Gastrointestinal Bleeding

Nonvariceal Upper Gastrointestinal Bleeding

Epidemiology, Risk Factors, and Outcomes

A trend toward a lower relative frequency of peptic ulcer disease (PUD) as the cause of upper gastrointestinal bleeding has been observed in recent years. A multicenter study in the United States confirmed this tendency, comparing data from the last 3 years with historical controls from the years 1983 - 1992. The frequency of PUD decreased significantly from 59 % to 38 %. Effective antisecretory drugs, Helicobacter pylori eradication treatment, and newer nonsteroidal anti-inflammatory drugs (NSAIDs) are all probably responsible for this decline. The frequency of variceal bleeding increased to a lesser extent, but also significantly, from 12 % to 16 %. Probably the most striking finding was an increase in the frequency of erosive esophagitis, from 4.3 % to 12.9 %; the authors were not able to explain this increase. The frequencies of other causes remained at a similar level to that seen before, except for gastric/duodenal erosions (with a decline from 4.4 % to 1.7 %) and Dieulafoy’s lesions (with an increase from 0.6 % to 2.3 %); however, these changes were not significant. A significant improvement in almost all outcome measures (rebleeding, surgery, and death rates) in all groups of patients (PUD, varices, others) was observed in the recent period in comparison with the decade 1983-1992 [1].

The same authors reported the characteristics of patients with PUD bleeding, comparing duodenal with gastric ulcers. The male-to-female ratio was significantly greater in duodenal ulcers (males: 74 % vs. 61 % in the gastric ulcer group). In both types of ulcer, NSAID/acetylsalicylic acid (ASA) ingestion was a more frequent potential risk factor than Helicobacter pylori infection, but the use of NSAIDs was more prevalent in gastric ulcers than in duodenal ulcers (57 % vs. 53 %), while the opposite situation (45 % vs. 50 % in gastric ulcer and duodenal ulcer patients, respectively) was observed with regard to H. pylori infection. The severity of bleeding was greater (in terms of prevalence of major stigmata of bleeding, need for endoscopic hemostasis and blood transfusion, the rate of re-bleeding and surgical treatment) in the duodenal ulcer group versus the gastric ulcer one [2].

A group of Finnish authors analyzed risk factors in a case-control setting, finding a greater prevalence of both NSAID use (60 % vs. 37 %) and H. pylori infection (77 % vs. 40 %) in bleeding patients with peptic ulcer disease in comparison with non-ulcer patients undergoing elective endoscopy. H. pylori infection (OR 5.3), a history of duodenal ulcer (OR 4.7) and use of NSAIDs/ASA (OR 2.2) were found to be significant risk factors in the logistic regression analysis. CagA-positive strains of H. pylori were not associated with a greater risk. A dose-dependency in the risk was observed for NSAID/ASA use and for heavy smoking (> 20 cigarettes/day) [3]. A study in Egypt found the highest prevalence of H. pylori infection (78 %) or NSAID use (67 %) among patients with bleeding peptic ulcers, with only 3 % of those with bleeding lacking H. pylori infection or NSAID intake [4]. Another case-control study on risk factors for upper gastrointestinal bleeding in NSAID users found that the probability of bleeding increased with H. pylori infection (OR 4.2) and with multiple NSAID use (OR 8.1), suggesting the need for prophylactic H. pylori eradication in NSAID users [5].

It is well known that gastrointestinal bleeding involves significant treatment costs. Thanks to the development of a database (the Registry on Upper Gastrointestinal Bleeding and Endoscopy, RUGBE), Canadian authors were able to calculate precisely the mean cost of treatment per patient with upper gastrointestinal bleeding as C$ 4346. Advanced age and comorbidities were associated with higher costs, and the main cost factors were hospitalization and professional fees [6].

Prognosis and Stratification

The usefulness of the Rockall scoring system was confirmed by groups from Canada [7], the United States [8], Spain [9], Ireland [10], and the United Kingdom [11]. The Spanish group demonstrated the usefulness of the Rockall score in patients undergoing endoscopic treatment. The Irish and British groups documented the safety and opportunities for significant cost savings when treating patients with low Rockall scores in an outpatient setting. The same findings were reported in another study using different triage criteria [12].

