GI Bleed Questionnaire Responses
IDTitleNameCreatedQ1Q2Q3Q4Q5Q6Q7
1001DrKeshav2014-11-20 08:22:24 Anaemia, Hypoferritinaemia, ongoing bleeding, symptomatic anaemia or iron deficiency As above, + intolerance of oral iron + severity of iron deficit and anaemia + IBD Pallor, haematemesis, melaena, hypotension, tachycardia Active bleeding, visible vesselAnaemia, Hypoferritinaemia, microcytosis Coeliac disease, chronic bleeding conditions such as Gastric Vascular Ectasia, causes not amenable to definitive treatment Occult bleeding with no apparent cause, not amenable to definitive treatment
1006ProfessorMohr Drewes2014-12-12 12:57:30Occult bleeding and symptoms After major blood loss Laboratory values (haemoglobin and ferritin primarily)When oral therapy does not succeed in sufficient improvement in laboratory values (haemoglobin and ferritin) for 2 months When the haemoglobin is so low that oral therapy can hardly be expected to work When the patient cannot be expected to absorb iron orallyHaemorrhoids if haemoglobin too lowAll bleedings identified with endoscopy if haemoglobin too lowIf haemoglobin too low If the clinical impression is that there is a major blood loss therapy may be initiated without laboratory valuesSame as above
1020DrCiriza de los Rios2014-12-12 13:02:58-Clinical symptoms suggestive of anemia: weakness, headache, irritability, and varying degrees of fatigue, dry mouth, alopecia, glossitis, pica, and restless legs syndrome (associated with iron deficiency). Alarm GI clinical symptoms such as abdominal pain, change in bowel habit, weight loss and dysphagia. -Drugs treatment such as aspirin, clopidogrel, NSAIDs (can produce blood loss), anticoagulants. - Antecedents: past history of liver disease or alcohol abuse, renal disease, aortic stenosis,heart failure history or hereditary hemorrhagic telangiectasia. -Rectal examination: confirm melena, hemaotchezia and exclude ano-rectal lesions. -Demonstration of anemia: (< 13 g/dl in men and below 12 g/dl in non-pregnant women and below 11 g/dl in pregnant women). -Demonstration of absolute iron deficiency (without anemia): ferritin level < 30 ng/mL (if there is not inflammatory, infectious or malignant disease). If inflammation suspected: ferritin level < 60 ng/nL. (percent saturation of transferring , reticulocyte count are helpful in diagnosis) and recurrent episodes of GI bleeding caused by: Visible GI blood loss (hematemesis, melena caused by different GI lesions such as: esophagitis, Mallory-Weiss syndrome, peptic ulcers, GI tumours, Dieulafoy lesion, angiodysplasia, diverticulum..) Anemia or iron deficiency secondary to a chronic GI bleeding lesion (portal hypertensive gastropathy, antral vascular ectasia, telangiectasia, tumours...) Anemia or iron deficiency in patients with acute or chronic GI bleeding and associated malabsortion (celiac disease, atrophic gastritis, bacterial overgrowth syndromes …) Anemia or iron deficiency in inflammatory bowel disease In other conditions that can be required: Anemia or iron deficiency after bariatric surgery (by-pass) or subtotal gastric resection Anemia induced by chemotherapy (in GI tumours) Acute or chronic GI bleeding in patients receiving chronic dialysis Anemia in patients admitted into the intensive care unit (with or without GI bleeding) DEMONSTRATION OF FERROPENIC ANEMIA or IRON DEFICIENCY (using the same criteria as mentioned previously) and: Patients unresponsive to oral iron Patients intolerant to oral iron because of side effects In all the conditions that cause GI iron deficiency when the amount of iron lost through daily blood loss exceeds the capacity of the gastrointestinal tract to absorb oral iron preparations (ongoing blood loss). Malabsortion condition associated with poor efficacy of oral iron such as celiac disease. Patients with inflammatory bowel disease both with or without intolerance to oral preparations (intravenous iron therapy is of choice because the chronic disease can reduce the iron absorption by the gut). Anemic cancer patients with or without chemotherapy treatment Acute or chronic GI bleeding in patients receiving chronic dialysis Anemia in patients admitted into the intensive care unit GI bleeding that is presented as melena, hematemesis, coffee-ground like vomits, maroon stool with intermixed bright red blood or scant rectal bleeding. Clinical symptoms and signs: that suggest severe bleeding such as tachycardia, dizziness, confusion, angina, palpitations. Laboratory indices (for acute bleeding): haemoglobin (Hb), urea (increased with normal creatinine suggest upper GI bleeding), creatinine. Anemia severity assessment: Mild (Hb: 10.9-12.9 g/dL in men and Hb: 10.9-11.9 g/dL in women), moderate (Hb: 8-10.9 g/dL) and severe anemia (Hb < 8) in a hemodinamically stable patient and also in ferropenia (intravenous iron therapy is of choice). In severe anemia (Hb < 7 in nonvariceal and < 8 mg/dL in variceal bleeding ) and patient instability blood transfusion should be indicated. If active bleeding and hypovolemia may require also blood transfusion even if the haemoglobin is apparently normal. Fresh blood during the endoscopic examination or potential bleeding lesions without acute bleeding at the endoscopy. Laboratory indices (for acute bleeding): haemoglobin (Hb), urea (increased with normal creatinine suggest upper GI bleeding), creatinine. Anemia severity assessment: Mild (Hb: 10.9-12.9 g/dL in men and Hb: 10.9-11.9 g/dL in women), moderate (Hb: 8-10.9 g/dL) and severe anemia (Hb <7 in non variceal bleeding) in a hemodinamically stable patient and also in ferropenia (intravenous iron therapy is of choice). In severe anemia (Hb < 7 in nonvariceal and < 8 mg/dL in variceal bleeding) and patient instability blood transfusion should be indicated. If active bleeding during the endoscopy and hypovolemia may require also blood transfusion even if the hemoglobin is apparently normal. Specific endoscopic treatment of the bleeding lesion if it is possibleFerropenic anemia or iron deficiency (decrease ferritin level as previously mentioned before) without visible blood loss and also positive fecal occult blood test (with or without anemia). If the patient has anemia upper gastroscopy and colonoscopy should be performed. When upper endoscopy and colonoscopy are performed in a patient with occult GI bleeding and no etiology was found it is considered an obscure bleeding. This type of bleeding recurs after treatment. The next step is to study the small bowel with capsule endoscopy.Clinical symptoms such as melena, hematemesis, coffee-ground like vomits in patients with anemia or iron deficiency (decreased ferritin level). Then rule out the following: Acute and chronic blood loss (peptic ulcers, esophagogastric varices, Mallory-Weiss syndrome, Dieulafoy's lesion, portal hypertensive gastropathy, antral vascular esctasia, angiodysplasia, esophagitis, erosive gastritis and duodenitis, lesions secondary to NSAIDs therapy) Associated malabsortion (celiac disease, atrophic gastritis, etc) Esophageal and gastric cancer patients with or without chemotherapy treatment Surgery: subtotal gastric resection, gastric by-pass.Clinical symptoms such as hematochezia, melena, maroon stool with intermixed bright red blood or scant rectal bleeding in patients with anemia or iron deficiency (decreased ferritin level). Then rule out the following: Colo-rectal cancer and polyps Inflammatory bowel disease with or without intolerance to oral preparations (intravenous iron therapy is of choice) Angiodysplasia Telangiectasia after radiotherapy Ischemic colitis Colonic diverticula Any of the former disorders with associated cause of malabsortion (celiac disease)
