Pharmacologic provocation combined with endoscopy in refractory cases of gi bleeding.Raines DL, Jex KT, Nicaud MJ, Adler DG. Gastrointest Endosc. 2016 Jun 22. [Epub ahead of print]

BACKGROUND AND AIMS:The source of gastrointestinal bleeding (GIB) may elude us despite exhaustive testing in some cases. Bleeding in these cases is often related to a vascular lesion that is discernible only when actively bleeding.

The objective of this study was to determine the efficacy and safety of endoscopy combined with the administration of anti-platelet and/or anti-coagulant agents to stimulate bleeding in order to define a source.METHODS:A retrospective review of a database of device-assisted enteroscopy (DAE) procedures was completed to identify cases in which provocation with antiplatelet or anticoagulant agents was used as part of a GIB evaluation. Procedures were divided into three groups based upon the method of provocation: patients with previous bleeding on an antiplatelet/anticoagulant (provocation experienced); patients naïve to these medications (provocation naïve); and cases of recurrent, overt OGIB in which a combination of clopidogrel and intravenous heparin were administered for provocation (LSU protocol).RESULTS:A review of 824 DAE procedures was completed to identify a total of 38 instances in which provocation was attempted in 27 patients. These cases were subdivided into 13 provocation experienced procedures, 18 provocation naïve procedures, and 7 LSU protocol procedures. The diagnostic yield of provocative testing per procedure was 53% in the provocation-experienced group, 27% in the provocation naïve group and 71% in the full-protocol group. Provocative testing was revealing in 15 out of 27 patients with angioectasias and Dieulafoy lesions being the most common pathologies. Provocative testing was not beneficial in 4 patients who were eventually diagnosed with bleeding due to intestinal angioectasias (3) and an aorto-enteric fistula (1). There were no adverse events.CONCLUSIONS:Provocative testing combined with endoscopy can be justified as an option in the diagnostic algorithm of complex cases of GIB when intermittent bleeding related to a vascular lesion, such as an angioectasia or Dieulafoy, is suspected. However, this novel technique should be considered only after standard management has failed to define a bleeding source and bleeding continues to recur. This is the first reported case series of provocative testing combined with endoscopy.

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