Simplified acute physiology scores (SAPS) calculated on admission or at the onset of bleeding were good predictors of the outcome of gastrointestinal bleeding developing during an intensive-care unit (ICU) stay. Esophageal ulcers constituted 11 % of the causes, and massive bleeding made diagnosis impossible in 13 %. Endoscopic treatment was effective in only 64 % of cases, particularly in patients with lower SAPS scores [13].

A multivariate logistic regression analysis of 195 patients treated with injection showed that the presence of shock at admission and an ulcer diameter of more than 20 mm were independent predictors of failure of endoscopic treatment, while re-bleeding and the presence of comorbidities were predictors of death [14]. In an analysis of a subset of patients in whom a second-look endoscopy was carried out, the same team found that ulcer diameter over 20 mm and the presence of hematemesis or hematochezia at admission were the independent predictors of a need for repeated endoscopic treatment [15]. Another group of authors found that location of the ulcer in the gastric fundus and spurting bleeding (Forrest Ia) were significant risk factors for rebleeding after initial endoscopic hemostasis [16]. Among patients with high-risk stigmata, the presence of fresh blood in the nasogastric tube and hematochezia were risk factors, while a low American Society of Anesthesiology (ASA) score had a protective effect on the rebleeding rate [17]. The potential role of endoscopic Doppler ultrasound assessment in PUD bleeding was tested, but no additional role for this method (in addition to the Forrest classification) in clinical decision-making was found [18].

Preendoscopy Treatment

The initial management of patients with upper gastrointestinal bleeding may play an important role in improving the outcomes and lowering the costs of treatment.

Early intensive resuscitation (stabilization of hemodynamics, correction of hematocrit and coagulopathy) was found to decrease the overall mortality from gastrointestinal bleeding in patients with hemodynamic instability [19]. The introduction of a checklist, with specific recommendations being given to the admission service, was able to reduce the length of the hospital stay significantly (from 7 days before to 3.5 days after introduction) in two groups of patients with comparable Rockall and Blatchford scores [20].

Emergency Endoscopy

The timing of emergency endoscopy also has a significant influence on outcomes. Previous studies found poorer outcomes in patients admitted on weekends versus weekday hospital admissions. It has now been shown that the development of a dedicated gastrointestinal bleeding team with a fast response time can lead to identical outcomes irrespective of the day of admission. All of the outcomes (rebleeding, repeated endoscopy, surgery, transfusion requirements, length of stay, and mortality) were almost the same in 4098 weekday and 1656 weekend patients treated over a 14-year period [21].

Davis et al. analyzed 86 cases of bleeding developing after 48 h of hospitalization [22]. Eighty-six percent of the patients were receiving medications known to increase the risk of gastrointestinal hemorrhage (NSAIDs, steroids, anticoagulants, thrombolytics). Bleeding was not clinically important in 83 % of the patients, and was most often caused by gastritis/duodenitis (44 %) and esophagitis (22 %). No endoscopic therapy was required in patients with nonclinically significant in-hospital bleeding, and endoscopy changed the management in only one case (out of 71). The authors offer the rather provocative conclusion that hospitalized patients with nonclinically significant bleeding can be managed conservatively without endoscopy [22].

Endoscopic Hemostasis in Peptic Ulcer Bleeding

A meta-analysis (22 studies, 2350 patients) proved that combined treatment (second hemostatic procedure: either thermal, mechanical, or with a sclerosing agent added after epinephrine injection) was better than epinephrine injection alone, significantly reducing the rates of rebleeding (OR 0.61), surgery (OR 0.57), and mortality (OR 0.57). A separate analysis of the added methods showed good efficacy and equivalence for thermal (OR 0.50) and mechanical (OR 0.50) hemostasis and showed that they were superior to injection of a second agent, which did not reduce the rebleeding rate significantly (OR 0.86) [23]. A combined approach should probably be recommended as a standard for endoscopic treatment of PUD bleeding.