988ProfessorFischbach2014-12-12 13:19:44Chronic, overt or occult GI bleeding resulting in microcytic anemia and iron deficiency Definite gastrointestinal bleeding leading to microtytic anemia and iron deficiency. To avoid oral iron substitution in order to better verify a potential future rebleeding.Same arguments as answered to topic 2.Same arguments as answered to topic 2.Same arguments as answered to topic 2.Any disorders causing relevant iron deficiency anemia and therefore requiring iron substitution.Any disorders causing relevant iron deficiency anemia and therefore requiring iron substitution.
1029ProfessorPereira2014-12-12 13:24:43Upper GI haemorrhage, GI blood causing anaemiaIron deficience anaemia, intolerant of or poorly adherant to oral iron therapyHaematemesis / meleana, clinical features of anaemia – conjunctival / palmar crease pallorBlood, ulcers, visible vesselAnaemia, positive faecal occult bloodDyspepsia, upper abdominal pain, back pain, weight loss, PR bleeding, melaena, haematemesisAbdominal pain, weight loss, change in bowel habit, PR bleeding, melaena
1028DrIqbal2014-12-12 13:28:29Any patient who presents with gastro-intestinal bleeding which results in iron deficiency anaemia should receive iron therapy. Features which would point to first line iv treatment would be severity of the anaemia, co-morbidities and intolerance to iron tablets. This is particularly relevant given the recent move to restrictive blood transfusion in the context of GI bleeding (upper GI) Obvious haematemesis and/or melaena represent GI bleeding visible to the naked eye. These would not in themselves mandate iv iron if the patient has stopped bleeding, is stable, and has no endoscopic major stigmata of bleeding. Major and minor stigmata of bleeding as seen on endoscopy. Major stigmata would support blood transfusion, particularly if bleeding is ongoing and the patient unstable or at high risk (due to other co-morbidity) or, if stable, with iv iron. Minor stigmata in a stable patient would perhaps tend to favour iron tablets.Recurrent iron deficiency anaemia with normal GI investigations (upper and lower GI endoscopy, wireless capsule endoscopy). In this situation oral iron may create diagnostic uncertainty with respect to ongoing bleeding as this discolours stool and iv may be preferred.Caution may need to be exerted when contemplating bolus iv iron treatment in patients with advanced liver cirrhosis for fear of causing hepatocyte iron overload.Patients with bleeding due to bowel inflammation tend to tolerate oral iron poorly and, this group, mat benefit from iv in preference
1009ProfessorJayne2014-12-12 13:34:00Chronicity of bleeding, haemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiology contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiology with imminent surgery haemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiologyhaemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiologyInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resectionInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resectionInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resection
996ProfessorRaithel2014-12-12 13:39:31Extent of anemia; Acute or chronic bleeding; Reversible bleeding cause or not; Malignant or benign bleeding cause Extent of anemia; Estimated time requirement for normalization of hemoblobin; Small bowel disease, small bowel mucosal resorption area; Presence of systemic inflammation; Hematochezia – but needs further exploration, e.g. diverticular bleeding Teleangiectasia at the face or lips – chronic bleedingProgredient malignant tumors as chronic bleeding source - palliation Ulcerations and severe inflammation in the GI tract Submucosal tumors centrally eroding or ulcerating as bleeding source Axial hiatal and other hernia types at the cardia (paraesophgeal hernia; Cameron ulceration)Gastrointestinal vascular malformations (GIVM) = angiectasia in general Gastrointestinal allergy and eosinophilic gastroenteritisPeptic ulcer disease; gastric cancer; celiac disease, IBD, herniaCrohn’s disease and ulcerative colitis, diverticular disease
1005DrPehl2014-12-12 13:41:59iron deficiency anaemia; acute or chronic GI bleeding; inflammatory bowel disease; ferritin level below 5ng/ml; iron deficiency anaemia with haemoglobin level below 6g/dlhematemesis; melena; dark-red or maroon stool, rectal bleedingoesophageal varicose veins; ulcers; polyps; neoplasia; blood clots; intraluminal blood; visible vessel iron deficiency anaemia; fecal occult blood test; immunological fecal blood testheartburn; epigastric pain; nausea; vomiting; diarrhea; constipation;
1025DrClarke2014-12-12 13:46:11Iron deficiency anaemia (low ferritin &/or absent marrow iron stores). Hypoferritinaemia alone even in the absence of anaemia if symptomatic. Following a significant bleed where iron over and above estimated storage iron can be reasonably predicted to be required to fully replenish normal red cell mass. Other cause of anaemia where appropriate treatment is likely to require more storage iron than is estimated to be available to replenish red cell mass (eg pernicious anaemia or patients receiving erythropoietin) Failure to respond to oral iron Inability to tolerate oral iron Consider if non-compliance with oral iron if this cannot be directly addressed Ongoing blood loss at a rate greater than can be replaced orallyIn line with the above. If bleeding rate exceeds that which can be replaced orally then IV iron should be used regardless of cause. Onset of response with IV iron not likely to be much quicker that with oral iron but if ongoing loss then IV iron gives more certain and complete response. Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. As above. If source such as angiodysplasia identified then higher likelihood of ongoing loss therefore more likely to consider early use if IV iron especially if required transfusion. Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. In the absence of acute blood loss would give IV iron if failure to respond to oral (including rate of loss > rate of response) or poor tolerability Known angiodysplasia more likely to require IV iron rather than oral Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. Coexistent unrelated bowel disease eg Coeliac disease more likely to require IV iron if bleeding as may have reduced iron absorption although would still consider trial or oral iron first. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then I would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. Malignancy, angiodysplasia, Coeliac disease and IBD: lower threshold for IV rather than oral iron as detailed above but would not necessarily use IV iron unless clear indication for this in preference to oral therapy (see above)Malignancy, angiodysplasia, and IBD: lower threshold for IV rather than oral iron as detailed above but would not necessarily use IV iron unless clear indication for this in preference to oral therapy (see above)
992DrTeich2014-12-12 15:29:04Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. Significant iron deficiency with an estimated need of less than about 500 mg ferric carboxy maltose after failure of oral iron supplementation. As well, patients with functional iron deficiency (i.e. anemie of chronic disease) need IV iron therapy.Vomiting blood and/or haematin; pt. passes bloody stool or melena. Active bleeding from ulcerations/tumours/inflammatory bowel diseases/haemorrhoids/angiectasia Paleness, hypotension, positive occult faecal blood testVomiting blood and/or haematin, weight loss, dysphagiapt. passes bloody stool or melena, weight loss, abdominal pain
1036DrBiedermann2014-12-14 11:42:491036 - concomitant gastrointestinal and other diseases that modulate the risk of iron deficiency regardless of the current bleeding episode, such as celiac disease, IBD, malignancy, having received gastric bypass surgery, other intestinal surgical procedures, systemic sclerosis, M. Osler,. Hemochromatosis etc. - female sex and age (ongoing menstruation) - concomitant medical conditions, where an anemic state would be especially deleterious, such as coronary heart disease, COPD, pulmonal hypertension, physical deconditioning and sarkopenia- patient’s desire - factors related to the probability of tolerance of an oral approach for substitution, such as functional GI diseases above all IBS, functional constipation or diarrhoea, IBD - likelihood of adherence/compliance regarding prolonged oral substitution - previous history of allergy towards i.v. iron formulas - reimbursement policy in the respective country (always oral approach first required?)I do not think, that there are any features to the naked eye, providing a clear indication for iron supplementationI do not think, that there are endoscopic features, providing a clear indication for iron supplementationIndication for iron supplementation always given in case of a low haemoglobin (threshold remains to be defined) and/or serum ferritin (threshold remains to be defined) with or without symptoms. Especially in this condition in the vast majority of instances, blood transfusions may be avoided.No oral iron supplementation in case of upper GI Crohn’s disease, active celiac disease or after previous extensive surgical gastric/duodenal resections, including gastric bypass surgeryNo oral iron supplementation in ALL patients with IBD, as well as in most instances of functional disorders (IBS, all subtypes; dyspepsia; chronic constipation and diarrhea).
970ProfessorSchiefke2015-01-05 15:43:40Anemia, fatique, restless legs, Inflammation of the gut Rapid elevation of iron Safe accessICU? Circulation?Blatchford Score Transfusion Oral iron? Liver cirrhosis and variceal bleeding Helicobacter pylori Gastritis CarcinomaIBD Carcinoma
1047DrWendt2015-03-19 09:38:07ron deficiency, together with symptoms, e.g. anemia, low TSAT, Ferritin, Ret.Hb, increased sTFR, Deficiency or even relative deficiency together with heart failure (FairHF study) Renal anemia Recurrent GI bleeding with frequent need for transfusions Absence of acute or chronic inflammation Cave permanent catheter carriers medications, e.g. anticoagulation, platelet-inhibitions, NSAIDs, steroidsAdverse events during oral therapy Great extend of iron depletion or severe iron deficiency, severe iron anemia Cave: infusion reactions, issues at law, signed informed consent, monitoring during infusions, not in pregnancy, no iron dextrane preparationsRecurrent events of blood on stool or toilet paper or recurrent appearance of black stool together with anemia or iron deficiency in lab testing Ulcers Forrest I-III, Varices, gastritis, Mallory-weiss-esions, camerons-lesions, erosions, angiodysplasias, malignomasUnexplained iron deficiency Positive hemocare-test (occult blood test in stool)Unspecific: Hematemesis, melena Iron suggestable if Recurrent angiodysplasias with deficiency despite frequent laser coagulation Recurrent bleeding by esophageal varices not amenable for causal treatmentHematochezia, Blood-streaked stool Iron if: Recurrent angiodysplasias with deficiency despite frequent laser coagulation

GI Bleed Questionnaire Responses
IDTitleNameCreatedQ8Q9Q10Q11Q12Q13Q14Q15
1001DrKeshav2014-11-20 08:22:24Symptoms, objective bleeding Intolerance of oral iron, presence of IBD, Clinical signs of compromise Active bleeding, visible vessel, angioectasia Chronic anaemia Chronic anaemia Malabsorption Not amenable to treatment
1006ProfessorMohr Drewes2014-12-12 12:57:30Some may treat fatigue even though laboratory values are normal Same as aboveCannot think of anySame as aboveSame as aboveSame as aboveSame as above
1020DrCiriza de los Rios2014-12-12 13:02:58Apart from my previous answer Sometimes a diagnosis of iron deficiency based on hypochromia and microcytosis (I don´t agree because other conditions such as thalassemia can give that; also microcytosis may be absent in combined deficiency (folate deficiency)Adverse effects or poor efficacy of oral iron in patients with gastrointestinal disorders, such as celiac disease or inflammatory bowel disease and ongoing blood loss (I agree with this). In a patient that is non-adherent to the oral iron treatment (I don´t agree with this). As per my previous answer to this question.As per my previous answer to this question.As per my previous answer to this question.Chronic gastritis without atrophy demonstration (I don´t agree to this) Helicobacter pylori infection (can impair iron absorption in infected individuals).As per my previous answer to this question.
