|
1
|
Vaira LA, Massaiu A, Massaiu G, Salzano G, Maglitto F, Lechien JR, Biglio A, Visaloco G, Piombino P, Biglioli F, De Riu G. Efficacy of auriculotherapy in the control of pain, edema, and trismus following surgical extraction of the lower third molars: a split-mouth, randomized, placebo-controlled, and triple-blind study. Oral Maxillofac Surg 2024; 28:279-287. [PMID: 36735078 PMCID: PMC10914868 DOI: 10.1007/s10006-023-01140-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this split-mouth, randomized, placebo-controlled, and triple-blind study was to evaluate whether auriculotherapy had any effect on the post-operative course after the extraction of third molars in terms of the control of pain, edema, and trismus. MATERIALS AND METHODS The study included 42 patients (84 teeth) who had undergone a surgical extraction of the lower third molars. In each patient, the two extractions were randomly assigned to two study groups. In the therapy group, the patients underwent auriculotherapy with vaccaria seeds applied with patches in 6 ear points. In the control group, the patches were applied, without seeds, to the same ear points. After the extraction, the patients were asked to stimulate the ear points three times a day and whenever they felt pain. The patients were asked to keep a diary in which they assessed their pain by means of the Visual Analog Scale (VAS) for 8 days. Edema and trismus were assessed 1, 2, 3, and 8 days after surgery. RESULTS The differences between the two groups were statistically significant at the 12-h control (auriculotherapy group (AG) VAS 5.5 [IQR 4.25-6.75], placebo group (PG) VAS 6 [IQR 5-8], p = 0.040), after 24 h (AG VAS 5 [IQR 4-6], PG VAS 6 [IQR 4.25-7], p = 0.024), after 2 days (AG VAS 4 [IQR 3-5], PG VAS 4.5 [IQR 4-6], p = 0.044), and after 3 days (AG VAS 3 [IQR 0-5], PG VAS 4 [IQR 3-5], p = 0.024). Throughout the observation period, the AG took a significantly lower number of painkillers than the PG (AG 6 [IQR 4.25-7]; PG 8 [IQR 8-9], p < 0.001). There were no significant differences in the levels of edema and trismus between the two groups throughout the observation period. CONCLUSIONS On the basis of the results of the present study, auriculotherapy can be considered as a cost-effective adjuvant pain reliever treatment in patients undergoing an extraction of the lower third molars.
Collapse
Affiliation(s)
- Luigi Angelo Vaira
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy.
- Biomedical Science Department, PhD School of Biomedical Science, University of Sassari, Viale San Pietro 43B, Sassari, Italy.
| | | | | | - Giovanni Salzano
- Department of Maxillofacial Surgery, University of Naples "Federico II", Naples, Italy
| | - Fabio Maglitto
- Department of Maxillofacial Surgery, University of Naples "Federico II", Naples, Italy
| | - Jerome R Lechien
- Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head Neck Surgery, Polyclinic of Poitiers, Elsan Hospital, Poitiers, France
| | - Andrea Biglio
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
- Maxillofacial Surgery Department, San Paolo Hospital, ASST Santi Paolo E Carlo, University of Milan, Milan, Italy
| | - Giulio Visaloco
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
- Dental School, University Hospital of Sassari, Sassari, Italy
| | - Pasquale Piombino
- Department of Maxillofacial Surgery, University of Naples "Federico II", Naples, Italy
| | - Federico Biglioli
- Maxillofacial Surgery Department, San Paolo Hospital, ASST Santi Paolo E Carlo, University of Milan, Milan, Italy
| | - Giacomo De Riu
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| |
Collapse
|
|
2
|
Thirumalaisamy R, Ameen F, Subramanian A, Selvankumar T, Alwakeel SS, Govarthanan M. In-Vitro and In-Silico Anti-inflammatory Activity of Lupeol Isolated from Crateva adansonii and Its Hidden Molecular Mechanism. Int J Pept Res Ther 2020. [DOI: 10.1007/s10989-019-10006-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
|
3
|
Kim TJ, Kim ER, Hong SN, Kim YH, Lee YC, Kim HS, Kim K, Chang DK. Effectiveness of acid suppressants and other mucoprotective agents in reducing the risk of occult gastrointestinal bleeding in nonsteroidal anti-inflammatory drug users. Sci Rep 2019; 9:11696. [PMID: 31406189 PMCID: PMC6690955 DOI: 10.1038/s41598-019-48173-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/31/2019] [Indexed: 02/07/2023] Open
Abstract
Acid suppressants such as histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are effective in preventing gastrointestinal (GI) bleeding in nonsteroidal anti-inflammatory drugs (NSAIDs) users. Despite widespread acid suppressant use, there remain concerns about several potential risks of long-term use. Therefore, we investigated whether gastroprotective agents (GPAs) other than acid suppression therapy are effective in preventing NSAID-related GI injury. To this end, we studied 9,133 patients with osteoarthritis or rheumatoid arthritis who used NSAIDs for ≥1 month. A decrease of 2 g/dL or more in the hemoglobin level was considered a GI injury indicator. The GPAs included acid suppressants and other mucoprotective agents. Acid suppressants included PPIs and H2RAs. Other mucoprotective agents included misoprostol, rebamipide, and eupatilin. During a median follow-up period of 27 (range, 4.3-51.3) weeks, occult GI bleeding occurred in 1,191 (13%) patients. A comparison of patients who used GPAs concomitantly with that of nonusers in a multivariable analysis revealed the hazard ratios (HRs; 95% confidence intervals [CIs]) for occult GI bleeding were 0.30 (0.20-0.44), 0.35 (0.29-0.43), 0.47 (0.23-0.95), 0.43 (0.35-0.51), and 0.98 (0.86-1.12) for PPIs, H2RAs, misoprostol, rebamipide, and eupatilin, respectively. Compared to PPI co-treatment, H2RA, misoprostol, rebamipide, and eupatilin co-treatments were associated with occult GI bleeding HRs (95% CIs) of 1.19 (0.79-1.79), 1.58 (0.72-3.46), 1.44 (0.96-2.16), and 3.25 (2.21-4.77), respectively. Our findings suggest that mucoprotective agents, such as rebamipide and misoprostol, as well as acid suppressants, are effective in reducing the risk for GI injury in NSAID users.
Collapse
Affiliation(s)
- Tae Jun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeong Chan Lee
- Department of Digital Health, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Seung Kim
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyunga Kim
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| |
Collapse
|
|
4
|
Shafqet MA, Tonthat A, Esparragoza P, Toro B, Ehrlich AC, Friedenberg FK. Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram. Abdom Radiol (NY) 2019; 44:2632-2638. [PMID: 30949782 DOI: 10.1007/s00261-019-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Computed tomography angiography (CTA) is a diagnostic modality utilized in patients with suspected active lower gastrointestinal (GI) bleeding. CTA use in clinical practice is limited by the risk of contrast-induced nephropathy, and the loss of patients from direct physician observation while undergoing the test. Identifying clinical predictors of a positive result would be useful in guiding physician utilization of CTA studies. METHODS We performed a single-center retrospective study to determine which clinical predictors are associated with a positive CTA. Binary logistical regression modeling was used to identify the independent predictors and the results were expressed as adjusted odds ratios with corresponding 95% CI . RESULTS 262 patients met inclusion criteria and there were 61 (23.3%) positive CTA exams. In unadjusted analysis those who were CTA positive were more likely to require management in the intensive care unit (85.2% vs. 14.8%, p < 0.01) and being CTA positive was associated with a significantly increased in-hospital mortality (14.8% vs. 4.5%, p < 0.01). The use of a novel oral anticoagulant (NOAC) in the week prior to presentation was associated with a positive CTA after adjustment for confounders (adjusted odds ratio = 3.89; 95% CI 1.05-14.43). Similarly, the use of a non-steroidal anti-inflammatory drug (NSAID) was associated with a positive CTA (OR 2.36; 1.03-5.41). Only 8% of patients experienced contrast-induced nephropathy. CONCLUSION Use of either NOACs or NSAIDs in the previous week is independently associated with a positive CTA in the setting of acute lower GI bleeding. CTA exams appear to confer a low risk of contrast-induced nephropathy.
Collapse
Affiliation(s)
- Muhammad A Shafqet
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Alexander Tonthat
- School of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Paola Esparragoza
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Butros Toro
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Frank K Friedenberg
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| |
Collapse
|
|
5
|
Lenti MV, Pasina L, Cococcia S, Cortesi L, Miceli E, Caccia Dominioni C, Pisati M, Mengoli C, Perticone F, Nobili A, Di Sabatino A, Corazza GR. Mortality rate and risk factors for gastrointestinal bleeding in elderly patients. Eur J Intern Med 2019; 61:54-61. [PMID: 30522789 DOI: 10.1016/j.ejim.2018.11.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is burdened by high mortality rate that increases with aging. Elderly patients may be exposed to multiple risk factors for GIB. We aimed at defining the impact of GIB in elderly patients. METHODS Since 2008, samples of elderly patients (age ≥ 65 years) with multimorbidity admitted to 101 internal medicine wards across Italy have been prospectively enrolled and followed-up (REPOSI registry). Diagnoses of GIB, length of stay (LOS), mortality rate, and possible risk factors, including drugs, index of comorbidity (Cumulative Illness Rating Scale [CIRS]), polypharmacy, and chronic diseases were assessed. Adjusted multivariate logistic regression models were computed. RESULTS 3872 patients were included (mean age 79 ± 7.5 years, F:M ratio 1.1:1). GIB was reported in 120 patients (mean age 79.6 ± 7.3 years, F:M 0.9:1), with a crude prevalence of 3.1%. Upper GIB occurred in 72 patients (mean age 79.3 ± 7.6 years, F:M 0.8:1), lower GIB in 51 patients (mean age 79.4 ± 7.1 years, F:M 0.9:1), and both upper/lower GIB in 3 patients. Hemorrhagic gastritis/duodenitis and colonic diverticular disease were the most common causes. The LOS of patients with GIB was 11.7 ± 8.1 days, with a 3.3% in-hospital and a 9.4% 3-month mortality rates. Liver cirrhosis (OR 5.64; CI 2.51-12.65), non-ASA antiplatelet agents (OR 2.70; CI 1.23-5.90), and CIRS index of comorbidity >3 (OR 2.41; CI 1.16-4.98) were associated with GIB (p < 0.05). CONCLUSIONS A high index of comorbidity is associated with high odds of GIB in elderly patients. The use of non-ASA antiplatelet agents should be discussed in patients with multimorbidity.