In a study with historical controls, argon plasma coagulation (APC) as an adjunct to epinephrine injection was also found to be effective in reducing the rates of rebleeding (12 % vs. 27 %) and surgery, as well as shortening the hospital stay [24]. In another study with historical controls, APC combined with epinephrine in patients with adherent clot (5 % vs. 28 %) and APC alone in patients with flat spots (5 % vs. 12 %) also decreased the rebleeding rates in comparison with medical treatment [25]. APC alone was found also to be effective in patients in whom hemoclipping failed and for lesions with difficult access, while being less effective in spurting bleeding [26].

Prospective comparison of hemoclipping, APC, and fibrin-glue injection found that the mechanical method was the least effective in achieving initial hemostasis (80 % vs. 95 % for both of the other modalities), mainly due to inaccessible locations and a fibrotic ulcer bed. An ulcer diameter > 20 mm was a significant factor in preventing effective hemostasis by hemoclipping [27].

A meta-analysis of endoscopic clot removal with subsequent combined (injection plus thermocoagulation) endoscopic treatment showed a reduced early rebleeding rate (OR 0.08 for endoscopic vs. medical treatment), with a trend toward a reduced rate of surgical intervention, but no improvement in mortality [28]. Another study of Forrest II patients found that endoscopic methods (injection, mechanical, or combination) were superior to medical therapy alone (rebleeding 7 % vs. 14 % in Forrest IIa, 0 % vs. 9 % in Forrest IIb) [29]. A study in Greece reported adherent clots in 29 % of 1724 patients; the clot could not be irrigated from the ulcer base in 29 %, and it covered high-risk stigmata in 27 % [30].

Interesting nonstandard approaches to PUD bleeding were reported. In a randomized study of 99 patients with active PUD bleeding, hot-biopsy monopolar coagulation was significantly better than standard combined treatment (injection plus heater probe) with regard to initial hemostasis (96 % vs. 77 %), rebleeding (0 % vs. 18 %), and transfusion requirements. Eight of 10 failures of combined hemostasis were successfully managed with hot biopsy, and no complications occurred [31].

Fibrin glue injection through a standard needle (in the sequence thrombin, saline, fibrinogen, saline) led to a better outcome than epinephrine injection in a randomized study of 29 patients [32].

Band ligation was used with 100 % success in 19 superficial and nonfibrotic bleeding ulcers located in difficult-to-approach areas, mainly in the upper two-thirds of the posterior wall and lesser curvature of the gastric body [33].

Antisecretory Treatment and Helicobacter pylori Eradication

It has to be remembered that antisecretory treatment should only be an adjunct, and cannot replace endoscopic treatment of a bleeding ulcer. This was confirmed in a double-blind, randomized study in Hong Kong. A total of 156 patients with nonbleeding high-risk stigmata (Forrest IIa or IIb) were randomly assigned to receive omeprazole in the standard manner (an intravenous bolus followed by infusion) with or without endoscopic treatment (epinephrine injection with heater-probe coagulation). The rates of in-hospital (0 % vs. 9 %) and 30-day (1 % vs. 12 %) rebleeding, length of stay < 5 days (46 % vs. 28 %), and transfusion requirements (median 2.0 vs. 2.5 units) were significantly better in the combined group vs. the omeprazole one. Only one patient required surgery (in the combined group), and the mortality rate was halved in the combined treatment group (2.5 % vs. 5.1 %) [34]. In a much smaller study with historical controls, the differences were also evident, but did not reach significance [35]. A meta-analysis comparing proton-pump inhibitor (PPI) treatment vs. endoscopic treatment found no significant differences in the outcomes, but was also unable to confirm that methods are equivalent [36].