988ProfessorFischbach2014-12-12 13:19:44Chronic fatigue and borderline iron serume concentration or anemia, sometimes irrespective of the type of anemia.Side effects of or discomfort by oral iron substitution – uncertain patient’s adherence to oral medication.
1029ProfessorPereira2014-12-12 13:24:43Anaemia, iron deficiencyIntolerant or non-adherant to oral iron supplementation
1028DrIqbal2014-12-12 13:28:29In my opinion iron stores are still very poorly assessed in both primary and secondary care. Management is driven by Hb (not WHO levels either!)Cost and convenience, availability facilities for giving iv iron. Ease of deferring responsibility to Primary Care Fear of reactionsVolume resuscitation is still too reliant on blood productsThere is scant consideration given to replenishing iron stores after the patient has stopped bleeding and a considerable proportion are sent home anaemic without any form of iron replacement. Iron replacement tends to be reactive (driven by fatigue and dyspnoea!) rather than proactive.Most patients, when they do get iron replacement, get tabletsI think the place of iv iron in treating colitis is now widely accepted I think.
1009ProfessorJayne2014-12-12 13:34:00Mouth ulcerationLogistics of administration i.e. requirement for in-patient infusion
996ProfessorRaithel2014-12-12 13:39:31Extent of anemia Hemoglobin level only Price of intravenous preparations Physical status of the patientAdverse events CostErythrocyte supplementation mostly standardErythrocyte supplementation mostly standard Corrections of coagulation parameters decreases loss of ironExtent of anemia – which cause ? Are iron stores really depleted ? mostly oral iron supplementation Is long-term coagulation necessary ?Extent of bleeding determines supplementation measures, mostly blood transfusions in acute bleeding; sometimes intravenous iron supplementation in chronic bleeding malignancies without any other therapeutic option (e.g. surgery) or during chemo-radiotherapyInflammatory Bowel Disease
1005DrPehl2014-12-12 13:41:59pernicious anaemia – vitamin B12 replacement therapy
1025DrClarke2014-12-12 13:46:11Anaemia regardless of iron status frequently treated with iron without investigation as to other possible causes.IV iron more likely to be recommended if overt bleeding even if the anaemia has not been demonstrated to be caused by the blood loss eg Anaemia of Chronic Disorders + gastritis. IV iron also often used in preference to oral iron if more severe anaemia in belief that it will work more quickly. This may be reasonable as stated above when ongoing blood loss felt to be likely eg angiodysplasia etc but not for bleeding that has stoppedAs aboveAs aboveAs aboveAs aboveAs above
992DrTeich2014-12-12 15:29:04Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. However, patients with functional iron deficiency (i.e. anemie of chronic disease) need IV iron therapy but are treated with oral iron, which is not absorbed in the most patients. Vomiting blood and/or haematin; pt. passes bloody stool or melenaVomiting blood and/or haematin; pt. passes bloody stool or melena.Paleness, hypotension, positive occult faecal blood test Vomiting blood and/or haematin, weight loss, dysphagiapt. passes bloody stool or melena, weight loss, abdominal pain
1036DrBiedermann2014-12-14 11:42:49To this somewhat bizarre question, I do not have a good answer
970ProfessorSchiefke2015-01-05 15:43:40
1047DrWendt2015-03-19 09:38:07

GI Bleed Questionnaire Responses
IDTitleNameCreatedQ16Q17Q18Q19Q20Q21Q22
1001DrKeshav2014-11-20 08:22:24 Hb Ferritin MCV Transferrin saturation B12 level Endoscopy and capsule endoscopy Response to oral iron treatment CRP Hepcidin Iron deficient? Chronicity Iron deficiency Concurrent B12 deficiency, ?malabsorption, ? Crohn’s Site of bleeding? Able to use oral rather than iv Inflammation worsens iron absorption Low levels suggest that bleeding is the cause of anaemia, higEndoscopy Forrest score at Endoscopy Rockall Score for risk of mortality Glasgow-Blatchford Score Haemoglobin Hypotension Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet 2 (7877): 394–7 Rockall, T.A., Logan, R.F., Devlin, H.B. and Northfield, T.C. (1995) Incidence of and mortality from acute upper gastrointestinal ha
1006ProfessorMohr Drewes2014-12-12 12:57:30 Ordinary endoscopy (upper and lower) Double balloon endoscopy (done at a special endoscopy unit) Capsule endoscopy Laboratory values Radiology (angiography) Red blood cell scintigraphy Laparoscopy (surgical department) large medium large large Medium in difficult cases minor major I am not aware of any clinical trials at the moment – sorry, but this is not my expert area of research Anemia in patients with chronic inflammatory bowel disease. Cronin CC, Shanaha F. Am J Gastroenterol 2001; 96: 2296-8. 2. Anemia in IBD: The overlooked villain. Gasche C., Inflammatory bowel disaeses 2000; 6: 142-50. 3. Review article: iron and inflammatory bowel disease. Oldenburg B, Koningsberger J C,Henegouwen GPvB, Asbeck BSv., Aliment Pharmacol Ther 2001; 15: 429-38.