Collapse
Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Sara Cococcia
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Laura Cortesi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Emanuela Miceli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Costanza Caccia Dominioni
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Martina Pisati
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Caterina Mengoli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | | | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Gino Roberto Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
|
6
|
Sampaio-Filho H, Bussadori SK, Gonçalves MLL, da Silva DDFT, Borsatto MC, Tortamano IP, Longo PL, Pavani C, Fernandes KPS, Mesquita-Ferrari RA, Horliana ACRT. Low-level laser treatment applied at auriculotherapy points to reduce postoperative pain in third molar surgery: A randomized, controlled, single-blinded study. PLoS One 2018; 13:e0197989. [PMID: 29920521 PMCID: PMC6007895 DOI: 10.1371/journal.pone.0197989] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Evaluate the effectiveness of LLL (Low level laser therapy) in auriculotherapy points for pain reduction following lower third molar extractions. STUDY DESIGN Randomized, controlled, single-blinded study. METHODS Eighty-four bilateral, symmetrical third molar surgeries were performed in 42 healthy patients using a split-mouth design. In the immediate postoperative period, each side was randomly treated in a single-blind method with an LLL at the auriculotherapy points or simulation of its use (contralateral side) over a 21-day interval. This protocol was repeated 24 and 48 hours after surgery. All patients used the same analgesic (paracetamol) but only in case of pain. The primary variable was postoperative pain according to the visual analogue scale, and the secondary variables were mouth opening, edema, local temperature, dysphagia, and the presence of infection (systemic temperature, lymphadenopathy). These variables were evaluated at baseline and at 24 hours, 48 hours and seven days after surgery. Adverse effects were recorded and reported. RESULTS There was no difference between the groups in relation to any of the evaluated parameters (p>0.05). CONCLUSION For this experimental model, application of a low-intensity laser at auriculotherapy points did not prevent postoperative pain following lower third molar surgery. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov; the registration number is NCT02657174 and the Unique Protocol ID number is 1.100.869. (https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View&listmode=Edit&uid=U0002BEY&ts=11&sid=S0006026&cx=6g4wff).
Collapse
Affiliation(s)
- Hélio Sampaio-Filho
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
| | - Sandra Kalil Bussadori
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
| | - Marcela Leticia Leal Gonçalves
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
| | | | | | | | | | - Christiane Pavani
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
| | | | - Raquel Agnelli Mesquita-Ferrari
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho, UNINOVE, São Paulo, SP, Brazil
| | | |
Collapse
|
|
7
|
Chi TY, Zhu HM, Zhang M. Risk factors associated with nonsteroidal anti-inflammatory drugs (NSAIDs)-induced gastrointestinal bleeding resulting on people over 60 years old in Beijing. Medicine (Baltimore) 2018; 97:e0665. [PMID: 29718891 PMCID: PMC6392961 DOI: 10.1097/md.0000000000010665] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Gastrointestinal (GI) bleeding is an unwanted side effect common to all chemical types of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in elderly people. However, the risk factors of GI bleeding associated with NSAIDs for elderly people remain unknown. This study aims to evaluate the risks of GI bleeding associated with NSAIDs in 4728 elderly people over 60 years old based on database from a hospital in Beijing.This retrospective hospital-based study included 4728 patients over 60 years old prescribed with NSAIDs, of which 928 patients had GI bleeding and 3800 did not have. Odds ratios (OR) for the risk of GI bleeding associated with NSAIDs were determined by logistic regression analysis. Mean Decrease Gini (MDG) involved in random forest algorithm was used to rank the associated factors with GI bleeding.In multivariate analysis, family history of GI bleeding (OR, 3.348; P = .000), history of peptic ulcers (OR, 4.068; P = .000), history of cardiovascular and cerebrovascular disease (OR, 1.476; P = .001), diabetes mellitus (OR, 1.408; P = .000), antiplatelet drugs (OR, 3.106; P = .000), Helicobacter pylori infection (OR, 1.312; P = .001), cholesterol level (OR, 0.516; P = .000), upper abdominal discomfort (OR, 3.467; P = .000), anorexia (OR, 2.038; P = .000), and NSAIDs used for 0.5 to 3 months (OR, 0.780; P = .000) were associated with GI bleeding. After ranked the MDG of each factor, the top 5 ranked factors associated with GI bleeding were melena, hematemesis, antiplatelet drugs, cholesterol level, and upper abdominal discomfort.We found that family history of GI bleeding, history of peptic ulcers, history of cardiovascular and cerebrovascular disease, diabetes mellitus, antiplatelet drugs, Helicobacter pylori infection, hypocholesterolemia, and NSAIDs used for 0.5 to 3 months were independent risk factors for GI bleeding on people over 60 years old. Meanwhile, upper abdominal discomfort might be the predictor of GI bleeding associated with NSAIDs elderly users.
Collapse
Affiliation(s)
- Tian-Yu Chi
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | | |
Collapse
|
|
8
|
Ng KS, Nassar N, Soares D, Stewart P, Gladman MA. Acute lower gastrointestinal haemorrhage: outcomes and risk factors for intervention in 949 emergency cases. Int J Colorectal Dis 2017; 32:1327-1335. [PMID: 28712008 DOI: 10.1007/s00384-017-2844-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Outcomes of acute lower gastrointestinal haemorrhage (ALGIH) are mostly derived from studies performed in the sub-acute/elective rather than the emergency department (ED) setting. The aims of this study were to determine the incidence and outcomes of patients presenting to a tertiary hospital ED with ALGIH and to identify associated clinicopathological risk factors. METHOD A retrospective observational cohort study of consecutive patients presenting with ALGIH to a tertiary hospital ED was performed. Primary outcome measures included mortality and hospital (including high dependency [HDU]) admission. Secondary outcome measures included rates of (i) blood transfusion, (ii) radiological/endoscopic investigation(s) and (iii) therapeutic intervention. RESULTS ALGIH accounted for 949 (512 M, mean age 62.3 years) of 130,262 (0.73%) ED presentations, of which 285 patients (30.1%) were on anti-platelet/coagulant therapy. There were five deaths (0.5%). Hospital admission was required in 498 patients (52.5%), of which 19 (3.8%) required HDU monitoring. Hospital admission was twice as likely in males and four times more likely in patients >75 years old and those taking multiple anti-platelet/coagulant therapy (P < 0.05). Blood product transfusion was required in 172 patients (34.5%), specialist investigations in 230 (46.2%) and therapeutic intervention in 51 (10.2%) (surgery in 24 [4.8%]; endoscopic haemostasis in 20 [4.0%] and angiographic embolisation in 9 [1.8%] patients). CONCLUSION ALGIH accounts for 1% of all ED presentations, with half requiring hospital admission. Mortality and surgical intervention rates are low and although most patients can be managed supportively, access to interventional radiology/endoscopy is important.
Collapse
Affiliation(s)
- Kheng-Seong Ng
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Deanne Soares
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Patrick Stewart
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Marc A Gladman
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia. .,Adelaide Medical School, Faculty of Health & Medical Sciences, The University of Adelaide, Medical School South, Frome Road, Adelaide, 5005, Australia.
| |
Collapse
|
|
9
|
Chung SJ, Park HJ, Park MC. Cost-effectiveness of Non-steroidal Anti-inflammatory Drugs Adjusting for Upper and Lower Gastrointestinal Toxicities in Rheumatoid Arthritis Patients. JOURNAL OF RHEUMATIC DISEASES 2017. [DOI: 10.4078/jrd.2017.24.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Soo-Jin Chung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye-Jin Park
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
|
10
|
Sugihara Y, Kudo SE, Miyachi H, Misawa M, Okoshi S, Okada H, Yamamoto K. Analysis of Risk Factors for Colonic Diverticular Bleeding: A Matched Case-Control Study. Gut Liver 2016; 10:244-9. [PMID: 26087793 PMCID: PMC4780454 DOI: 10.5009/gnl14407] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Diverticular bleeding can occasionally cause massive bleeding that requires urgent colonoscopy (CS) and treatment. The aim of this study was to identify significant risk factors for colonic diverticular hemorrhage. METHODS Between January 2009 and December 2012, 26,602 patients underwent CS at our institution. One hundred twenty-three patients underwent an urgent CS due to acute lower gastrointestinal hemorrhage. Seventy-two patients were diagnosed with colonic diverticular hemorrhage. One hundred forty-nine age- and sex-matched controls were selected from the patients with nonbleeding diverticula who underwent CS during the same period. The relationship of risk factors to diverticular bleeding was compared between the cases and controls. RESULTS Uni- and multivariate conditional logistic regression analyses demonstrated that the use of nonsteroidal anti-inflammatory drugs (odds ratio [OR], 14.70; 95% confidence interval [CI], 3.89 to 55.80; p<0.0001), as well as the presence of cerebrovascular disease (OR, 8.66; 95% CI, 2.33 to 32.10; p=0.00126), and hyperuricemia (OR, 15.5; 95% CI, 1.74 to 138.00; p=0.014) remained statistically significant predictors of diverticular bleeding. CONCLUSIONS Nonsteroidal anti-inflammatory drugs, cerebrovascular disease and hyperuricemia were significant risks for colonic diverticular hemorrhage. The knowledge obtained from this study may provide some insight into the diagnostic process for patients with lower gastrointestinal bleeding.
Collapse
Affiliation(s)
- Yuusaku Sugihara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.,Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shogo Okoshi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Kazuhide Yamamoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan
| |
Collapse
|
|
11
|
Harris CL, Raisch DW, Abhyankar U, Marfatia S, Campbell HM, Sather MR. GI Risk Factors and Use of GI Protective Agents Among Patients Receiving Nonsteroidal Antiinflammatory Drugs. Ann Pharmacother 2016; 40:1924-31. [PMID: 17047140 DOI: 10.1345/aph.1h183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Patient characteristics increase the risk of gastrointestinal (GI) complications associated with nonsteroidal antiinflammatory drugs (NSAIDs). Patients at risk may not be prescribed protective therapies that might mitigate their risk of NSAID-associated GI complications. Objective: To assess GI risk among Veterans Affairs (VA) patients on NSAID therapy, determine whether therapy conformed to VA guidelines for lessening the risk of GI complications, and identify patient risk factors associated with conformance. Methods: Using databases from 3 VA medical centers, we retrospectively identified patients receiving NSAIDs and obtained data regarding age, history of GI bleed over 8 years, GI adverse effects associated with NSAIDs, diagnoses, and medication history over one year. We inferred health status from age-adjusted Charlson comorbidity index values. Each patient's risk of developing GI complications over one year was calculated using these data. Among patients at significant or substantial risk, we assessed conformance to VA guidelines. We used logistic regression to identify risk factors associated with conformance and determine adjusted ORs (AORs) with 95% CIs for each risk factor. Results: There were 19122 patients receiving NSAIDs. Of 4589 patients at significant risk and 1246 at substantial risk, 1161 (25.3%) and 356 (28.6%), respectively, were prescribed guideline-conformant therapy. Risk factors associated with conformance (p s 0.001) among patients at significant risk were rheumatoid arthritis (AOR 1.34; 95% CI 1.13 to 1.58) and GI adverse effects (AOR 1.53; 95% CI 1.42 to 1.64). For substantial risk patients, risk factors associated with conformance (p s 0.031) were rheumatoid arthritis (AOR 1.65; 95% CI 1.37 to 1.98), concomitant corticosteroids (AOR 1.21; 95% CI 1.02 to 1.43), GI hospitalization (AOR 2.01; 95% CI 1.57 to 2.59), and GI adverse effects (AOR 1.79; 95% CI 1.47 to 2.18). Conclusions: Many patients at risk for GI adverse events do not receive guideline-conformant therapy. Educational interventions to improve conformance could focus on specific risk factors for GI complications.