By contrast, two meta-analyses comparing PPIs with a placebo or H₂-receptor antagonists (H₂RAs) irrespective of endoscopic treatment, found that PPIs significantly improved most of the outcomes of PUD bleeding. In a study by Martin et al. (29 trials, 4973 patients), PPIs significantly reduced the rates of rebleeding (OR 0.44), endoscopic re-treatment (OR 0.59), and surgery (OR 0.69), as well as the need for transfusion (difference 0.36 units), and length of hospital stay (difference 0.62 days), with no significant reduction in the mortality (OR 0.97). The benefit of PPI administration appeared to be independent of the route and dosage, and it was greater in patients not receiving endoscopic treatment [37]. Bardou et al. (30 trials, 3530 patients) found that high-dose intravenous PPI treatment (bolus plus continuous infusion, high-dose intravenous PPIs) significantly reduced rebleeding (difference 20 % vs. H₂RAs, 16 % vs. placebo) and mortality (difference 2.8 % vs. placebo). PPIs given by all routes and doses, with the exception of high-dose intravenous PPIs, also significantly reduced rebleeding (difference 20 %) and mortality (difference 2.4 %) in comparison with placebo. Neither somatostatin nor H₂RAs were found to have a similar beneficial effect [38]. In an interim analysis of an ongoing study comparing PPIs with H₂RAs in patients with PUD with high risk of rebleeding (124 patients included; initial hemostasis achieved by injection plus heater or bipolar probe), the rebleeding rate was lower (5.6 %) than historically reported [39]. An Italian group found no difference between omeprazole and pantoprazole, with similar rebleeding rates [40]. An assessment of the effect of PPIs started before or after endoscopy found no differences in the outcomes, but only ”downstaging” of high-risk stigmata of bleeding, with a significantly reduced prevalence of active bleeding (34.5 % of Forrest Ia + Ib before vs. 53 % after endoscopy) [41].

Taking all of the above-mentioned advantages of PPIs into account, two cost simulations found that the use of PPIs was cost-effective irrespective of route of administration. When the high-dose intravenous route was compared with the oral route, intravenous administration was found to be slightly more effective but more costly, and neither strategy was dominant [42] [43].

A clearly beneficial effect of intravenous PPIs may lead to significant overuse or misuse of the drugs and a subsequent increase in the costs of treatment. In a study in the United Kingdom, only four of 92 patients who received intravenous PPIs for upper gastrointestinal bleeding were found to have a bleeding peptic ulcer with high-risk stigmata, and only one of the four received the typical dosage [44]. In a study in the United States, the indication and dosage regimen were appropriate in 46 of 90 patients [45].

Interestingly, repeated PPI boluses were found to be very effective in raising the intragastric pH in H. pylori-positive vs. -negative patients with nonvariceal upper gastrointestinal bleeding [46].

The effectiveness of H. pylori eradication in preventing ulcer bleeding was confirmed in a multicenter study in the USA. A total of 341 patients with previous clinically significant and endoscopically documented ulcer bleeding underwent successful eradication therapy and were randomly assigned to receive continuous therapy with famotidine (40 mg/d) or a placebo. Low-dose aspirin was allowed for patients with serious cardiovascular risk. During a mean follow-up period of 2 years, the incidence of complications (ulcer and nonulcer bleeding, ulcer recurrence) was exactly the same in both groups at 4 %, with a 0.6 % incidence of ulcer bleeding [47].

Other Causes of Bleeding

Mechanical hemostatic devices - e. g., miniloops [48], rubber bands [49], and hemoclips [50] [51] [52] - were reported to be extremely effective in the treatment of Dieulafoy’s lesions and angiectasia. Altogether, 81 patients were treated, with an initial hemostasis rate of 96 % (99 % after combination with injection) and a 6 % early rebleeding rate. In a randomized study, a group in South Korea found that hemoclipping was much better than epinephrine injection, with the difference being most significant for Dieulafoy’s lesions located in the gastric body [50]. A Taiwanese group observed a trend toward better results with combined treatment (epinephrine injection followed by heater probe) than with injection alone [52].

