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Someili AM, Mobarki SJ, Moafa RH, Alsury LN, Shadad RH, Fathi SM, Hamrani AH, Darisi AM, Mohamed AH, Alqassmi S, Mohrag M, Abdulrasak M. Upper Gastrointestinal Bleeding: A Retrospective, Single-Center Experience on the Role of Endoscopy and Outcomes. J Clin Med Res 2025; 17:22-34. [PMID: 39866814 PMCID: PMC11753981 DOI: 10.14740/jocmr6134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 01/02/2025] [Indexed: 01/28/2025] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) is a common and potentially fatal medical emergency. This study aimed to investigate the frequency, causes, outcomes, and efficacy of endoscopy in the treatment of UGIB at King Fahad Central Hospital in Jazan, Saudi Arabia. Methods Between January 2017 and December 2023, a retrospective study was performed including all hospitalized patients with UGIB. This research investigated sociodemographic characteristics, clinical history, endoscopic findings, treatment options, and results using statistical analysis, which included both descriptive and inferential approaches. Results The study included 483 patients (of which 74.1% men), with a mean age of 53.9 ± 19.5 years. Hematemesis was observed in 67.5% of the patients, whereas melena occurred in 49.7% of the cases. Two-hundred sixty-two (54.2%) patients underwent endoscopy within the first 24 h from presentation. The most frequent endoscopic findings were esophageal varices (52.2%) and duodenal ulcers (21.7%). Bandings accounted for 48.0% of all endoscopic procedures, whereas 36.9% of the patients received epinephrine injections along with endoclips. Medical therapy mostly consisted of a mix of proton pump inhibitors (PPIs) and octreotide. A significant minority (43.5%) of the patients stayed in the hospital for 1 - 3 days, while 59.6% did not need blood transfusions. During the first 3 days, 7% of patients experienced rebleeding, with a 6% mortality rate. Using multivariate regression analysis, rebleeding was strongly associated with initial presentation with shock (P < 0.001), renal disease (P = 0.01), and increased transfusion requirement (P = 0.001). Mortality was strongly associated with steroid usage (P = 0.007), increasing transfusion requirements (P < 0.0001), and rebleeding (P = 0.002). Conclusions Timely endoscopy and proper treatment dramatically improved UGIB results. Identifying those who are at high risk and acting swiftly is a critical step in reducing the likelihood of recurrent bleeding and fatality.
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Affiliation(s)
- Ali M. Someili
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Saudi Arabia
| | | | | | | | | | | | | | | | - Amal H. Mohamed
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Saudi Arabia
| | - Sameer Alqassmi
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Saudi Arabia
| | - Mostafa Mohrag
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Saudi Arabia
| | - Mohammed Abdulrasak
- Department of Clinical Sciences, Malmo, Lund University, Malmo, Sweden
- Department of Gastroenterology and Nutrition, Skane University Hospital, Malmo, Sweden
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Improta L. Clinical landscape and treatment of acute non-variceal upper gastrointestinal bleeding: Insights from a high-volume center in Shaanxi, China. World J Clin Cases 2024; 12:6855-6858. [PMID: 39687644 PMCID: PMC11525905 DOI: 10.12998/wjcc.v12.i35.6855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 09/08/2024] [Accepted: 10/10/2024] [Indexed: 10/24/2024] Open
Abstract
In this editorial we comment on the article by Wang et al, recently published on World Journal of Clinical Cases. Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) represents a common and potentially serious gastroenterological emergency. Wang et al conducted a detailed study on the management of ANVUGIB in a high-volume center in the Shaanxi region, China. Analyzing data from over 530 patients provided a comprehensive overview of clinical, epidemiological, and treatment characteristics. Results highlighted a younger patient population compared to European studies, with a higher prevalence of gastric and duodenal ulcers as the leading cause of bleeding. Endoscopic treatment is currently the preferred therapeutic option, offering a variety of effective techniques. This study emphasizes the importance of implementing current guidelines in ANVUGIB management and highlights the crucial role of endoscopy in its management.