1020DrCiriza de los Rios2014-12-12 13:02:58Clinical history and examination GI bleeding severity index (Blatchford score) Laboratory test: Hb, Hct, VCM, percent saturation of transferring , reticulocyte count, Ferritin level, percent saturation of transferring, serum iron. Coagulation study Other laboratory biochemical test: Urea and creatinin, liver test and ions Gastroscopy with biopsies and colonoscopy Capsuloscopy and eventually enteroscopy Yes. Particularly to evaluate the severity in acute GI bleeding Yes . Diagnosis of ferropenic anemia and iron deficiency and if this is confirmed to treat it. In moderate-severe anemia Important in acute bleeding (elevated blood urea nitrogen to creatinine suggest upper GI bleeding) Yes . Allows the diagnosis of GI causes of acute or chronic bleeding. Also allows the evaluation of the degree of stigmata of hemorrhage (high risk, low risk, or no stigmata). Depending on the type of lesion longer iron therapy can be required (chronic bleeding lesions, inflammatory bowel disease, etc) To diagnose the origin of obscure GI bleeding (normal upper endoscopy and colonoscopy) in case of ongoing bleeding without improvement with iron therapy Clinical features: hemodynamic shock, hematemesis, melena, coffee grounds Clinical features: : hemodynamic shock, hematochezia Hemoglobin Ferritin, transferring saturation, reticulocytes Other laboratory test: urea, creatinin, coagulation Upper endoscopy Colonoscopy Reliable and relevant to assess clinical upper GI bleeding Relevant to assess clinical lower GI bleeding Reliable/Relevant for diagnosis of anemia and to assess improvement after therapy (endpoint) Relevant to assess iron depletion and treatment endpoint in these trials Relevant. High urea levels with normal creatinin suggest upper GI bleeding. Coagulation to assess coagulopaty Reliable/Relevant to assess the type of bleeding lesion, degree of stigmata of hemorrhage and recurrence of bleeding Relevant to confirm lower GI bleeding and treatment Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Srygley FD. JAMA. 2012 Mar 14;307(10):1072-9. Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Bager P, et al. Aliment Pharmacol Ther 2014; 39: 176–187 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Bager P, et al. Aliment Pharmacol Ther 2014; 39: 176–187 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Srygley FD. JAMA. 2012 Mar 14;307(10):1072-9. Iwakiri R, et al. Aliment Pharmacol Ther 2014; 40: 780–795 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Hemoglobin, ferritin, reticulocytes, Transferring saturation. Hemoglobin, ferritin, reticulocytes, Transferring saturation. Hemoglobin, ferritin, Quality of life (SF-36), Crohn's Disease Activity Index (CDAI) and the median Colitis Activity Index (CAI) Hemoglobin, ferritin, Need of red blood cell transfusion Auerbach M, Ballard H. Clinical use of intravenous iron: administration, efficacy, and safety. Hematology Am Soc Hematol Educ Program 2010; 2010:338–347. Goddard AF. Guidelines for the management of iron deficiency anaemia. Gut 2011 Oct;60(10):1309-16. C Gasche, M C E Lomer, I Cavill, G Weiss. Iron, anaemia, and inflammatory bowel diseases. Gut 2004;53:1190–1197 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Notebaert E, Chauny JM, Albert M, et al. Short-term benefits and risks of intravenous iron: A systematic review and meta-analysis. Transfusion. 2007;47(10):1905-1918. Lee TW, Kolber MR, Fedorak RN, van Zanten SV. Iron replacement therapy in inflammatory bowel disease patients with iron deficiency anemia: A systematic review and meta-analysis. J Crohns Colitis. 2012;6(3):267-275. Litton E. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013;347:f4822
988ProfessorFischbach2014-12-12 13:19:44Esophago-gastro-duodenoscopy Ileocolonoscopy Video-capsule-endoscopy Push-Enteroscopy Double-Balloon-Enteroscopy MR Sellink CT-Angiography Surgery Very important as initial routine diagnostic tool Very important as initial routine diagnostic tool Important if GI-bleeding is evident and no bleeding source was found in upper and lower GI-endoscopy Additional diagnostics in case of a positive finding in capsule-endoscopy or in the individual patient to look for causes of chronic GI-blood-lost In case of positive findings in capsule-endoscopy indicating GI-bleeding from jejunum or ileum To exclude intestinal stenosis in case of suspected Crohn’s disease or in the individual patient before using capsule-endoscopy Important in case of acute GI-bleeding which cannot be localised by endoscopy (diagnostic) or in case of failed endoscopic control of haemorrhage (therapeutic approach) In the individual patient if GI-bleeding is evident but the bleeding source is not detectable by any diagnostics or in case of failed endoscopic or interventional radiology treatment Hematemesis or melena or both confirmed by medical stuff Endoscopically verified bleeding either in upper or lower GI-track Iron deficiency anemia and history of GI-bleeding actually not active Composite of clinically events and endoscopic findings Very relevant Very relevant Weak parameters Relevant Villanueva C et al, NEJM 2013; 368: 11-21 Chan FKL et al, Condor-Study, Lancet 2010; 376: 173-9 NICE – clinical guideline 141: Acute upper gastrointestinal bleeding: managementGuidance.nice.org.uk/cg141
1029ProfessorPereira2014-12-12 13:24:43 Clinical features anaemia Clinical features hypotension Blood loss (eg > 3L) by haematemesis or meleana Haem/biochem indices: Hb, platelets, clotting, urea Measurement of iron stores Metabolic acidosis Blood products required to maintain Hb Risk assessment tools – Rockall score >= 3, Blanchford score Significant comorbidity, suspected variceal bleeding, on anticoagulants / NSAIDs Age, comorbidity – IHD, renal failure, b-blockers Pulse and BP, urea, Hb Endoscopic diagnosis – ulcers, cancer Endoscopic stigmata – blood, clot, vessel etc Rockall Lancet 1996 Blatchford Lancet 2000 Stanley AJ et al Lancet 2009 Vienna consensus Ann Intern Med 2010; 152: 101-13 Lau et al NEJM 2000 Sung et al Ann Intern Med 2009 Bager and Dahlerup. Aliment Pharm Therap 2014 NICE guidelines on UGI bleeding 2012 Villanueva C et al NEJM 2013