References

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• 67 Aldana L P, Kato M, Asaka M. et al . Mucosal fibrosis therapy to prevent recurrence of esophageal varices after endoscopic variceal ligation: a prospective comparative study with argon plasma and microwave coagulation techniques [abstract].  Gastrointest Endosc. 2003;  57 AB 146
• 68 Kiafar C, Gerkin R D, Ramirez F C. Variceal eradication is not associated with better outcomes than non-eradication [abstract].  Gastrointest Endosc. 2003;  57 AB 120
• 69 Nagamine N, Ono K, Ido K. et al . A prospective study of the risk of bacteremia in endoscopic band ligation of esophageal varices [abstract].  Gastrointest Endosc. 2003;  57 AB 142
• 70 Romero R, Pellicer F, Jimenez M. et al . Recombinant activated factor VII (RFVIIA) in the treatment of seven cases of severe and active bleeding esophageal varices [abstract].  Gastrointest Endosc. 2003;  57 AB 143
• 71 Thabut D, de Franchis R, Bendtsen F. et al . Efficacy of activated recombinant factor VII (rFVIIa; Novoseven) in cirrhotic patients with upper gastrointestinal bleeding: a randomized, placebo-controlled, double blind multicenter trial [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 697
• 72 Altorjay I F, Papp M, Palatka K. et al . Additional PPIs treatment significantly prolonged survival in cirrhotic patients following sclerotherapy because of variceal bleeding [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 734
• 73 Ramage Jr J I, Grisolano S W, Harewood G C. et al . Outcome of gastric versus esophageal variceal bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 117
• 74 Omar M M, Fakhry S, El-Khyyat H. et al . Endoscopic control of bleeding gastric fundal varices by butyl cyanoacrylate: an Egyptian experience [abstract].  Gastrointest Endosc. 2003;  57 AB 143
• 75 Saravanan R, Nayar M, Rowlands P. et al . Transjugular intrahepatic portosystemic shunt in the treatment of ectopic varices secondary to portal hypertension [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 665
• 76 Ward E M, Bonatti H, Machicao V I. et al . Prevalence and natural history of gastric antral vascular ectasia (GAVE) in patients undergoing orthotopic liver transplantation (OLT) [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 665
• 77 Leerdam van M E, Ramsoekh D, Rauws E AJ. et al . Epidemiology of acute lower intestinal bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 93
• 78 Jensen D M, Machicado G A, Dulai G. et al . A prospective study of patients hospitalized for severe hematochezia: diagnosis, treatment and outcomes [abstract].  Gastrointest Endosc. 2003;  57 AB 92
• 79 Green B, Rockey D C, Portwood G. et al . Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 17-18
• 80 Probst A, Hunstiger M, Barnert J. et al . Characteristics of lower GI bleeding in critically ill patients: bleeding source and prognosis [abstract].  Gastrointest Endosc. 2003;  57 AB 215
• 81 Aljabiri M R, Vansomeren N, Kooner P. et al . What proportion of patients who undergo flexible sigmoidoscopy for rectal bleeding subsequently require colonoscopy?.  Gastroenterology. 2003;  124 (Suppl 1) A 355
• 82 Grisolano S W, Pardi D S, Petersen B T. et al . Stigmata associated with recurrence of lower gastrointestinal hemorrhage [abstract].  Gastrointest Endosc. 2003;  57 AB 215
• 83 Strate L L, Canale S, Ookubo R. et al . Risk stratification in acute lower intestinal bleeding: prospective validation of a clinical prediction rule [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 508
• 84 Chi K D, Kasza K, Karrison T. et al . Accuracy and reliability of the endoscopic classification of chronic radiation-induced proctopathy using a novel grading method [abstract].  Gastrointest Endosc. 2003;  57 AB 218
• 85 Alfadhli A A, Gregor J C, Ponich T. et al . Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy [abstract].  Gastrointest Endosc. 2003;  57 AB 218
• 86 Adler D G, Gostout C, Knipshield M. Prospective, blinded comparison of video capsule endoscopy versus push enteroscopy in patients with gastrointestinal bleeding of obscure origin [abstract].  Gastrointest Endosc. 2003;  57 AB 164