Collapse
Affiliation(s)
- Crystal L Harris
- Pharmaceutical Management and Research, Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy, Albuquerque, NM 87106-4180, USA.
| | | | | | | | | | | |
Collapse
|
|
12
|
Sampaio-Filho H, Sotto-Ramos J, Pinto EH, Cabral MR, Longo PL, Tortamano IP, Marcos RL, Silva DFT, Pavani C, Horliana ACRT. Evaluation of low-level laser at auriculotherapy points to reduce postoperative pain in inferior third molar surgery: study protocol for a randomized controlled trial. Trials 2016; 17:432. [PMID: 27590454 PMCID: PMC5010672 DOI: 10.1186/s13063-016-1540-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 08/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background A comfortable postoperative return to daily activities has increased the need to control inflammation after third molar surgery. Anti-inflammatory drugs and analgesics are not exempt from adverse effects such as allergies and chronic gastritis, and they are not without cost. The association between low-level laser and auricular acupuncture can be an alternative when conventional drugs are contraindicated. Among its advantages, we can mention the low risk of side effects, low cost and simplicity of application. The objective of this study is to evaluate the efficiency of low-level laser at auriculotherapy points in reducing postoperative pain in lower third molar surgery. Methods/design Ninety bilateral, symmetrical lower third molar surgeries will be performed in 45 healthy patients. Each patient will be their own control, through a split-mouth crossover study. One side of the mouth will be randomly chosen and, immediately after surgery, will be treated with low-level laser. After 21 days, the contralateral side will be operated on with low-level laser simulation used postoperatively. This regimen (laser application or not) will be repeated at 24 and 48 h after surgery. All patients will be requested to take analgesics (acetaminophen) if they have pain, i.e. in case of pain. Neither the surgeon nor the patients will know the assigned treatment. The primary variable will be postoperative pain assessed using a Visual Analog Scale, and the secondary variables will be trismus, edema, local temperature, dysphagia, presence of infection and painkiller ingestion. These variables will be assessed at baseline, 24 h, 48 h and 7 days after surgery. Blood samples for systemic inflammatory cytokine (TNF-α, IL-1, IL-6 and IL-8) analysis will be assessed at baseline and 24 h after surgery. Discussion Some authors believe that using a wavelength of 633 to 670 nm is a good option for laser therapy in the field of acupuncture. This wavelength can penetrate biological tissue to a depth of about 3 mm. However, for auriculotherapy points, the stimulus (mustard seeds, needles 1 to 2.5 mm) does not penetrate so deeply. For this reason, we chose a laser wavelength of 660 nm (red wavelength). Trial registration ClinicalTrials.gov Identifier: NCT02657174, registered on 11 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1540-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Hélio Sampaio-Filho
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Juliane Sotto-Ramos
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Erika Horácio Pinto
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Marcia Regina Cabral
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Priscila Larcher Longo
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | | | - Rodrigo Labat Marcos
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Daniela Fátima Teixeira Silva
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Christine Pavani
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil
| | - Anna Carolina Ratto Tempestini Horliana
- Postgraduate program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho, UNINOVE, R. Vergueiro, 235/249, CEP 01504-001, São Paulo, Brazil.
| |
Collapse
|
|
13
|
Lorenzo D, Gallois C, Lahmek P, Lesgourgues B, Champion C, Charpignon C, Faroux R, Bour B, Remy AJ, Naouri C, Picon M, Poncin E, Macaigne G, Seyrig JA, Bernardini D, Bellaïche G, Grasset D, Henrion J, Heluwaert F, Piperaud R, Bordes G, Bourhis F, Arpurt JP, Pariente A, Nahon S. Middle-term mortality and re-bleeding after initial diverticular bleeding: A nationwide study of 365 mostly elderly French patients. United European Gastroenterol J 2016; 5:119-127. [PMID: 28405330 DOI: 10.1177/2050640616647816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS The aim of this study was to determine the mortality and re-bleeding rates, and the risk factors involved, in a cohort of patients with previous diverticular bleeding (DB). METHODS In 2007, data on 2462 patients with lower gastrointestinal (GI) bleeding were collected prospectively at several French hospitals. We studied the follow-up of patients with DB retrospectively. The following data were collected: age, mortality rates and re-bleeding rates, drug intake, surgery and comorbidities. RESULTS Data on 365 patients, including 181 women (mean age 83.6 ± 9.8 years) were available. The median follow-up time was 3.9 years (IQR 25-75: 1.7-5.4). Of these, 148 patients died (40.5%). Among the 70 patients (19.2%) who had at least one re-bleeding episode, nine died and three underwent surgical procedures. Anticoagulation and antiplatelet therapy was discontinued in 70 cases (19.2%). The independent risk factors contributing to mortality were age > 80 years (HR = 3.18 (2.1-4.9); p < 0.001) and a Charlson comorbidity score > 2 (1.91 (1.31-2.79); p = 0.003). Discontinuation of therapy was not significantly associated with a risk of death due to cardiovascular events. No risk factors responsible for re-bleeding were identified, such as antiplatelet and anticoagulant therapy in particular. CONCLUSIONS In this cohort, the rates of mortality and DB re-bleeding after a median follow-up time of 3.9 years were 19.2% and 40.5%, respectively. The majority of the deaths recorded were not due to re-bleeding.
Collapse
Affiliation(s)
- Diane Lorenzo
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Claire Gallois
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Pierre Lahmek
- Service d'addictologie. Hôpital Emile Roux AP-HP, Limeil-Brévannes, France
| | - Bruno Lesgourgues
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Christine Champion
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Claire Charpignon
- Service d'Hépato-Gastroentérologie. Centre Hospitalier Intercommunal Villeneuve Saint-Georges, Villeneuve Saint-Georgess, France
| | - Roger Faroux
- Service d'Hépato-Gastroentérologie. Centre hospitalier départemental de Vendée, La Roche-sur-Yon, France
| | - Bruno Bour
- Service d'Hépato-Gastroentérologie. Centre hospitalier-LeMans, Le Mans, France
| | - André-Jean Remy
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Perpignan, Perpignan, France
| | - Chantal Naouri
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Mâcon, Mâcon, France
| | - Magali Picon
- Service d'Hépato-Gastroentérologie. Centre hospitalier d'Aix-en-Provence, Aix-en-Provence, France
| | - Eric Poncin
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Dax, Dax, France
| | - Gilles Macaigne
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Marne La Vallée, Lagny-sur-Marne, France
| | - Jacques-Arnaud Seyrig
- Service d'Hépato-Gastroentérologie. Centre hospitalier du centre Bretagne, Pontivy, France
| | - David Bernardini
- Service d'Hépato-Gastroentérologie. Centre hospitalier intercommunal de Toulon, Toulon, France
| | - Guy Bellaïche
- Service d'Hépato-Gastroentérologie. Centre hospitalier intercommunal d'Aulnay-sous-Bois, Aulnay-sous-Bois, France
| | - Denis Grasset
- Service d'Hépato-Gastroentérologie. Centre hospitalier Bretagne Atlantique, Vannes, France
| | - Jean Henrion
- Service d'Hépato-Gastroentérologie. Hôpital de Jolimont, Haine-Saint-Paul, Belgium
| | - Frédéric Heluwaert
- Service d'Hépato-Gastroentérologie. Centre hospitalier Annecy Genevois, Annecy, France
| | - René Piperaud
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Laon, Laon, France
| | - Gilbert Bordes
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Digne les Bains, Dignes, France
| | - Francois Bourhis
- Service d'Hépato-Gastroentérologie. Hôpital d'Aix Les Bains et de Chambery, Chambery, France
| | - Jean-Pierre Arpurt
- Service d'Hépato-Gastroentérologie. Centre hospitalier d'Avignon, Avignon, France
| | - Alexandre Pariente
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Pau, Pau, France
| | - Stéphane Nahon
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | | |
Collapse
|
|
14
|
Hreinsson JP, Palsdóttir S, Bjornsson ES. The Association of Drugs With Severity and Specific Causes of Acute Lower Gastrointestinal Bleeding: A Prospective Study. J Clin Gastroenterol 2016; 50:408-13. [PMID: 26280706 DOI: 10.1097/mcg.0000000000000393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Studies on the association of acute lower gastrointestinal bleeding (ALGIB) and drugs are scarce. We aimed to investigate the association of drugs and ALGIB, especially regarding specific causes of ALGIB, and their role in the severity of ALGIB. MATERIALS AND METHODS The study was prospective and included all patients undergoing colonoscopy in 2010 and 2013 at the National University Hospital of Iceland. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin (LDA), and warfarin before ALGIB was registered. Clinically significant bleeding was defined as: hemoglobin <100 g/L, hemodynamic instability, blood transfusion, surgery, or death. RESULTS Overall, 2392 patients underwent 2751 colonoscopies, of those, 325 (14%) had ALGIB, mean age 64 years (±20). The commonest diagnoses were diverticulosis (22%) and ischemic colitis (14%). In multivariate analysis, NSAIDs, LDA, and warfarin use was associated with ALGIB, odds ratio (OR) 3.3 [95% confidence interval (95% CI), 1.99-5.82], OR 1.5 (95% CI, 1.01-2.13), and OR 2.7 (95% CI, 1.61-4.57), respectively. Clinically significant bleeders were more likely than nonclinically significant bleeders to use NSAIDs or LDA+warfarin, OR 2.3 (95% CI, 1.26-3.76) and OR 33.0 (95% CI, 6.74-595), respectively. Patients with diverticular bleeding had greater odds than controls of NSAID, LDA, and warfarin use, OR 8.3 (95% CI, 3.8-18.3), OR 2.1 (95% CI, 1.15-3.67), and OR 2.6 (95% CI, 1.24-5.56), respectively. Patients with ischemic colitis were more likely than controls to use LDA, OR 2.3 (95% CI, 1.14-4.45). CONCLUSIONS NSAIDs, LDA, and warfarin were associated with ALGIB and diverticular bleeding. These drugs may have a role in other etiologies of ALGIB and seem to increase the risk of clinically significant bleeding.
