17.3 Gastrointestinal bleeding

Background
GI bleeding is the most common cause of hospital readmission [428] and is observed early and late after implantation. Reported incidences range between 5% and 34%.

Description of the evidence
The incidence of GI bleeding is comparable between patients supported with different CF-LVADs. Upper and lower GI endoscopies are the mainstay of initial investigations. Angiography and radionuclide imaging are best suited for acute overt GI bleeding. Capsule endoscopy may play a role in the diagnosis of obscure GI bleeding, usually from the small bowel. Diagnosis and concomitant treatment are possible once the bleeding source is identified. Despite this, no active bleeding site is identified in 30–50% of the cases [344, 429], and it is often then assumed that the site of the bleeding is the small intestine, where arterio-venous malformations are difficult to identify and treat. The primary treatment goal is to stabilize the patient; blood transfusions may be required. Anticoagulation therapy is often interrupted until bleeding is resolved. Recurrent GI bleeding warrants complete withdrawal of antiplatelet therapy and setting a lower target INR, acknowledging the possible increased risk of thromboembolic complications. There are positive reports of the use of octreotide and thalidomide in treating occult and recurrent GI bleeding [430, 431]. However, these drugs are not commonly used in some European countries and there is limited long-term experience. Discontinuation of antithrombotic and antiplatelet therapy poses a potential prothrombotic risk that has to be balanced against the risk of recurrent bleeding episodes [432].