• 87 Bolz G, Hartmann D, Hahne M. et al . Wireless capsule endoscopy compared to push enteroscopy in the management of obscure gastrointestinal bleeding [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 245
• 88 Buchman A, Wallin A. Videocapsule endoscopy renders obscure gastrointestinal bleeding no longer obscure [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 244-245
• 89 Cave D, Wolff R, Mitty R. et al . Validation and initial management of video capsule endoscopy findings performed for obscure gastrointestinal bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 165
• 90 Wolff R S, Cave D, Doherty S. et al . Surgical experience after video capsule endoscopy: the fantastic voyage to the operating room [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 814
• 91 Lee H, Cave D. Melena and its anatomical sources [abstract].  Gastrointest Endosc. 2003;  57 AB 168
• 92 Chong A, Taylor A, Miller A. et al . Clinical outcomes following capsule endoscopy (CE) examination of patients with obscure gastrointestinal bleeding (OGB) [abstract].  Gastrointest Endosc. 2003;  57 AB 166
• 93 Chutkan R, Toubia N, Balba N. Findings and follow-up of the first 125 video capsule patients at Georgetown University Hospital [abstract].  Gastrointest Endosc. 2003;  57 AB 85
• 94 Ciorba M, Jonnalagadda S, Zuckerman G. et al . Capsule endoscopy: varied outcomes over short-term follow-up [abstract].  Gastrointest Endosc. 2003;  57 AB 167
• 95 De Franchis R, Rondonotti E, Zatelli S. et al . Diagnostic yield of capsule enteroscopy (CE) in 63 consecutive patients with obscure GI bleeding (OGIB) [abstract].  Gastrointest Endosc. 2003;  57 AB 171
• 96 De Leusse A, Landi B, Burtin P. et al . Video capsule endoscopy (CE) for obscure gastrointestinal bleeding: feasibility, diagnostic yield and interobserver agreement [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 245
• 97 Delvaux M, Fassler I, Gay G. Obscure digestive bleeding (ODB): validation of a diagnostic strategy integrating capsule enteroscopy (CE) as first-line intestinal investigation [abstract].  Gastrointest Endosc. 2003;  57 AB 162
• 98 Enns R, Mergener K, Brandabur J. et al . Capsule endoscopy (CE): a multicenter, international review and comparison of capsule studies done in three different tertiary-care centers [abstract].  Gastrointest Endosc. 2003;  57 AB 101
• 99 Enns R, Mergener K, Brandabur J. et al . Capsule endoscopy in obscure gastrointestinal bleeding: a multicenter evaluation of clinical variables that predict a positive study [abstract].  Gastrointest Endosc. 2003;  57 AB 165
• 100 Fireman Z, Eliakim R, Adler S. et al . Capsule endoscopy (CE) in real life: a 4 centers’ experience of 160 consecutive patients in Israel [abstract].  Gastrointest Endosc. 2003;  57 AB 85
• 101 Furman M A, Mylonaki M, Fritscher-Ravens A. et al . Wireless capsule endoscopy in children: a study to assess the diagnostic yield in small bowel disease in pediatric patients [abstract].  Gastrointest Endosc. 2003;  57 AB 89
• 102 Goelder S K, Schreyer A, Kullmann F. et al . Clinical value of video capsule endoscopy (VCE) and small bowel MR imaging (SBMRI) in suspected small bowel disease [abstract].  Gastrointest Endosc. 2003;  57 AB 163
• 103 Guda N, Molloy R, Carron D. et al . Does capsule endoscopy change the management of patients?.  Gastrointest Endosc. 2003;  57 AB 167
• 104 Hartmann D, Schmidt H, Schilling D. et al . Prospective, controlled multicentric trial comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with chronic gastrointestinal bleeding: preliminary results [abstract].  Gastrointest Endosc. 2003;  57 AB 166
• 105 Jensen D M, Dulai G, Kovacs T OG. et al . A gold standard for diagnosis of very severe GI bleeding of obscure etiology [abstract].  Gastrointest Endosc. 2003;  57 AB 166
• 106 Jones B H, Sharma V K, Leighton J A. et al . Yield of repeat wireless video capsule endoscopy (CE) in patients with obscure GI bleeding (OGIB) [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 244