Collapse
Affiliation(s)
- Johann P Hreinsson
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, The National University Hospital of Iceland, Reykjavik, Iceland
| | | | | |
Collapse
|
|
15
|
Wong SH, Chan FKL. Adverse Effects of NSAIDs in the Gastrointestinal Tract: Risk Factors of Gastrointestinal Toxicity with NSAIDs. NSAIDS AND ASPIRIN 2016:45-59. [DOI: 10.1007/978-3-319-33889-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
|
|
16
|
Nagata N, Niikura R, Aoki T, Sakurai T, Moriyasu S, Shimbo T, Sekine K, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Effect of proton-pump inhibitors on the risk of lower gastrointestinal bleeding associated with NSAIDs, aspirin, clopidogrel, and warfarin. J Gastroenterol 2015; 50:1079-86. [PMID: 25700638 DOI: 10.1007/s00535-015-1055-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/10/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND We investigated the effects of proton-pump inhibitors (PPIs) on lower gastrointestinal bleeding (LGIB) and of their interactions with nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, clopidogrel, and warfarin on LGIB risk. METHODS We prospectively studied 355 patients emergently hospitalized for LGIB and 8,221 nonbleeding patients. All patients underwent colonoscopy. Smoking, alcohol drinking, drug exposure, and the Charlson comorbidity index score were assessed before colonoscopy. Adjusted odds ratios (AOR) of LGIB were estimated. RESULTS LGIB was significantly associated with older age, higher comorbidity index, and NSAID, aspirin, clopidogrel, or warfarin use. PPI use was significantly associated with older age, male sex, being a current alcohol drinker, higher comorbidity index, and NSAID, aspirin, clopidogrel, warfarin, acetaminophen, or corticosteroid use. Multivariate analysis adjusted by the confounding factors revealed LGIB was not significantly associated with PPI use (AOR 0.87; 95 % confidence interval 0.68-1.13; p = 0.311), or specifically with omeprazole (AOR 1.18; p = 0.408), esomeprazole (AOR 0.76; p = 0.432), lansoprazole (AOR 0.93; p = 0.669), or rabeprazole (AOR 0.63; p = 0.140). In the interaction model, no significant interactions were observed between PPIs and NSAIDs (AOR 1.40; p = 0.293), aspirin (AOR 1.09; p = 0.767), clopidogrel (AOR 0.99, p = 0.985), or warfarin (AOR 1.52; p = 0.398). CONCLUSIONS This large case-control study demonstrated that PPI use did not lead to an increased risk of LGIB, regardless of the type of PPI used. Further, LGIB risk was not affected by PPI use, irrespective of concomitant therapy with NSAIDs, low-dose aspirin, clopidogrel, or warfarin.
Collapse
Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Ryota Niikura
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Tomonori Aoki
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Takuro Shimbo
- Department of Clinical Research and Informatics, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| |
Collapse
|
|
17
|
Aoki T, Nagata N, Niikura R, Shimbo T, Tanaka S, Sekine K, Kishida Y, Watanabe K, Sakurai T, Yokoi C, Akiyama J, Yanase M, Mizokami M, Uemura N. Recurrence and mortality among patients hospitalized for acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2015; 13:488-494.e1. [PMID: 24997327 DOI: 10.1016/j.cgh.2014.06.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/24/2014] [Accepted: 06/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The long-term recurrence of lower gastrointestinal bleeding (LGIB) and associated mortality have not been studied extensively. We investigated rates of recurrence of LGIB, mortality, and associated risk factors. METHODS In a retrospective study, we analyzed data from 342 patients hospitalized for overt LGIB at the National Center for Global Health and Medicine in Japan from December 2004 through June 2013. All patients underwent colonoscopy. We assessed Charlson comorbidity index scores and the use of nonsteroidal anti-inflammatory drugs, low-dose aspirin, other antiplatelet drugs, or warfarin. Rebleeding, the total number of rebleeding episodes, and mortality were measured. The Cox proportional hazards model was used to estimate hazard ratios (HRs). RESULTS Rebleeding occurred in 84 patients, at a mean follow-up time of 19 months. The cumulative percentages of patients with rebleeding at 1 and 5 years were 19% and 46%, respectively. During the follow-up period, 29 patients (39%) had secondary rebleeding and 18 patients (62%) had subsequent rebleeding. Multivariate analysis showed age 65 years and older (HR, 1.7; P = .04) and the use of nonsteroidal anti-inflammatory drugs (HR, 2.0; P < .01) and nonaspirin antiplatelet drugs (HR, 1.8; P < .05) as independent risk factors for rebleeding. Dual therapy had a higher risk than single therapy (adjusted HR, 1.8; P < .05). During the mean follow-up period of 28 months, 21 patients died (2 from bleeding). Cumulative mortality rates at 1 and 5 years were 4.2% and 13%, respectively. Mortality was associated significantly with age ≥65 years (P < .05), Charlson comorbidity index score, and warfarin use. CONCLUSIONS Based on a retrospective analysis of patients with LGIB, 46% of all patients have rebleeding, and the overall mortality rate is 13% within 5 years after hospitalization. Besides age ≥65 years, use of antithrombotic drugs increases the risk of bleeding recurrence and mortality among patients with LGIB.
Collapse
Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Ryota Niikura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takuro Shimbo
- Department of Clinical Research and Informatics, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shohei Tanaka
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshihiro Kishida
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masashi Mizokami
- The Research Center for Hepatitis and Immunology, Kohnodai Hospital, National Center for Global Health and Medicine, Kohnodai, Chiba, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Kohnodai, Chiba, Japan
| |
Collapse
|
|
18
|
Abstract
PURPOSE OF REVIEW Diverticular disease is the most commonly reported finding at the time of colonoscopy and one of the most common gastrointestinal indications for hospitalization. Much of our previous understanding of diverticular disease has recently been challenged. RECENT FINDINGS There is emerging evidence that the long-accepted hypothesis of diverticulosis as a consequence of fiber deficiency may be more complex than commonly thought, with recent evidence suggesting that high-fiber diet and frequent bowel movements are associated with a greater and not lower prevalence of diverticular disease. There is also emerging support for the concept of low-grade inflammation in symptomatic uncomplicated diverticular disease (SUDD), and the role of anti-inflammatory treatment with mesalamine is being actively investigated. Additionally, elective 'prophylactic' surgery after diverticulitis, previously considered after a second confirmed diverticulitis episode, is being increasingly deferred. SUMMARY The pathogenesis of diverticular disease is likely multifactorial and complex. More studies are needed to evaluate the role of fiber in the pathogenesis and treatment of diverticular disease. The search for an effective medical therapy for SUDD and to prevent recurrent diverticulitis is being actively investigated. The efficacy of mesalamine does not appear to be strong data supported.
Collapse
|
|
19
|
Hreinsson JP, Bjarnason I, Bjornsson ES. The outcome and role of drugs in patients with unexplained gastrointestinal bleeding. Scand J Gastroenterol 2015; 50:1482-9. [PMID: 26087014 DOI: 10.3109/00365521.2015.1057861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Studies on unexplained gastrointestinal bleeding (GIB) are lacking. We aimed to study the clinical outcomes of patients with unexplained GIB and to determine the incidence of obscure GIB. MATERIAL AND METHODS A population-based study on all patients undergoing endoscopy at the National University Hospital of Iceland in 2010. Indications, results of endoscopies and drug history were prospectively registered with a follow-up of 3 years. A national pharmaceutical database containing prescription data was utilized. Patients were categorized into unexplained overt and occult GIB and obscure GIB. Patients undergoing endoscopy and without GIB acted as controls. RESULTS Of 2471 patients undergoing endoscopy, 11% had unexplained GIB. Of those, 46% had unexplained overt GIB, 44% had unexplained occult GIB and 11% had obscure GIB. Multivariate analysis showed that patients with unexplained GIB and unexplained overt GIB had greater odds of NSAID use than controls, OR 1.8 (CI 1.03-3.03) and OR 2.0 (CI 1.01-3.77), respectively. Warfarin was strongly associated with all bleeder groups, OR 4-4.8. The incidence of obscure GIB was 10/100,000 inhabitants annually. Two (0.8%) patients were diagnosed with colon cancer 16 and 30 months after the index colonoscopy. Of patients with unexplained overt, unexplained occult GIB and controls, 5%, 6% and 3.5% (NS) had another overt bleeding episode, during the study period. CONCLUSIONS NSAIDs and warfarin seem to play an important role in unexplained GIB. The incidence of obscure GIB is low and missed cancers are very rare. The probability of a repeat bleeding episode is similar to that of controls.
Collapse
Affiliation(s)
- Johann P Hreinsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital , Reykjavik , Iceland
| | | | | |
Collapse
|
|
20
|
Nagata N, Niikura R, Aoki T, Shimbo T, Kishida Y, Sekine K, Tanaka S, Okubo H, Watanabe K, Sakurai T, Yokoi C, Akiyama J, Yanase M, Mizokami M, Uemura N. Lower GI bleeding risk of nonsteroidal anti-inflammatory drugs and antiplatelet drug use alone and the effect of combined therapy. Gastrointest Endosc 2014; 80:1124-31. [PMID: 25088922 DOI: 10.1016/j.gie.2014.06.039] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/24/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND The effect of a combined antithrombotic drug regimen on lower GI bleeding (LGIB) remains unknown. OBJECTIVE To investigate the risk of LGIB associated with nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, thienopyridine (ticlopidine or clopidogrel), or other antiplatelets used. DESIGN Prospective study. SETTING Emergency hospital, gastroenterology department. PATIENTS A cohort of 319 patients emergently hospitalized for acute, continuous, or frequent LGIB and 3358 patients with no bleeding on colonoscopy. MAIN OUTCOME MEASUREMENTS Odds ratios (ORs) for the risk of LGIB associated with drug exposure adjusting for age, sex, smoking, alcohol, medications, comorbidities, and GI symptom scores. RESULTS After considering antithrombotic drugs by dividing them into single- and combined-use, single use of nonselective NSAID or cyclooxygenase-2 inhibitor was independently associated with LGIB. The combined use of NSAIDs with low-dose aspirin (OR 4.3) or with other antiplatelets (OR 4.9) was more associated with LGIB than the use of NSAIDs alone (OR 2.3). Use of low-dose aspirin, thienopyridine, or other antiplatelets alone was not significantly associated with LGIB, but combined use of low-dose aspirin with thienopyridine (OR 2.2) or with other antiplatelets (OR 3.6) was associated with LGIB. Combined use of different NSAIDs carried a higher risk than single use (combined use, OR 4.9; single use, OR 2.3). LIMITATIONS Single-center study. CONCLUSION The use of nonselective or selective NSAIDs alone was associated with LGIB. Although antiplatelet use alone was not significantly associated with LGIB, combined use of NSAIDs with antiplatelets or of low-dose aspirin with thienopyridine or with nonthienopyridine antiplatelets was independently associated with LGIB.