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Affiliation(s)
- Luca Improta
- Department of General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome 00128, Italy
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Obeidat M, Teutsch B, Floria DE, Veres DS, Hegyi P, Erőss B. Early nutrition is safe and does not increase complications after upper gastrointestinal bleeding-a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2024; 14:10725. [PMID: 38730079 PMCID: PMC11087503 DOI: 10.1038/s41598-024-61543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/12/2024] Open
Abstract
Despite a lack of evidence, patients are often not fed for 48-96 h after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB. The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27th of April 2024 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model. A total of 10 trials with 1051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR 1.20, CI 0.85-1.71, I2 = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR 0.61, CI 0.35-1.06, I2 = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR 1.04, CI 0.66-1.63, I2 = 0% and RR 1.16, CI 0.63-2.13, I2 = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD -1.22 days, CI: -2.43 to -0.01, I2 = 94%). In conclusion, compared with DN, EN (within 24 h) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.
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Affiliation(s)
- Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
| | - Diana-Elena Floria
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Grigore T. Popa University of Medicine and Pharmacy, 700115, Iași, Romania
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, 1083, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, 1085, Hungary.
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, 7623, Hungary.
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, 1083, Hungary.
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Lesmana CRA. Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management. Artif Intell Gastrointest Endosc 2023; 4:12-17. [DOI: 10.37126/aige.v4.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/14/2023] [Accepted: 12/04/2023] [Indexed: 12/07/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta 12950, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta 12930, Indonesia
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Obeidat M, Teutsch B, Rancz A, Tari E, Márta K, Veres DS, Hosszúfalusi N, Mihály E, Hegyi P, Erőss B. One in four patients with gastrointestinal bleeding develops shock or hemodynamic instability: A systematic review and meta-analysis. World J Gastroenterol 2023; 29:4466-4480. [PMID: 37576706 PMCID: PMC10415974 DOI: 10.3748/wjg.v29.i28.4466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Hemodynamic instability and shock are associated with untoward outcomes in gastrointestinal bleeding. However, there are no studies in the existing literature on the proportion of patients who developed these outcomes after gastrointestinal bleeding. AIM To determine the pooled event rates in the available literature and specify them based on the bleeding source. METHODS The protocol was registered on PROSPERO in advance (CRD42021283258). A systematic search was performed in three databases (PubMed, EMBASE, and CENTRAL) on 14th October 2021. Pooled proportions with 95%CI were calculated with a random-effects model. A subgroup analysis was carried out based on the time of assessment (on admission or during hospital stay). Heterogeneity was assessed by Higgins and Thompson's I2 statistics. The Joanna Briggs Institute Prevalence Critical Appraisal Tool was used for the risk of bias assessment. The Reference Citation Analysis (https://www.referencecitationanalysis.com/) tool was applied to obtain the latest highlight articles. RESULTS We identified 11589 records, of which 220 studies were eligible for data extraction. The overall proportion of shock and hemodynamic instability in general gastrointestinal bleeding patients was 0.25 (95%CI: 0.17-0.36, I2 = 100%). In non-variceal bleeding, the proportion was 0.22 (95%CI: 0.14-0.31, I2 = 100%), whereas it was 0.25 (95%CI: 0.19-0.32, I2 = 100%) in variceal bleeding. The proportion of patients with colonic diverticular bleeding who developed shock or hemodynamic instability was 0.12 (95%CI: 0.06-0.22, I2 = 90%). The risk of bias was low, and heterogeneity was high in all analyses. CONCLUSION One in five, one in four, and one in eight patients develops shock or hemodynamic instability on admission or during hospitalization in the case of non-variceal, variceal, and colonic diverticular bleeding, respectively.