1028DrIqbal2014-12-12 13:28:29Evidence of ongoing haematemesis, melaena, haemodynamic compromise Findings at endoscopy Assessment of coagulopathy and need to continue anti-coagulants after acute bleeding has settled Regular assessment of iron stores in patients with occult bleeding-ferritin, TSAT Blatchford and Rockall risk scoring Hb, ferritin, MCV and, occasionally, TSAT when patient is stable Ongoing bleeding-more aggressive with volume fluid replacement Predict chances of re-bleeding and seriousness of event Predict chances of bleeding stopping and re-bleeding risk. Maybe direct aggressiveness of iron replacement Drive proactive response to replacing iron stores To assess risk in ED (Blatchford) and risk of re-bleeding after endoscopy (Rockall) To decide on whether patient should be discharged on oral iron or given an iv bolus prior to discharge Blatchford score-pre-endoscopy scoring tool Rockall endoscopic risk score Iron status on discharge Iron status 6 weeks later Used to risk stratify patients before endoscopy in Emergency Department and to decide which patients can be discharged with out-patient endoscopy To risk stratify patients at endoscopy and assess risk of re-bleeding NOT EVER measured to my knowledge NOT EVER measured to my knowledge NICE GI bleeding guideline summarises the trials As above In my opinion there is NO guidance on this topic. All the GI bleeding guidance is about: 1 saving lives, comparing endoscopic treatment modalities, comparing endoscopy with surgery and radiology, assessing risk of re-bleeding acutely and then later, especially in patients who are discharged on non-steroidal anti-inflammatory drugs, aspirin and platelet inhibitors. There is no concern about anaemia accompanying GI bleeding and there is a feeling that iron stores will put themselves right. This is why I have been advocating (for some time) a trial of standard management vs active oral or iv iron replacement after upper GI bleeding having stratified against risk first. Rockall score Glasgow-Blatchford score Again-please refer to NICE upper GI bleeding guidelines As above-easier than me having to dig out the references one by one
1009ProfessorJayne2014-12-12 13:34:00 Haemoglobin measurement Faecal occult blood testing Serum ferritin Serum B12 Endoscopy – colonoscopy & upper Gi endoscopy CT angiography Mesenteric angiography White cell isotope studies Very important Moderate importance Moderate importance Moderate importance Very important Very important in acute setting Very important in the acute setting Only useful for Meckel’s diverticulum Flexible sigmoidoscopy Faecal occult blood testing For Lower GI bleed Good screening tool, but poor compliance, good sensitivity, poor specificity UK flexible sigmoidoscopy trial Numerous British Society of Gastroenterology Guidelines- see attached manuscript
996ProfessorRaithel2014-12-12 13:39:31Cardiovascular parameters (RR, pulse) and oxygen saturation Blood count, haemoglobin, haematocrit etc. Coagulation parameters Ouvert bleeding or occult bleeding Comorbidity, e.g. coagulopathy, coronary syndrome Emergency endoscopy Extent of anemia Type of bleeding Emergency endoscopy Risk scores – e.g. Rockall score Blatchford Score Score of Villanueva et al. Score Guglielmi et al. Mortality risk score from Chiu et al. Yes yes – need for intervention Outcome parameters Rebleeding Mortality assessment Endoscopy. 2012 Aug;44(8):731-9. doi: 10.1055/s-0032-1309361. Epub 2012 Jul 25. WHO, Iron deficiency anemia: Assessment, Prevention and Control, 2001 Stein J et al. Z Gastroenterol 2009; 47; Gasche C et al. Inflamm Bowel Dis 2007;13:1545–1553 Cucino C et al. Cause of death in patients with IBD. Inflamm Bowel Dis 2001; 7: 250-255 Dohil R et al. Recombinant human erythropoetin for treatment of anemia of chronic disease in children with Crohn’s disease. J Pediatr 1998; 132: 155-159 Giesler T, Raithel M. Bleeding stromal tumor. Gastrointest Endosc 2005; 61: 593 Bar-Meier S et al. Gastrointest Endosc 2004; 60: 711 – 713 Iron metabolism Inflammatory Bowel Disease Case report other bleeding sources Diagnostics
1005DrPehl2014-12-12 13:41:59laboratory counts (haemoglobin and ferritin level) ultrasound endoscopy (gastroscopy, colonoscopy) duodenal biopsies; transglutaminase antibodies history endoscopic ultrasound video capsule endoscopy blood transfusion; iron supplementation neoplasia? Ultrasound guided therapies Bleeding GI disorders; endoscopic therapy Coeliac disease; diet symptomatic disease necessitating therapy ultrasound guided therapies enteroscopy with endoscopic therapy
1025DrClarke2014-12-12 13:46:11Hb yes MCV yes RDW Useful for assessing early response to iron Ferritin Useful if low. May be normal or even high if iron deficiency + inflammatory process Transferrin saturation May help clarify if iron deficiency in presence of inflammatory process Pulse/ BP etc for acute bleeding essential Not aware of any No current SIGN or BCSH guidelines on this topic
992DrTeich2014-12-12 15:29:04 Anamnesis Hb MCV Ferritin + CRP Upper and lower endoscopy MCH and MCHC Iron contration in Plasma Transferrin saturation Hepcidin Very important Very important Very important Very important Very important Less important Less important important Not measured Anamnesis Colitis activity index Yes yes yes www.dgvs.de – Crohns and Colitis guideline in Germans www.ecco.eu – European Crohn’s and Colitis organisation yes yes