Collapse
Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Niikura
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tomonori Aoki
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takuro Shimbo
- Department of Clinical Research and Informatics, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshihiro Kishida
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shohei Tanaka
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masashi Mizokami
- Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| |
Collapse
|
|
21
|
Nonsteroidal anti-inflammatory and antiplatelet drugs and risk of GI bleeding: don't forget the colon. Gastrointest Endosc 2014; 80:1132-4. [PMID: 25434661 DOI: 10.1016/j.gie.2014.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/28/2014] [Indexed: 12/11/2022]
|
|
22
|
Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis. J Gastroenterol 2014; 49:992-1000. [PMID: 24221694 DOI: 10.1007/s00535-013-0905-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 10/20/2013] [Indexed: 02/07/2023]
Abstract
Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.
Collapse
|
|
23
|
Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis 2014; 16:O189-96. [PMID: 24320820 DOI: 10.1111/codi.12516] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 02/08/2023]
Abstract
AIM Complications of colonic diverticula, perforation and bleeding are a source of morbidity and mortality. A variety of drugs have been implicated in these complications. We present a systemic review and meta-analysis of the literature to assess the importance of this relationship. METHOD A systematic review of articles in PubMed, Cochrane Reviews, Embase and Google Scholar was undertaken in February 2013. An initial literature search yielded 2916 results that were assessed for study design and topicality. Twenty-three articles were included in the review. A qualitative data synthesis was conducted using forest plots of studies comparing single medication with complications. RESULTS Individual studies demonstrated the odds of perforation and abscess formation with nonsteridal anti-inflammatory drugs (NSAIDs) (1.46-10.30), aspirin (0.66-2.40), steroids (2.17-31.90) and opioids (1.80-4.51) and the odds of bleeding with NSAIDs (2.01-12.60), paracetamol (0-3.75), aspirin (1.14-3.70) and steroids (0.57-5.40). Pooled data showed significantly increased odds of perforation and abscess formation with NSAIDs (OR = 2.49), steroids (OR = 9.08) and opioids (OR = 2.52). They also showed increased odds of diverticular bleeding from NSAIDs (OR = 2.69), aspirin (OR = 3.24) and calcium-channel blockers (OR = 2.50). Most studies did not describe the duration or dosage of medication used and did not systematically describe the severity of diverticular complications. CONCLUSION Various common medications are implicated in complications of diverticular disease.
Collapse
Affiliation(s)
- C L Kvasnovsky
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | | | | |
Collapse
|
|
24
|
Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage. Arthritis Res Ther 2013; 15 Suppl 3:S3. [PMID: 24267289 PMCID: PMC3890944 DOI: 10.1186/ar4175] [Citation(s) in RCA: 238] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
NSAIDs are among the most commonly used drugs worldwide and their beneficial therapeutic properties are thoroughly accepted. However, they are also associated with gastrointestinal (GI) adverse events. NSAIDs can damage the whole GI tract including a wide spectrum of lesions. About 1 to 2% of NSAID users experienced a serious GI complication during treatment. The relative risk of upper GI complications among NSAID users depends on the presence of different risk factors, including older age (>65 years), history of complicated peptic ulcer, and concomitant aspirin or anticoagulant use, in addition to the type and dose of NSAID. Some authors recently reported a decreasing trend in hospitalizations due to upper GI complications and a significant increase in those from the lower GI tract, causing the rates of these two types of GI complications to converge. NSAID-induced enteropathy has gained much attention in the last few years and an increasing number of reports have been published on this issue. Current evidence suggests that NSAIDs increase the risk of lower GI bleeding and perforation to a similar extent as that seen in the upper GI tract. Selective cyclooxygenase-2 inhibitors have the same beneficial effects as nonselective NSAIDs but with less GI toxicity in the upper GI tract and probably in the lower GI tract. Overall, mortality due to these complications has also decreased, but the in-hospital case fatality for upper and lower GI complication events has remained constant despite the new therapeutic and prevention strategies.
Collapse
Affiliation(s)
- Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
| | - Carla J Gargallo
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
- CIBERehd, c/Córcega 180 bajos dcha, 08036 Barcelona, Spain
- University of Zaragoza, c/Pedro Cerbuna s/n, 50009 Zaragoza, Spain
| |
Collapse
|
|
25
|
Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48:439-47. [PMID: 23356751 PMCID: PMC3613943 DOI: 10.3109/00365521.2012.763174] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The authors aimed to investigate the incidence and outcomes of acute upper gastrointestinal bleeding (AUGIB) and to examine the role of drugs potentially associated with AUGIB. METHODS The study was prospective, population-based and consisted of all patients who underwent upper gastrointestinal endoscopy (UGE), during the year of 2010 at the National University Hospital of Iceland. Drug intake of NSAIDs, low-dose aspirin (LDA), warfarin, SSRIs and bisphosphonates prior to GIB was prospectively registered and also checked in a Pharmaceutical Database covering all prescriptions in Iceland. An age- and gender-matched control group consisted of patients who underwent UGE during the study period and were without GIB. RESULTS A total of 1731 patients underwent 2058 UGEs. Overall, 156 patients had AUGIB. The crude incidence for AUGIB was 87/100,000 inhabitants per year. The most common etiologies were duodenal (21%) and gastric ulcers (15%). Use of LDA (40% vs. 30%), NSAIDs (20% vs. 8%), warfarin (15% vs. 7%), combination of NSAIDs + LDA (8% vs. 1%) and SSRIs + LDA (8% vs. 3%) were significantly more common among bleeders than non-bleeders. Three patients (1.9%) had emergency surgery and two patients died of AUGIB. Independent predictors of clinically significant bleeding were gastric ulcer (OR 6.6, p = 0.012) and NSAIDs (OR 6.6, p = 0.004). CONCLUSIONS LDA, NSAIDs and warfarin play an important role in AUGIB etiology and particularly combinations of drugs. Gastric ulcer and NSAIDs were independent predictors of severe bleeding. Mortality and the need for surgery during hospitalization was low in this population-based setting.
Collapse
Affiliation(s)
- Jóhann P. Hreinsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
| | | | | | - Einar S. Björnsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
| |
Collapse
|
|
26
|
Mandegaran R, Conway C, Elton C. Lower gastrointestinal adverse effects of NSAIDS: an extreme example of a common problem. BMJ Case Rep 2013; 2013:bcr-2012-008274. [PMID: 23429022 DOI: 10.1136/bcr-2012-008274] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed throughout the world. Their adverse effects on the upper gastrointestinal (GI) tract are well documented and well known among clinicians and often mitigated against by coprescribing proton pump inhibitors. This case exemplifies the lesser-known lower GI adverse effects of NSAIDS. A 55-year-old patient took a large mixed overdose including more than 11 g of diclofenac. He went onto require subtotal colectomy following widespread perforations of an ulcerated large bowel as a direct result of exposure to a high-dose of NSAIDs. However, the upper GI tract remained relatively unaffected in comparison. This case highlights important lessons from recent literature identifying an increasing incidence of lower GI complications of NSAIDS, the limited protective effect of PPIs on the lower GI tract and the need for clinicians to now consider the integrity of the whole GI tract when prescribing NSAIDS.
Collapse
Affiliation(s)
- Ramin Mandegaran
- Department of Nuclear Medicine, Royal Free Hospital NHS Foundation Trust, London, UK.
| | | | | |
Collapse
|
|
27
|
Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013; 25:37-43. [PMID: 23013623 DOI: 10.1097/meg.0b013e32835948e3] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To investigate the incidence and outcomes of acute lower gastrointestinal bleeding (ALGIB) in a population-based setting and examine the role of drugs potentially associated with GIB. METHODS The study was prospective and population based. The cohort included all patients who underwent colonoscopy during the year 2010 at the National University Hospital of Iceland. Indications for endoscopies and drug history were recorded in a systematic manner. The inclusion criteria were overt bleeding leading to hospitalization or occurring in hospitalized patients. The use of NSAIDs, low-dose aspirin, warfarin, selective serotonin receptor inhibitors, and bisphosphonates before GIB was also checked in a Pharmaceutical Database covering all drug prescriptions in the country. A control group included patients who underwent colonoscopy during the study period and did not have GIB. RESULTS Altogether, 1134 patients underwent 1275 colonoscopies. Overall, 163 patients had ALGIB. The crude incidence for ALGIB was 87/100 000 inhabitants/year. The most common findings were diverticulosis (23%) and ischemic colitis (16%). A total of 7.4% of individuals had endoscopic therapy and none had undergone surgery. Two (1.2%) patients died because of ALGIB, both with severe comorbidities. Overall, 19% with ALGIB were on NSAIDs versus 9% in nonbleeders (P=0.0096); 37% with ALGIB were on low-dose aspirin versus 25% in nonbleeders (P=0.0222). CONCLUSION The incidence for ALGIB is the highest reported to date. The most common reasons for ALGIB were diverticulosis and ischemic colitis. Mortality during hospitalization was very low. NSAIDs and low-dose aspirin seem to increase the risk for ALGIB.
Collapse
|
|
28
|
Sostres C, Gargallo CJ. Gastrointestinal lesions and complications of low-dose aspirin in the gastrointestinal tract. Best Pract Res Clin Gastroenterol 2012; 26:141-51. [PMID: 22542152 DOI: 10.1016/j.bpg.2012.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/20/2012] [Accepted: 01/24/2012] [Indexed: 01/31/2023]
Abstract
Low dose aspirin (ASA) use has been associated with a wide range of adverse side effects in the upper gastrointestinal (GI) tract, which range from troublesome symptoms without mucosal lesions to more serious toxicity, including ulcers, GI bleeding, perforation and even death. Upper GI symptoms in low dose ASA users are common but often careless or misinterpreted and they are not always related to the presence of mucosal injury. Usually, low dose ASA related ulcers are reasonably small and asymptomatic, and probably heal over a period of weeks to a few months. But, the real clinical problem occurs when the ulcer results in a GI complication (mostly bleeding). The estimated average excess risk of symptomatic or complicated ulcer related to low dose ASA is five cases per 1000 ASA users per year. Death is the worst outcome of GI complications in low dose ASA users, but data about this aspect are scarce. Current evidence indicates that low dose ASA can damage the lower GI tract also, but the real size of the problem is still unknown.