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Affiliation(s)
- Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
| | - Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Edina Tari
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Katalin Márta
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest 1085, Hungary
| | - Nóra Hosszúfalusi
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Emese Mihály
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
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Hollenbach M, Decker A, Schmidt A, Möschler O, Jung C, Blasberg T, Seif AAH, Vu Trung K, Hoffmeister A, Hochberger J, Ellenrieder V, Wedi E. Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching. Gastrointest Endosc 2023; 98:51-58.e2. [PMID: 36738794 DOI: 10.1016/j.gie.2023.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far. METHODS This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. RESULTS The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001). CONCLUSIONS For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.
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Affiliation(s)
- Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Annegrit Decker
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Möschler
- Department of Internal Medicine and Gastroenterology, Marienhospital Osnabrück, Osnabrück, Germany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Tobias Blasberg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Ali Amir Hosseini Seif
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Albrecht Hoffmeister
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Jürgen Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - Volker Ellenrieder
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - Edris Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany; Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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Laursen SB, Stanley AJ, Laine L, Schaffalitzky de Muckadell OB. Rebleeding in peptic ulcer bleeding - a nationwide cohort study of 19,537 patients. Scand J Gastroenterol 2022; 57:1423-1429. [PMID: 35853234 DOI: 10.1080/00365521.2022.2098050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rebleeding is a frequent complication of peptic ulcer bleeding (PUB). The associated prognosis remains rather unclear because previous studies generally also included non-ulcer lesions. OBJECTIVE We aimed to identify predictors for rebleeding; clarify the prognostic consequence of rebleeding; and develop a score for predicting rebleeding. METHODS Nationwide cohort study of consecutive patients presenting to hospital with PUB in Denmark from 2006-2014. Logistic regression analyses were used to identify predictors for rebleeding, evaluate the association between rebleeding and 30-day mortality, and develop a score to predict rebleeding. Patients with persistent bleeding were excluded. RESULTS Among 19,258 patients (mean age 74 years, mean ASA-score 2.4), 10.8% rebled, and 10.2% died. Strongest predictors for rebleeding were endoscopic high-risk stigmata of bleeding (Odds Ratio (OR): 2.12 [95% Confidence Interval (CI): 1.91-2.36]), bleeding from duodenal ulcers (OR: 1.87 [95% CI: 1.69-2.08]), and presentation with hemodynamic instability (OR: 1.55 [95% CI: 1.38-1.73]). Among patients with all three factors (7.9% of total), 24% rebled, 50% with rebleeding failed endoscopic therapy, and 23% died. Rebleeding was associated with increased mortality (OR: 2.04 [95% CI: 1.78-2.32]). We were unable to develop an accurate score to predict rebleeding. CONCLUSION Rebleeding occurs in ∼10% of patients with PUB and is overall associated with a two-fold increase in 30-day mortality. Patients with hemodynamic instability, duodenal ulcers, and high-risk endoscopic stigmata are at highest risk of rebleeding. When rebleeding occurs in such patients, consultation with surgery and/or interventional radiology should be obtained prior to repeat endoscopy.
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Affiliation(s)
- Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Adrian J Stanley
- Department of Gastroenterology, Walton Building, Glasgow Royal Infirmary, Glasgow, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ove B Schaffalitzky de Muckadell
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
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Bai Y, Lei C, Zhang N, Liu Y, Hu Z, Li Y, Qi R. Peri-Ulcerative Mucosal Inflammation Appearance is an Independent Risk Factor for 30-Day Rebleeding in Patients with Gastric Ulcer Bleeding: A Multicenter Retrospective Study. J Inflamm Res 2022; 15:4951-4961. [PMID: 36065317 PMCID: PMC9440673 DOI: 10.2147/jir.s378263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 12/07/2022] Open
Abstract
AIM The aim of this study was to identify clinical endoscopic indicators related to peri-ulcerative mucosal inflammation and to analyze whether the degree of peri-ulcerative mucosal inflammation appearance is an independent risk factor for gastric ulcer rebleeding. METHODS We conducted a retrospective study that included patients with gastric ulcer bleeding who were hospitalized at three medical centers in China from January 1, 2016 to December 31, 2019. Ulcer rebleeding that occurred within 30 days of successful initial hemostasis was analyzed to determine whether this event was related to the degree of peri-ulcerative mucosal inflammation appearance or other mucosal inflammation-related factors. RESULTS We enrolled 1111 patients and determined that GBS-Rebleeding-ROC (P<0.001), age (P=0.01), use of NSAIDs (P=0.001), bile reflux (P<0.001), and Helicobacter pylori (P<0.001) are all risk factors for peri-ulcerative mucosal inflammation appearance. Through multivariate analysis, we determined that severe peri-ulcerative mucosal inflammation appearance (P=0.002) was an independent risk factor for ulcer rebleeding within 30 days. Finally, we developed a risk assessment model using factors associated with mucosal inflammation that may be useful for early prediction of rebleeding. CONCLUSION The risk factors for peri-ulcerative mucosal inflammation appearance were identified. Severe peri-ulcerative mucosal inflammation appearance is an independent risk factor for ulcer rebleeding.