1036DrBiedermann2014-12-14 11:42:49Comment on Section:What exactly is meant by “the various features of gastrointestinal bleeding”? Vital signs (blood pressure, heart rate, orthostatic reaction), moreover peripheral perfusion (time to recapillarisation) is a good indicator of volume loss Haemoglobin and more importantly hb-drop Comorbid diseases Endoscopic feature, above all Forrest classification of gastric (and also duodenal) ulcers Biochemical measures of iron deficiency (within the first days after bleeding episode) Ferritin Transferrin saturation Soluble transferrin receptor Mean corpuscular volume of red blood cell Reticulocyte count Most important method at all to determine severity of bleeding Very important – indication of blood transfusion largely depends on this value Most important factor for the prognosis of the patient in case of severe GI-bleeding, including mortality. Providing a good estimate of the risk of re-bleeding. First three parameters give a reliable estimate of iron deficiency. The latter two somewhat aid in determining, whether blood loss is acute or rather subacute/chronic (if analysed at hospital entry) Prognostic scores: Blatchford, Rockall, APACHE II Clinical factors, such as age, shock, severe comorbid disease, low haemoglobin level, hematemesis or hematochezia, renal insufficiency, malignant disease, chronic alcohol abuse or poor socioeconomic background Placement of nasogastric tube Determination and correction of coagulopathy Various trials have prospectively investigated the prognostic potential of these scores. I think that they indeed are relevant. However in clinical practise, they are only rarely used (rather inconvenient). Again, various trials have shown, that these factors are of importance. Yes, these factors are very important. Every clinician integrates them while decision making (either consciously or not). May help to recognize early re-bleeding, may help to obtain information about localization of bleeding. I do not think, that this is relevant or really necessary. It appears logical, that in case of severe coagulopathy, correction may be supportive in controlling the bleeding episode. Most clinicians prefer to correct a severe thrombocytopenia or severe elvation of INR in case of active bleeding – although the evidence on that is not really clear. Various studies have used these scores. Just one prominent example (Rockall score): [1] Villanueva C, Colomo A, Bosch A et al., "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding" New England Journal of Medicine, vol. 368, no. 1, pp. 11–21, 2013. There are a bunch of other trials Again, various references. These factors are also included in several guidelines, for instance: [1] Barkun AN, Bardou M, Kuipers EJ et al., "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding" Ann. Intern. Med., vol. 152, no. 2, pp. 101–13, 2010. Useage is not uniformly recommended in guidelines However, the evidence for corrective measures in the setting of bleeding is very scarce. This is nicely reviewed here: [1] Baron TH, Kamath PS, McBane RD, "Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures" New England Journal of Medicine, vol. 368, no. 22, pp. 2113–24, 2013. Original publication of GBS Prokinetics prior to endoscopy in bleeding? GI-Tumors and bleeding – a common reason for iron deficiency Good metaanalysis on endoscopic treatment of ulcer bleeding Milestone publication for low transfusion threshold. Withholding transfusion is directly related to iron substitution GAVE and angiodysplasia. A very important cause of chronic bleeding anemia. Very often, patients can be treated without blood transfusion solely with (repetitive) iron substitution Two important reviews on NOACs. This will be (and in fact already is) an important topic. Although NOACs appear even safer than warfarin regarding intracranial bleeding complications, the risk of GI-bleeding appears to be increased in most (but not all) studies, which is why (also considering the increasing age an comorbidities of our patients) GI blood loss, both acute and chronic, will be an even more important topic – and consecutively also iron substitution. [1] Barkun AN, Bardou M, Kuipers EJ et al., "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding" Ann. Intern. Med., vol. 152, no. 2, pp. 101–13, 2010. [1] Greenspoon J, Barkun A, Bardou M et al., "Management of patients with nonvariceal upper gastrointestinal bleeding" Clin. Gastroenterol. Hepatol., vol. 10, no. 3, pp. 234–9, 2012. [1] Swanson E, Mahgoub A, Macdonald R, Shaukat A, "Medical and Endoscopic Therapies for Angiodysplasia and Gastric Antral Vascular Ectasia: A Systematic Review" Clinical Gastroenterology and Hepatology, vol. 12, no. 4, pp. 571–82. [1] Stanley AJ, Ashley D, Dalton HR et al., "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation" Lancet, vol. 373, no. 9657, pp. 42–7, 2009. [1] Barkun AN, Bardou M, Martel M, Gralnek IM, Sung JJY, "Prokinetics in acute upper GI bleeding: a meta-analysis" Gastrointest. Endosc, vol. 72, no. 6, pp. 1138–45, 2010. [1] Sheibani S, Kim JJ, Chen B et al., "Natural history of acute upper GI bleeding due to tumours: short-term success and long-term recurrence with or without endoscopic therapy" Aliment Pharmacol Ther pp. n/a, 2013. [1] Laine L, McQuaid KR, "Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials" Clin. Gastroenterol. Hepatol., vol. 7, no. 1, pp. 33-47; quiz 1-2, 2009. [1] Villanueva C, Colomo A, Bosch A et al., "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding" New England Journal of Medicine, vol. 368, no. 1, pp. 11–21, 2013. [1] Swanson E, Mahgoub A, Macdonald R, Shaukat A, "Medical and Endoscopic Therapies for Angiodysplasia and Gastric Antral Vascular Ectasia: A Systematic Review" Clinical Gastroenterology and Hepatology, vol. 12, no. 4, pp. 571–82. [1] Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ETTL, "New Oral Anticoagulants Increase Risk for Gastrointestinal Bleeding: A Systematic Review and Meta-analysis" Gastroenterology, vol. 145, no. 1, pp. 105–112.e15, 2013. [1] Desai J, Granger CB, Weitz JI, Aisenberg J, "Novel oral anticoagulants in gastroenterology practice" Gastrointest. Endosc., vol. 78, no. 2, pp. 227–39, 2013.