Collapse
Affiliation(s)
- Carlos Sostres
- Service of Digestive Diseases, University Hospital Lozano Blesa, Zaragoza, Spain.
| | | |
Collapse
|
|
29
|
The APC and PreSAP Trials: A Post Hoc Noninferiority Analysis Using a Comprehensive New Measure for Gastrointestinal Tract Injury in 2 Randomized, Double-Blind Studies Comparing Celecoxib and Placebo. Clin Ther 2012; 34:569-79. [DOI: 10.1016/j.clinthera.2012.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2012] [Indexed: 11/18/2022]
|
|
30
|
Abstract
The aging of the population is associated with the increased risk of chronic diseases, and greater consumption of drugs used in their treatment, which may lead towards gastrointestinal bleeding.The aim of the study was to analyze the reasons, treatment results, complications and mortality connected with gastrointestinal bleeding in patients aged 85 years and older.Material and methods. The study comprised the retrospective analysis of 84 patients, aged between 85 and 97 years admitted to the Department of General Surgery with diagnosis of gastrointestinal bleeding, during the period between 2005 and 2010. The results were compared to a younger control group of 151 patients (mean age-53 years) with gastrointestinal bleeding, admitted to the department during the same period. Diagnosis was based on the history, physical examination, endoscopy, morphology and biochemical lab results. Analysis considered the therapeutic method used, treatment results, complications and hospital mortality. The endoscopic picture and risk of recurrent bleeding in patients with upper gastrointestinal hemorrhage was evaluated by means of the clinical Forrest scale. Results were subject to statistical analysis.Results. Most of the gastrointestinal bleeding cases considering patients aged 85 years and older concerned the upper gastrointestinal tract (41.67%). Thirty (35.71%) patients were on drugs affecting the coagulation system. On admission, the average hemoglobin concentration level in the elderly was comparable to results observed in case of the control group. Considering patients aged 85+, drugs affecting the coagulation system were used statistically more frequently, as compared to younger patients. Recurrence of bleeding was observed in 10 (11.9%) study group patients.Overall mortality due to gastrointestinal bleeding in elderly patients amounted to 20.24% and was statistically higher, as compared to the control group- 7.2%.Conclusions. Treatment results in case of gastrointestinal bleeding in the elderly patients (above 85 years) are burdened with a higher mortality rate. Different diagnostic and therapeutic methods should be applied in case of elderly patients (above 85 years), in order to increase their chance of survival. The problem of aging is an epidemiological phenomenon and gastrointestinal bleeding will become an increasing problem, needing to be solved in everyday clinical practice.
Collapse
|
|
31
|
Pitchumoni CS, Pitchumoni CS, Pitchumoni CS. Diverticular Disease. GERIATRIC GASTROENTEROLOGY 2012:511-517. [DOI: 10.1007/978-1-4419-1623-5_53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
32
|
Hypertension and concomitant arteriosclerotic diseases are risk factors for colonic diverticular bleeding: a case-control study. Int J Colorectal Dis 2012; 27:1137-43. [PMID: 22354135 PMCID: PMC3430839 DOI: 10.1007/s00384-012-1422-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Colonic diverticular bleeding is a major cause of lower gastrointestinal bleeding. However, a limited number of studies have been reported on the risk factors for diverticular bleeding. Our aim was to identify risk factors for diverticular bleeding. METHODS Our study design is a case (diverticular bleeding)-control (diverticulosis) study. We prospectively collected information of habits, comorbidities, history of medications and symptoms by a questionnaire, and diagnosed diverticular bleeding and diverticulosis by colonoscopy. Logistic regression models were used to estimate odds ratio (OR) and 95% confidence interval (CI). RESULTS A total of 254 patients (diverticular bleeding, 45; diverculosis, 209) were selected for analysis. Cluster (≥10 diverticula) type (OR, 4.0; 95% CI, 1.8-8.9), hypertension (OR, 2.2; 95% CI, 1.0-4.6), ischemic heart disease (OR, 2.4; 95% CI, 1.1-5.4), and chronic renal failure (OR, 6.4; 95% CI, 1.3-32) were independent risk factors for diverticular bleeding. CONCLUSIONS Large number of diverticula, hypertension, and concomitant arteriosclerotic diseases including ischemic heart disease and chronic renal failure are risk factors for diverticular bleeding. This study identifies new information on the risk factors for diverticular bleeding.
Collapse
|
|
33
|
Suh S, Seo PJ, Park H, Shin CM, Jo HJ, Kim HY, Lee SH, Park YS, Hwang JH, Kim JW, Jeong SH, Kim N, Lee DH, Song IS, Jung HC. The Risk Factors for Colonic Diverticular Bleeding. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 60:349-54. [DOI: 10.4166/kjg.2012.60.6.349] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Seungchul Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Pyoung Ju Seo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyunkyung Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyun Jin Jo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyun Young Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Jin Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Sook Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - In Sung Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
|
34
|
Shibuya T, Ohkusa T, Yokoyama T, Matsumoto K, Beppu K, Sakamoto N, Osada T, Nagahara A, Otaka M, Ogihara T, Watanabe S. Colonic mucosal lesions associated with low-dose aspirin: a case control study. Scand J Gastroenterol 2011; 46:810-7. [PMID: 21506629 DOI: 10.3109/00365521.2011.574733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Low-dose aspirin (LDA) is widely used because it reduces the risk of vascular events in patients with atherosclerosis. Recently, there has been a substantial increase in prescriptions for LDA. We analyzed the risk of colonic mucosal lesions associated with the long-term use of LDA. MATERIAL AND METHODS Among Japanese patients who underwent a colonoscopy between January 2004 and December 2006, 199 colitis cases and 5764 non-colitis controls were identified after excluding 749 patients based on study criteria. The history of LDA use was compared between the cases and controls and the multivariate (age-, sex- and underlying diseases-) adjusted odds ratio (OR) was estimated using a multiple logistic regression model. RESULTS The adjusted OR for colonic mucosal lesions associated with LDA use versus non-use was 1.45 [95% confidence interval (CI), 0.87-2.42; p = 0.152]. In terms of gender differences, the OR for LDA-induced colitis in females was significantly increased at 2.55 (95% CI, 1.31-4.94; p = 0.006) but was not significantly increased in males at 0.70 (95% CI, 0.34-1.45; p = 0.334). CONCLUSIONS In females, LDA increased the risk of colonic mucosal lesions, suggesting that LDA may contribute to the pathogenesis of colonic ulceration or colitis. Therefore, it is essential that prescribing physicians be aware of the risk of LDA-induced colonic lesions.
Collapse
Affiliation(s)
- Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
35
|
Tsuruoka N, Iwakiri R, Hara M, Shirahama N, Sakata Y, Miyahara K, Eguchi Y, Shimoda R, Ogata S, Tsunada S, Sakata H, Fujimoto K. NSAIDs are a significant risk factor for colonic diverticular hemorrhage in elder patients: evaluation by a case-control study. J Gastroenterol Hepatol 2011; 26:1047-52. [PMID: 21198829 DOI: 10.1111/j.1440-1746.2010.06610.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Diverticular bleeding is a common cause of lower gastrointestinal hemorrhage. Several factors, including use of non-steroidal anti-inflammatory drugs (NSAIDs), antithrombotic agents and arteriosclerosis, could be risk factors. The aim of this study is to identify these risk factors. METHODS Between January 2000 and December 2008, 51 patients among 178 acute lower gastrointestinal hemorrhages who visited Saga Medical School were diagnosed as colonic diverticular hemorrhage, established by emergency endoscopy and diagnostic criteria. Gender and age matched control cases were selected from patients of other diseases hospitalized during the same period. We evaluated by using logistic regression analysis the influences of comorbidities such as cerebrovascular disease, ischemic heart disease, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, and osteoporosis, medications including NSAIDs and antithrombotic agents, and habits of smoking, alcohol, and chronic constipation. RESULTS Fifty one patients out of 178 acute lower gastrointestinal bleeding (28.7%) were diagnosed as diverticular hemorrhage, which was the most common cause of lower gastrointestinal hemorrhage. Sex ratio of men versus women for colonic diverticular hemorrhage was 35:16. NSAIDs were a significant risk factor for colonic diverticular hemorrhage in elder patients (odds ratio [OR] = 7.492, 95% CI: 1.516-37.024, P = 0.0135). Hypertension and hyperlipidemia had significant association with diverticular hemorrhage among patients younger than 65 years old. This study also indicated that use of NSAIDs was a risk factor for re-bleeding (OR = 5.4, 95% CI: 1.01-28.78, P = 0.048). CONCLUSION This case-control study revealed that the use of NSAIDs was a significant risk factor for colonic diverticular hemorrhage in elder patients. In addition, use of NSAIDs is a risk factor for re-bleeding from colonic diverticula.
Collapse
Affiliation(s)
- Nanae Tsuruoka
- Department of Internal Medicine, Saga Medical School, Saga, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Ahsberg K, Höglund P, Kim WH, von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol 2010; 45:1404-15. [PMID: 20695720 DOI: 10.3109/00365521.2010.510567] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds. METHODS Retrospective review of 731 patients with peptic ulcer bleeds (PUBs), non-ulcer, non-variceal upper (NUUPGIBs) and lower GI bleeds (LGIBs) in 1984, 1994 and 2004 at Lund University Hospital, Sweden. Incidence and mortality rates, risk factors for fatal outcome and associations with different sites of GI bleeds were evaluated. RESULTS Between 1984 and 2004, incidence of PUBs decreased from 62.0 to 32.1 per 100,000 inhabitants (p<0.001). Incidence of NUUPGIBs (29.0-30.4 per 100,000) and LGIBs (45.5-43.2 per 100,000) was stable. The case-fatality rate ranged from 4-6% (p=0.65) for upper GI bleed to 1-8% (p=0.033) for LGIB. No drug impacted on fatal outcome. Aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity. CONCLUSION Increased use of drugs that promote bleeding has not impacted on incidence and fatal outcome of non-variceal GI bleeds, although the severity of bleeding has increased. Aspirin is more strongly associated with PUBs, while corticosteroids and SSRIs are associated with non-ulcer, non-variceal GI bleeds.