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Affiliation(s)
- Yixuan Bai
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Chenggang Lei
- Department of Hepatobiliary Surgery, Qingdao Municipal Hospital, Qingdao, People’s Republic of China
| | - Na Zhang
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Yuhui Liu
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Zhengyu Hu
- Department of General Surgery, Shanghai Tenth People’s Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Yan Li
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Ran Qi
- Department of General Surgery, Tongji Hospital of Tongji University, School of Medicine, Tongji University, Shanghai, People’s Republic of China
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Tajika M, Matsuhashi T, Shimodaira Y, Fukuda S, Tsuji T, Sugawara K, Saruta Y, Takahashi Y, Watanabe K, Iijima K. Usefulness of the CHAMPS score for risk stratification in lower gastrointestinal bleeding. Sci Rep 2022; 12:7587. [PMID: 35534654 PMCID: PMC9085815 DOI: 10.1038/s41598-022-11666-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022] Open
Abstract
We have recently developed a simple prediction score, the CHAMPS score, to predict in-hospital mortality in patients with upper gastrointestinal bleeding. In this study, the primary outcome of this study was the usefulness of the CHAMPS score for predicting in-hospital mortality with lower gastrointestinal bleeding (LGIB). Consecutive adult patients who were hospitalized with LGIB at two tertiary academic medical centers from 2015 to 2020 were retrospectively enrolled. The performance for predicting outcomes with CHAMPS score was assessed by a receiver operating characteristic curve analysis, and compared with four existing scores. In 387 patients enrolled in this study, 39 (10.1%) of whom died during the hospitalization. The CHAMPS score showed good performance in predicting in-hospital mortality in LGIB patients with an AUC (95% confidence interval) of 0.80 (0.73–0.87), which was significantly higher in comparison to the existing scores. The risk of in-hospital mortality as predicted by the CHAMPS score was shown: low risk (score ≤ 1), 1.8%; intermediate risk (score 2 or 3), 15.8%; and high risk (score ≥ 4), 37.1%. The CHAMPS score is useful for predicting in-hospital mortality in patients with LGIB.