970ProfessorSchiefke2015-01-05 15:43:40Blood test (ferritin, TF saturation, iron, Hb) Clinical symptoms Upper and lower gi endoscopy Capsule endoscopy, single ballon endoscopy nutrition Iron y/n, blood transfusion Start therapy If upper an d lower -ve vegetarian FATIC scale CH-RLS q Ferritin, TF satt relevant relevant relevant Guidelines for the Management of Iron Deficiency Anaemia Andrew F Goddard, Martin W James, Alistair S McIntyre, Brian B Scott, on behalf of the British Society of Gastroenterology Gut 2011;60:1309-1316. doi:10.1136/gut.2010.228874 UK guidelines on the management of iron deficiency in pregnancy Writing group: S Pavord1, B Myers2, S Robinson3, S Allard4, J Strong5, C Oppenheimer6 Guidelines on the Diagnosis and Management of Iron Deficiency and Anemia in Inflammatory Bowel Disease Gasche et al. (Inflamm Bowel Dis 2007;13:1545–1553 Guideline for the laboratory diagnosis of functional iron deficiency D. Wayne Thomas,1 Rod F. Hinchliffe,2 Carol Briggs,3 Iain C. Macdougall,4 Tim Littlewood5and Ivor Cavill6 on behalf of British Committee for Standards in Haematology British Journal of Haematology, 2013, 161, 639–648
1047DrWendt2015-03-19 09:38:07Occult blood test Upper and lower endoscopy Capsula endoscopy Push enteroscopy Extend of anemia (Hb-value, Retikulcytes) Extend of iron deficiency – TSAT and ferritin Extend of iron deficiency – Ret.HB, sTFR Associated disorder (inflammation ?) Chronicity of disorder, treatment of underlying pathology possible ? Clinical feature of bleeding: Hematemesis, Melena, Hematochezia, Blood-streaked stool Hemodynamic features blood pressure, HF, history of syncope, dyspno, angina pectoris. Little important important very important very important important important Very important important important 1. hematemesis 2. 3. melena 4. Hematochezia 5. Blood on Nasogastric tube lavage 6. Rockall score and Blatchford score 7. UGISQUE questionaire for elderly patients 8. Blood pressure, HF Shock index, syncopes etc. 9. Bun/Creatinin reatio 10. Extend of anemia (haemoglobin level) 11. CRP 1. relevant 2. 3. relevant 4. 5. Not often used 6. relevant 7. interesting 8. Most relevant 9. Interesting tool, not much used... 10. Very relevant 11. Risk for rebleeding 1. Almost all trials 2. World J Gastrointest Pathophysiol. 2014 Nov 15;5(4):467-78 3. Almost all trials 4. 5. JAMA 2012; 307: 1072-1079 6. Hepatogastroenterology. 2013 Nov-Dec;60(128):1990-7. 7. J Gerontol A Biol Sci Med Sci. 2010 Feb;65(2):174-8. 8. Almost all trials 9. Am J Emerg Med. 2006 May;24(3):280-5; Lancet. 1986 May 10;1(8489):1064-5. 10. N Engl J Med 2013;368:11-21 11. Dig Liver Dis. 2015 Feb 23 For what ???? bleeding ? or estimation of extend iron deficiency ?Aliment Pharmacol Ther. 2014 Jan;39(2):176-87 Dan Med J. 2013 Mar;60(3):A4583. Am J Gastroenterol. 2011 Nov;106(11):1872-9 Gut. 2011 Oct;60(10):1309-16 Ther Adv Chronic Dis. 2010 Mar;1(2):67-75 Am J Crit Care. 2013 Nov;22(6 Suppl):eS1-13 JPEN J Parenter Enteral Nutr. 2013 Sep;37(5):599-606

Section 1

Q1 Features relating to a requirement for iron therapy

Q2 Features relating to a requirement for bolus IV iron therapy

Q3 Features related to GI Bleeding, visible to the naked eye

Q4 Features relating to GI Bleeding visible on endoscopy
Q5 Features relating to occult GI bleeding
Q6 Features relating to specific upper GI disorders
Q7 Features relating to specific lower GI disorders
Section 2
Q8 Features relating to a requirement for iron therapy
Q9 Features relating to bolus IV iron therapy
Q10 Features relating to GI bleeding visible to the naked eye
Q11 Features relating to GI bleeding visible on endoscopy
Q12 Features relating to occult GI bleeding
Q13 Features relating to specific upper GI disorders
Q14 Features relating to specific lower GI disorders
Section 3
Q15 Routine Clinical Measures I Use In My Practice?
Q16 Important For Treatment Decisions?
Section 4
Q17 Clinical trial assessment tools?
Q18 Reliability / Relevance?
Q19 Reference to trial using tool
Section 5
Clinical trial assessment tools?
Q20 Reference to trial using each tool or to guideline proposing use of each tool