Collapse
Affiliation(s)
- Kristina Ahsberg
- Department of Surgery, Lund University Hospital, Lund University, Lund, Sweden.
| | | | | | | |
Collapse
|
|
37
|
Lee KK, Shah SM, Moser MA. Risk factors predictive of severe diverticular hemorrhage. Int J Surg 2010; 9:83-5. [PMID: 20937418 DOI: 10.1016/j.ijsu.2010.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 09/18/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diverticular disease is a common cause for lower gastrointestinal bleeding. Although the hemorrhage often resolves spontaneously, some patients will require massive transfusions and emergency surgery. In this study we report risk factors predictive of severe diverticular bleeds. METHODS We completed a retrospective analysis of 99 patients, admitted with lower gastrointestinal bleeding and colonoscopic evidence of diverticulosis and no other cause of the hemorrhage between January 1995 and December 2005. A database was generated and univariate and multivariate analyses were carried out. RESULTS Of the 99 patients, 23 patients were classified as having a severe bleed defined as having a systolic blood pressure below 90 mm Hg, requirement for more than 6 units of transfusion, or emergent surgery. Multiple logistic regression showed that the initial hemoglobin (p = 0.001), INR ≥ 1.5 (p = 0.003), initial diastolic blood pressure (p = 0.024), initial heart rate (p = 0.047), and blood pressure medications (p = 0.049) predicted severe diverticular hemorrhage. CONCLUSIONS The identified predictor variables are all quantifiable at the time of initial presentation, and these may help identify severe cases of diverticular bleeding requiring urgent management.
Collapse
Affiliation(s)
- Kathy K Lee
- Department of Surgery, University of Calgary, Tom Baker Cancer Center, Education Office TBCC110D, 1331 - 29 St. NW, Calgary, AB, Canada, T2N 4N2.
| | | | | |
Collapse
|
|
38
|
Vieth M, Görgens D, Langner C. [Pseudoneoplastic regeneration of the stomach. Histopathology and differential diagnosis]. DER PATHOLOGE 2010; 31:171-6. [PMID: 20336298 DOI: 10.1007/s00292-009-1266-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudoneoplastic regeneration has become an important differential diagnosis to gastric carcinoma. Increasing use of acetylsalicylic acid (ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) appears to be related to this entity. In recent years knowledge of pseudoneoplastic regeneration has continuously improved and the proportion of this designation among cases sent to our institute for second opinion decreased from more than 50% in 2000 to approximately 10% today. In diagnostically difficult cases the gastritis status may help: the majority of patients with gastric carcinoma show either active or treated Helicobacter gastritis, whereas individuals with pseudocarcinomatous regeneration often show chemical reactive gastritis (reactive gastropathy). Gastric ulcers should always be followed-up during the healing phase. A second opinion may confirm the differential diagnosis.
Collapse
Affiliation(s)
- M Vieth
- Institut für Pathologie, Klinikum Bayreuth, Preuschwitzerstr. 101, 95445 Bayreuth.
| | | | | |
Collapse
|
|
39
|
Chait MM. Lower gastrointestinal bleeding in the elderly. World J Gastrointest Endosc 2010; 2:147-54. [PMID: 21160742 PMCID: PMC2998909 DOI: 10.4253/wjge.v2.i5.147] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 04/09/2010] [Accepted: 04/16/2010] [Indexed: 02/06/2023] Open
Abstract
Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.
Collapse
Affiliation(s)
- Maxwell M Chait
- Maxwell M Chait, The Hartsdale Medical Group, 180 East Hartsdale Avenue, Hartsdale, New York, NY 10530, United States
| |
Collapse
|
|
40
|
Lanas A. A review of the gastrointestinal safety data--a gastroenterologist's perspective. Rheumatology (Oxford) 2010; 49 Suppl 2:ii3-10. [PMID: 20407138 PMCID: PMC2857792 DOI: 10.1093/rheumatology/keq058] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 01/29/2010] [Indexed: 12/19/2022] Open
Abstract
Although NSAIDs have a well-established place for certain indications in the management of OA and RA, they are associated with significant gastrointestinal (GI) toxicity. The risk of NSAID-related upper GI events, such as dyspepsia or peptic ulcer and complications such as perforation or bleeding, is well characterized. Non-selective NSAIDs increase the risk of peptic ulcer disease approximately 5-fold, and that of upper GI bleeding 4-fold, whereas selective cyclo-oxygenase-2 (COX) inhibitors are associated with a significantly lower GI toxicity than non-selective agents. There is evidence that, while the incidence of NSAID-related upper GI complications has decreased in recent years, that of lower GI complications is increasing. Observational studies and analyses from studies, primarily designed to investigate upper GI events, suggest that lower GI complications are relatively common in NSAID users and that COX-2 selective inhibitors are associated with a lower risk of these events. Such events have been poorly characterized, but are associated with significant mortality; indeed, they may have even more serious consequences than the better characterized upper GI events. There is thus a strong case for evaluating the impact of such complications in prospective outcome studies. To facilitate such studies a new endpoint, Clinically Significant Upper or Lower GI Events, has been introduced that captures both upper and lower GI events.
Collapse
Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, c/ San Juan Bosco 15, 50009 Zaragoza, Spain.
| |
Collapse
|
|
41
|
Sostres C, Gargallo C, Lanas A. Drug-related damage of the ageing gastrointestinal tract. Best Pract Res Clin Gastroenterol 2009; 23:849-60. [PMID: 19942163 DOI: 10.1016/j.bpg.2009.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 10/01/2009] [Accepted: 10/05/2009] [Indexed: 01/31/2023]
Abstract
Drug use increases with age and the elderly is at increased risk of adverse drug reactions. Gastrointestinal adverse effects are one of the most often reported. Serious event are mostly caused by NSAIDs and/or aspirin which are the most widely prescribed medications in the world. NSAIDs and/or aspirin use are associated with complications from both the upper and the lower gastrointestinal tract. The risk of these complications depends on presence of risk factors, and age is the most frequent and relevant one. At-risk patients should be on prevention strategies including the use of the lowest effective dose, co-therapy with a gastroprotective agents or use of a COX-2 selective agent. Treatment of Helicobacter pylori infection is beneficial in patients starting therapy with these agents, especially in the presence of ulcer history. The best strategy to prevent lower GI complications has yet to be defined.
Collapse
Affiliation(s)
- Carlos Sostres
- Service of Digestive Diseases, University Hospital, Instituto Aragones de Ciencias de la Salud, CIBERehd, University of Zaragoza, Spain
| | | | | |
Collapse
|
|
42
|
Chan FKL, Cryer B, Goldstein JL, Lanas A, Peura DA, Scheiman JM, Simon LS, Singh G, Stillman MJ, Wilcox CM, Berger MF, Breazna A, Dodge W. A novel composite endpoint to evaluate the gastrointestinal (GI) effects of nonsteroidal antiinflammatory drugs through the entire GI tract. J Rheumatol 2009; 37:167-74. [PMID: 19884267 DOI: 10.3899/jrheum.090168] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Nonsteroidal antiinflammatory drugs (NSAID) not only cause damage to the upper gastrointestinal (GI) tract but also affect the lower GI tract. To date, there is no endpoint that evaluates serious GI events in the entire GI tract. The objective of this report is to introduce a novel composite endpoint that measures damage to the entire GI tract - clinically significant upper and lower GI events (CSULGIE) - in patients with NSAID-induced GI damage. METHODS We reviewed the data from largescale, multicenter, randomized, clinical trials on lower GI toxicity associated with NSAID use. The rationale for using CSULGIE as a primary endpoint in 2 ongoing trials - the Celecoxib vs Omeprazole and Diclofenac for At-risk Osteoarthritis (OA) and Rheumatoid Arthritis (RA) Patients (CONDOR) trial and the Gastrointestinal Randomized Events and Safety Open-Label NSAID Study (GI-REASONS) - is also discussed. RESULTS Previous randomized trials focused primarily on damage to the upper GI tract and often neglected the lower GI tract. The CSULGIE endpoint extends the traditional "perforation, obstruction, and bleeding" assessment of upper GI complications by including events in the lower GI tract (small/large bowel) such as perforation, bleeding, and clinically significant anemia. CONCLUSION By providing clinicians with a new, descriptive language for adverse events through the entire GI tract, the CSULGIE endpoint has the potential to become a standard tool for evaluating the GI effects of a range of therapies.
Collapse
Affiliation(s)
- Francis K L Chan
- The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
43
|
Gastrointestinal bleeding: trends in gastrointestinal bleeding: top down and bottom up! Nat Rev Gastroenterol Hepatol 2009; 6:632-3. [PMID: 19881514 DOI: 10.1038/nrgastro.2009.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
|
|
44
|
Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009; 104:1633-41. [PMID: 19574968 DOI: 10.1038/ajg.2009.164] [Citation(s) in RCA: 395] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Changing patterns in medical practice may contribute to temporal changes in the incidence of upper and lower gastrointestinal (GI) complications. There are limited data on the incidence of lower GI complications in clinical practice and most studies that have been done have serious methodological limitations to inferring the actual burden of this problem. The aims of this study were to analyze time trends of hospitalizations resulting from GI complications originating both from the upper and lower GI tract in the general population, and to determine the risk factors, severity, and clinical impact of these GI events. METHODS This was a population-based study of patients hospitalized because of GI complications in 10 general hospitals between 1996 and 2005 in Spain. We report the age- and gender-specific rates, estimate the regression coefficients of the upper and lower GI event trends, and evaluate the severity and associated risk factors. GI hospitalization charts were validated by an independent review of large random samples of unspecific and specific codes distributed among all hospitals and study years. RESULTS Upper GI complications fell from 87/100,000 persons in 1996 to 47/100,000 persons in 2005, whereas lower GI complications increased from 20/100,000 to 33/100,000. Overall, mortality rates decreased, but the case fatality remained constant over time. Lower GI events had a higher mortality rate (8.8 vs. 5.5%), a longer hospitalization (11.6+/-13.9 vs. 7.9+/-8.8 days), and higher resource utilization than did upper GI events. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) without concomitant proton pump inhibitor was more frequently recorded among upper GI complications than among lower GI complications. When comparing upper GI events with lower GI events, we found that male gender (adjusted odds ratio (OR): 1.94; 95% confidence interval (CI): 1.70-2.21), and recorded NSAID use (OR: 1.92; 95% CI: 1.60-2.30) were associated to a greater extent with upper GI events, whereas older age (OR: 0.83; 95% CI: 0.77-0.89), number of comorbidities (OR: 0.91; 95% CI: 0.86-0.96), and having a diagnosis in recent years (OR: 0.92; 95% CI: 0.90-0.94) were all associated to a greater extent with lower GI events than with upper GI events after adjusting for age, sex, hospitalization, and discharge year. CONCLUSIONS Over the past decade, there has been a progressive change in the overall picture of GI events leading to hospitalization, with a clear decreasing trend in upper GI events and a significant increase in lower GI events, causing the rates of these two GI complications to converge. Overall, mortality has also decreased, but the in-hospital case fatality of upper or lower GI complication events has remained constant. It will be a challenge to improve future care in this area unless we develop new strategies to reduce the number of events originating in the lower GI tract, as well as reducing their associated mortality.