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Affiliation(s)
- Munehiko Tajika
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tsuyotoshi Tsuji
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Kae Sugawara
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Youhei Saruta
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | | | - Kenta Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Wehmeyer MH, Horvatits T, Buchholz A, Krause L, Walter S, Zapf A, Lohse AW, Kluwe J. Stop of proton-pump inhibitor treatment in patients with liver cirrhosis (STOPPIT): study protocol for a prospective, multicentre, controlled, randomized, double-blind trial. Trials 2022; 23:302. [PMID: 35414106 PMCID: PMC9003168 DOI: 10.1186/s13063-022-06232-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Proton-pump inhibitors (PPI) are liberally prescribed in patients with liver cirrhosis. Observational studies link PPI therapy in cirrhotic patients with an increased risk for infectious complications, hepatic encephalopathy and an increased risk for hospitalization and mortality. However, patients with liver cirrhosis are also considered to be at risk for peptic ulcer bleeding. The STOPPIT trial evaluates if discontinuation of a pre-existing PPI treatment delays a composite endpoint of re-hospitalization and/or death in patients (recently) hospitalized with liver cirrhosis compared to patients on continued PPI medication. Methods The STOPPIT-trial is a prospective, multicentre, randomized, double-blinded, placebo-controlled, parallel-group trial. In total, 476 patients with complicated liver cirrhosis who already receive long-term PPI therapy without evidence-based indication are 1:1 randomized to receive either esomeprazole 20 mg (control group) or placebo (intervention group) for 360 days. Patients with an indication for PPI therapy (such as a recent diagnosis of peptic ulcers, severe reflux esophagitis, severe hemorrhagic gastritis, recent endoscopic therapy for oesophageal varices) are excluded. The primary composite endpoint is the time-to re-hospitalization and/or death. Secondary endpoints include rates of re-hospitalization, mortality, occurrence of infections, hepatic decompensation and acute-on-chronic liver failure. The safety endpoint is defined as manifestation of an evidence-based indication for PPI re-therapy. The impact of PPI continuation or discontinuation on the intestinal microbiota will be studied. The recruitment will take place at 18 study sites throughout Germany. Recruitment has started in April 2021. Discussion The STOPPIT trial is the first clinical trial to study the effects of PPI withdrawal on relevant outcome variables in patients with complicated liver cirrhosis. If the hypothesis that PPI withdrawal improves clinical outcomes of cirrhosis patients is confirmed, this would argue for a strong restriction of the currently liberal prescription practice of PPIs in this population. If, on the other hand, the trial demonstrates an increased risk of gastrointestinal bleeding events in patients after PPI withdrawal, this could create a rationale for a more liberal, prophylactic PPI treatment in patients with liver cirrhosis. Trial registration EU clinical trials register EudraCT 2019-005008-16 (registered December 27, 2019). ClinicalTrials.gov NCT04448028 (registered June 25, 2020). German Clinical Trials Register DRKS00021290 (registered March 10, 2021).
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Affiliation(s)
- Malte H Wehmeyer
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Thomas Horvatits
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anika Buchholz
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Walter
- Coordinating Center for Clinical Trials Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Hosni M, Rahal M, Tamim H, Daniel F, Al Hashash J, Sharara AI, Soweid A, Shaib YH, Mourad FH, Wehbeh AN, Rockey DC, Barada K. Increased rebleeding and mortality in patients with gastrointestinal bleeding treated with anticoagulant drugs compared to antiplatelet drugs. Eur J Gastroenterol Hepatol 2021; 33:e490-e498. [PMID: 33867445 DOI: 10.1097/meg.0000000000002148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding. METHODS This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis. RESULTS A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease. CONCLUSION In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.
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Affiliation(s)
| | | | - Hani Tamim
- Biostatistics Support Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | | | | | | | | | | | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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13
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Marmo R, Soncini M, Bucci C, Zullo A. The "Hub and Spoke" model has no effect on mortality in acute upper gastrointestinal bleeding: A prospective multicenter cohort study. Dig Liver Dis 2021; 53:1178-1184. [PMID: 33965358 DOI: 10.1016/j.dld.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/10/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND the lack of standardized pathways for patients with gastrointestinal bleeding may have led to differences in their management and inequity to medical care access. The "Hub & Spoke" model was adopted to fill this gap in many disciplines, but, to our knowledge, no data exist on its efficacy on mortality in GI bleeding. We aimed to evaluate if the "Hub & Spoke" organizational model has an impact on mortality risk from UGIB. METHODS from January 2014 to December 2015, 3324 consecutive patients admitted for UGIB in 50 Italian hospitals were enrolled (1977 patients in hospitals within the "Hub & Spoke" network for digestive hemorrhagic emergency and 1347 in hospitals outside the "Hub & Spoke" network). Clinical, endoscopic and organizational data were recorded. RESULTS we observed no differences in mortality between patients admitted to hospitals included or not included in the "Hub & Spoke" network (5.2% vs 6.1%, p = 0.3). On multivariate analysis, admission in gastroenterology wards (OR 0.61, p = 0.001) or an academic hospital (OR 0.65, p < 0.056) were independent protective factors while being in "Hub & Spoke" organization system did not affect mortality (OR 1.09, p = 0.57). CONCLUSION the "Hub & Spoke" model per sé does not impact on mortality while being treated in academic hospital or gastroenterology wards improved survival.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology and Endoscopy Unit, "L. Curto" Hospital Polla, ASL Salerno, Polla 84025, Italy.
