decrease in pRBC transfusion if they did not report alcohol use, CKD, HF, AF, VTE, PVD. Patients on DOACs and alcohol use have an average pRBC transfusion count that is 0.922 units more than those without reported alcohol use (p=0.006). In the warfarin group, there was no statistical significance noted when comparing pRBC transfusions and also when comparing to baseline comorbidities. Conclusion The retrospective study leads us to conclude that overall, patients taking the DOACs or warfarin had no statistically significant increase in RBC transfusions, length of stay, shock, acute renal failure, or mortality rate compared to patients who were not on oral anticoagulation. Home PPI use was shown to lower odds of mortality in patients on anticoagulation who presented with upper GI bleeding. PPI use had no effect on the need for transfusion or length of stay in patients on anticoagulation. These results can help predict which patients are likely to have higher mortality based on the use of home PPIs.

Gastric Antral Diverticula: A Rare Diverticula with a Unique Presentation.

Gastric diverticula are the least common gastrointestinal diverticula. Patients can be diagnosed incidentally on EGD or present with variable symptoms such as abdominal fullness, anorexia, and perforation. Gastric diverticula can be acquired from malignancy, peptic ulcer disease, or prior surgery or be congenital. Treatment varies based on symptomatology ranging from conservative medical management with proton pump inhibitors to surgical treatment with open or laparoscopic resection. We present a case of a 73-year-old female with acquired gastric diverticulum presenting as a gastric outlet obstruction who was successfully treated with conservative medical therapy.

Intestinal Dysbiosis Disguised as a Rectal Fistula Treated With Autologous Fecal Microbiota Transplantation.

Fecal microbiota transplantation (FMT) has been efficacious in the treatment of intestinal dysbiosis, derangement of the native intestinal microflora, and the indications for autologous FMT are growing. A 69-year-old Caucasian man with a past medical history of paraplegia secondary to motor vehicle accident and sigmoid-end colostomy presented to his gastroenterologist with the complaint of rectal discharge. A complicated medical course pre-dated his presentation and included multiple decubitus ulcers requiring debridement and several courses of broad-spectrum antibiotics. The rectal discharge was initially presumed to be from a fistula leading to one of his ulcers; however, workup with anoscopy, flexible sigmoidoscopy, and magnetic resonance imaging of the pelvis showed no visible perirectal abscess or connection to the sigmoid colon through a fistula. Intestinal dysbiosis was an alternative theory considered to be the cause of his copious rectal discharge due to his several courses of broad-spectrum antibiotics and prolonged inactivity of his gut. This prompted a trial treatment plan utilizing autologous FMT, with the patient administering enemas containing his own stool to the distal limb of his bowel. As a result of this treatment, the patient's chief complaint completely resolved within days of initiating treatment, although symptoms did eventually return. We would like to propose that further randomized studies should be done to investigate autologous FMT as a treatment for patients suffering from intestinal dysbiosis following sigmoid-end colostomy.

'Where the money is': a case report of the successful removal of a large number of coins by esophagogastroduodenoscopy utilizing a Roth net.

OBJECTIVE: To demonstrate the use of a Roth net and to determine the maximum number of coins that can be removed per net. METHODS: During esophagogastroduodenoscopy, a Roth net was passed multiple times in order to retrieve 49 ingested coins without the use of an over tube. RESULTS: Removal of 49 coins of various sizes was accomplished. The largest of the coins was 2.4 cm. Because of damage to the nets during the withdrawal past the gastroesophageal junction, several nets were required. But, there was minimal trauma to the esophageal mucosa and no complications. CONCLUSIONS: Removal of ingested foreign objects requires individually tailored treatment. From an extensive literature search, there does not appear to be consensus for standard of care based on the variability of presentation and multiple modalities available for removal.