Collapse
|
|
45
|
Lanas A, Sopeña F. Nonsteroidal anti-inflammatory drugs and lower gastrointestinal complications. Gastroenterol Clin North Am 2009; 38:333-52. [PMID: 19446262 DOI: 10.1016/j.gtc.2009.03.007] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In addition to the upper GI tract, NSAIDs can damage the small bowel and the colon. NSAID enteropathy is frequent and may be present in more than 60% of patients taking these drugs long term. In most cases, damage is subclinical, including increased mucosal permeability, inflammation, erosions, ulceration, but other more serious clinical outcomes such as anemia, and overall bleeding, perforation, obstruction, diverticulitis and deaths have also been described. The magnitude of these serious outcomes from the lower GI tract is not well defined, but recent data suggest that they may be as frequent and severe as upper GI complications. Contrary to what happens in the upper GI tract, treatment and prevention of NSAID enteropathy is difficult, since the pathogenic mechanisms are different and not well understood. Among other options, misoprostol, antibiotics, and sulphasalazine have been proved to be effective in animal models, but they have not been properly tested in humans. Selective COX-2 inhibition is emerging as a potential alternative to tNSAIDs in the prevention of damage in the lower GI tract in rheumatologic patients. Preliminary studies in healthy volunteers have shown that these drugs are associated with no or less small bowel damage than tNSAIDs plus PPI, although their long-term effects in patients need to be properly tested. Post hoc analysis of previous outcome studies focused on complications of upper GI tract or cardiovascular events have shown contradictory results. Data from one ongoing trial comparing celecoxib versus diclofenac plus PPI and examining serious outcomes from the whole GI tract will probably provide new insights in this area.
Collapse
Affiliation(s)
- Angel Lanas
- Service of Digestive Diseases, University Hospital, University of Zaragoza, Instituto Aragonés de Ciencias de la Salud, CIBERehd, C/San Juan Bosco 15, 50009 Zaragoza, Spain.
| | | |
Collapse
|
|
46
|
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, and a growing body of evidence suggests that they have adverse effects in the lower gastrointestinal (GI) tract in addition to the well-described toxicity in the upper GI tract. Among NSAID users who develop adverse GI effects, the proportion with lower GI events is as high as 40%. Most of the available evidence is taken from case-control studies and case reports; no large, randomized, placebo-controlled study has specifically set out to determine the magnitude of NSAID toxicity on the colon. However, the data suggest that NSAIDs cause a primary macroscopic colitis, collagenous colitis, an increased risk of complicated diverticular disease, and exacerbations of preexisting inflammatory bowel disease. Treatment depends on withdrawal of the causative drug.
Collapse
|
|
47
|
Angi A, Lakatos L. [Adverse effects of non-steroidal anti-inflammatory drugs in the lower gastrointestinal tract]. Orv Hetil 2009; 150:27-34. [PMID: 19091672 DOI: 10.1556/oh.2009.28508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Non-steroidal antiinflammatory drugs (NSAID) are among the most commonly used drugs worldwide. Together with the beneficial effects, several adverse effects have become evident in the past decades. NSAIDs may damage any part of the gastrointestinal (GI) tract. The adverse effect in the lower GI tract was thought to be less important, but more and more data confirm that NSAIDs can cause equally severe lesions in the lower GI tract as well, only the diagnostic procedures are limited. NSAIDs may damage the intact mucosa, and they also may cause flare-up of a preexisting disease. Adverse events in the lower GI tract are caused mainly by the dual (COX-1 and COX-2) inhibitors. Besides the inhibiting of the cyclooxygenase enzymes, an important step is the local effect of the drug that initiates the chain reaction with the damage of the epithelial cells (increase of mucosal permeability, influx of luminal factors, produce of inflammatory mediators etc.). The spectrum of adverse effects of NSAIDs on the lower GI are reviewed according to the latest literature and the available prevention and therapeutic strategies.
Collapse
Affiliation(s)
- Andrea Angi
- Csolnoky Ferenc Megyei Kórház, Belgyógyászati Centrum, Veszprém
| | | |
Collapse
|
|
48
|
Laine L, Curtis SP, Langman M, Jensen DM, Cryer B, Kaur A, Cannon CP. Lower gastrointestinal events in a double-blind trial of the cyclo-oxygenase-2 selective inhibitor etoricoxib and the traditional nonsteroidal anti-inflammatory drug diclofenac. Gastroenterology 2008; 135:1517-25. [PMID: 18823986 DOI: 10.1053/j.gastro.2008.07.067] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Revised: 06/20/2008] [Accepted: 07/24/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Nonsteroidal anti-inflammatory drugs (NSAIDs) cause lower gastrointestinal (GI) clinical events such as bleeding. Cyclo-oxygenase (COX)-2 selective inhibitors decrease upper GI events, but no prospective trial has prespecified assessment of lower GI clinical events. METHODS Patients >or=50 years old with osteoarthritis or rheumatoid arthritis were randomly assigned to etoricoxib (60 or 90 mg qd) or diclofenac (150 mg qd). Lower GI clinical events, confirmed by a blinded adjudication committee, included perforation or obstruction requiring hospitalization or bleeding (gross or occult rectal bleeding without upper GI cause associated with hypotension, orthostatic changes in heart rate [>20 beats per minute] or blood pressure [>20 mmHg systolic or >10 mmHg diastolic], hemoglobin drop >or=2 g/dl, or transfusion; or observed active bleeding or stigmata of hemorrhage). RESULTS We enrolled 34,701 patients with mean duration of therapy of 18 months. Rates were 0.32 and 0.38 lower GI clinical events per 100 patient-years for etoricoxib and diclofenac (hazard ratio [HR] = 0.84; 95% confidence interval [CI], 0.63-1.13). Bleeding was the most common event (rates of 0.19 and 0.23 per 100 patient-years, respectively). Multivariable analysis revealed significant risk factors to be prior lower GI event (HR = 4.06; 95% CI, 2.93-5.62) and age >or=65 years (HR = 1.98; 95% CI, 1.45-2.71). CONCLUSIONS A statistically significant decrease in lower GI clinical events was not seen with the COX-2 selective inhibitor etoricoxib versus the traditional NSAID diclofenac. The risk of a lower GI clinical event with NSAID use seems to be constant over time, and the major risk factors are a prior lower GI event and older age.
Collapse
Affiliation(s)
- Loren Laine
- Division of Gastrointestinal & Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
| | | | | | | | | | | | | |
Collapse
|
|
49
|
Abstract
Lower GI bleeding is a very broad topic, which can encompass situations from a small amount of red blood on tissue paper associated with formed brown stool, to life-threatening severe haemorrhage. Much of the literature on this topic focuses on acute bleeding necessitating hospitalisation and urgent intervention. The literature that is available focuses primarily on medical intervention and support, which will be covered in another review in this series. Causes for lower GI bleeding include diverticular disease, vascular ectasia, ischemic, inflammatory or infectious colitis, colonic neoplasia (including post polypectomy bleeding), anorectal causes (including haemorrhoids, fissures and rectal varices), and small bowel lesions (Crohn's, vascular ectasia, Meckel's diverticula, and small bowel tumours). Different clinical series identified these lesions in varying frequencies. Factors associated with the development of acute lower GI bleeding include advanced age and use of non-steroidal anti-inflammatory medication. Colonoscopy is the single most frequent intervention in evaluating all the patients with lower GI bleeding. Determining the precise impact of colonoscopy on the outcome of lower GI bleeding is difficult due to the retrospective nature of many studies, and the frequent inability to definitively establish the exact bleeding site.
Collapse
Affiliation(s)
- Gregory Zuccaro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
|
50
|
Rahme E, Barkun A, Nedjar H, Gaugris S, Watson D. Hospitalizations for upper and lower GI events associated with traditional NSAIDs and acetaminophen among the elderly in Quebec, Canada. Am J Gastroenterol 2008; 103:872-82. [PMID: 18371130 DOI: 10.1111/j.1572-0241.2008.01811.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The risk of upper/lower gastrointestinal (GI) adverse events associated with the concomitant use of traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) with acetaminophen has not been assessed. Among users of these drugs, the concomitant use of proton pump inhibitors (PPIs) with tNSAIDs may reduce the risk of upper GI adverse events, but its effect on lower GI events is not clear. OBJECTIVE To compare the rates of GI hospitalization (ulceration, perforation, or bleeding in the upper or lower GI tract) among elderly patients taking tNSAIDs or the combination of a tNSAID and acetaminophen with and without a PPI versus those taking acetaminophen alone. METHODS We conducted a population-based retrospective cohort study using data obtained from the government of Quebec health insurance agency databases and the hospital discharge summary database. Patients of 65 yr of age or older who filled a prescription for acetaminophen or a tNSAID between January 1998 and December 2004 were entered in the cohort at the date of the first filled prescription from either of these medications (index date). Follow-up ended at the first date of a GI hospitalization, death, or the end of the study period. RESULTS The cohort included 644,183 elderly patients. These patients received 1,778,541 prescriptions for tNSAIDs (315,222, 17.7% with a PPI), 158,711 for the combination of a tNSAID and acetaminophen (40,797, 25.7% with a PPI), 1,597,725 for acetaminophen (> 3 g/day) (504,939, 31.6% with a PPI), and 3,641,140 for acetaminophen (< or = 3 g/day) (1,031,939, 28.3% with a PPI). Using Cox regression models that adjusted for time-dependent variables (aspirin, anticoagulants, and clopidogrel) and other fixed patient baseline characteristics, we found similar risks of GI hospitalizations among time periods when patients were exposed to either a tNSAID with a PPI, acetaminophen (> 3 g/day) with a PPI, or acetaminophen (< or = 3 g/day) with a PPI. The risk of GI hospitalization among users of PPIs during exposure to the combination of acetaminophen with a tNSAID was twice as high as that of the reference category, acetaminophen (< or = 3 g/day) without a PPI (hazard ratio [HR] 2.15, 95% confidence interval [CI][1.35-3.40]). Among nonusers of PPIs, the risk of GI hospitalization was 1.20 (1.03-1.40) during exposure to acetaminophen (> 3 g/day), 1.63 (1.44-1.85) during exposure to tNSAIDs, and 2.55 (1.98-3.28) during exposure to the combination of a tNSAID and acetaminophen compared with the reference category. CONCLUSION Among elderly patients requiring analgesic/anti-inflammatory treatment, use of the combination of a tNSAID and acetaminophen may increase the risk of GI bleeding compared with either agent alone.
Collapse
Affiliation(s)
- Elham Rahme
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | | | | | | |
Collapse
|