• 107 Katz D, Lewis B, Katz L B. Surgical experience following capsule endoscopy [abstract].  Gastrointest Endosc. 2003;  57 AB 169
• 108 Liangpunsakul S, Mays L, Rex D K. Performance of Given suspected blood indicator [abstract].  Gastrointest Endosc. 2003;  57 AB 164
• 109 Napierkowski J, Maydonovitch C, Belle L. et al . Wireless capsule endoscopy (WCE): a review of community gastroenterology experience [abstract].  Gastrointest Endosc. 2003;  57 AB 118
• 110 Neu B, Schmid E, Ell C. et al . GECCO: German Cooperative Capsule Outcome Study 2: capsule endoscopy compared to other diagnostic tests in suspected small bowel bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 164
• 111 Rastogi A, Schoen R E, Slivka A. Diagnostic yield and outcomes of capsule endoscopy [abstract].  Gastrointest Endosc. 2003;  57 AB 163
• 112 Sacher-Huvelin S, Barouk J, Le Rhun M. et al . Wireless capsule endoscopy of the small intestine: does it really impact the management strategy?.  Gastrointest Endosc. 2003;  57 AB 167
• 113 Sant’anna A MGD, Miron M-C, Dubois J. et al . Wireless capsule endoscopy for obscure small bowel disorders: final results of the first pediatric trial [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 17
• 114 Saurin J C, Delvaux M, Gaudin J L. et al . Clinical impact of small-bowel examination by wireless video-capsule (WVC) compared to push-enteroscopy (PE) in obscure digestive bleeding: one-year follow-up study [abstract].  Gastrointest Endosc. 2003;  57 AB 84
• 115 Sultan S, Dobozi B M, Palmer P. et al . Assisted wireless capsule endoscopy in a six-year-old with abdominal pain and obscure GI bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 127
• 116 Milkes D E, Gerson L B, Cheung R. Upper endoscopy (EGD) has a high diagnostic yield in asymptomatic, non-anemic patients with a positive fecal occult blood test (FOBT) compared to patients with a negative FOBT [abstract].  Gastrointest Endosc. 2003;  57 AB 116
• 117 Panzuto F, Capurso G, D’Ambra G. et al . Large hiatal hernia is a underdiagnosed disease in patients with iron deficiency anemia [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 627
• 118 Bancroft J, Dietrich C, Gilger M. et al . Upper endoscopic findings in children with hematemesis [abstract].  Gastrointest Endosc. 2003;  57 AB 121
• 119 Nugent S G, Chong S K, Benson M J. An unusual case of massive upper GI hemorrhage in a 15-year-old: a case report [abstract].  Gastrointest Endosc. 2003;  57 AB 124
• 120 Tang S J, Gordon M L, Yang V XD. et al . In vivo color Doppler optical coherence tomography of mucocutaneous telangiectases in hereditary hemorrhagic telangiectasia [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 17
• 121 Nakamura Y, Fujisaki J, Matsuda K. et al . The efficacy of a new multi-bending scope (M-scope) for endoscopic mucosal resection (EMR) of early gastric cancer [abstract].  Gastrointest Endosc. 2003;  57 AB 181
• 122 Hu B, Sun L, Barlow D. et al . Eagle Claw II: Endosuture device for major arterial bleeding: bench experiments with splenic arteries [abstract].  Gastrointest Endosc. 2003;  57 AB 84
• 123 Hu B, Sun L, Chung S. Animal model of massive ulcer bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 187
• 124 Schwartz D C, Ringwala S N, Said A. et al . Acute gastrointestinal hemorrhage in the Jehovah’s Witness (JW): a ten year study of outcomes [abstract].  Gastroenterology. 2003;  124 (Suppl 1) A 508-509
• 125 Yousfi M, Gostout C J, Ott B. et al . Post-polypectomy lower gastro-intestinal bleeding: is advanced age a predictor?.  Gastroenterology. 2003;  124 (Suppl 1) A 357
• 126 Yousfi M, Gostout C J, Baron T H. et al . Post-polypectomy lower gastrointestinal bleeding: potential role of aspirin [abstract].  Gastrointest Endosc. 2003;  57 AB 93
• 127 Pooran N, Rampertab S D, Greenberg R. et al . Aspirin and the risk of bleeding after percutaneous endoscopic gastrostomy placement [abstract].  Gastrointest Endosc. 2003;  57 AB 159