| | - Marco Soncini
- Department of Internal Medicine "A. Manzoni" Hospital, Lecco, Italy
| | - Cristina Bucci
- UOSD Endoscopia Digestiva, AORN Santobono-Pausilipon, Naples, Italy
| | - Angelo Zullo
- Gastroenterology Unit, "Nuovo Regina Margherita" Hospital, Rome, Italy
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14
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Wei L, Ding HG. Helicobacter pylori infection and peptic ulcer disease in cirrhotic patients: An updated meta-analysis. World J Clin Cases 2021; 9:7073-7084. [PMID: 34540962 PMCID: PMC8409208 DOI: 10.12998/wjcc.v9.i24.7073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/04/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peptic ulcer (PU) is more prevalent in patients with liver cirrhosis. The role of Helicobacter pylori (H. pylori) infection in the pathogenesis of PU in patients with cirrhosis is still not elucidated. AIM To perform a meta-analysis on the prevalence of H. pylori infection and PU and their association in liver cirrhosis patients. METHODS We searched PubMed, EMBASE, Web of Science, Cochrane, CNKI, Wangfang, and CQVIP databases from inception to July 10, 2020. Odds ratio (OR) and 95% confidence interval (CI) were pooled using a random-effects model. The statistical heterogeneity among studies (I 2-index), subgroup analyses, regression analysis, sensitivity analysis, and the possibility of publication bias were assessed. RESULTS A total of 14 studies (13 cross-sectional studies; 1 cohort study) involving 2775 individuals (611 cases with PU and 2164 controls) were included in our meta-analysis. The prevalence of PU in patients with cirrhosis was 22%. The prevalence of H. pylori infection was 65.6% in cirrhotic patients with PU, and 52.5% in those without. The pooled overall OR was 1.73 (95%CI: 1.16-2.56, I 2 = 66.2%, P < 0.001, Z = 2.7, P z < 0.05). We did not find the cause of heterogeneity in the subgroup analyses and meta-regression analysis except for one study. Funnel plot did not show significant publication bias. The results of Begg's test and Egger's test indicated no evidence of substantial publication bias (P Begg = 0.732, P Egger = 0.557). CONCLUSION There is a weakly positive association between H. pylori infection and PU in patients with liver cirrhosis. It is suggested that H. pylori infection may play a role in the pathogenesis of PU in liver cirrhotic patients.
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Affiliation(s)
- Lin Wei
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
| | - Hui-Guo Ding
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated with Capital Medical University, Beijing 100069, China
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15
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Matsuhashi T, Hatta W, Hikichi T, Fukuda S, Mikami T, Tatsuta T, Nakamura J, Abe Y, Onozato Y, Ogata Y, Masamune A, Ohyauchi M, Ito H, Hanabata N, Araki Y, Yanagita T, Imamura H, Tsuji T, Sugawara K, Horikawa Y, Ohara S, Kondo Y, Dohmen T, Kakuta Y, Nakamura T, Iijima K. A simple prediction score for in-hospital mortality in patients with nonvariceal upper gastrointestinal bleeding. J Gastroenterol 2021; 56:758-768. [PMID: 34143312 DOI: 10.1007/s00535-021-01797-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/29/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND No prediction scores for the mortality of both inpatients and outpatients who developed nonvariceal upper gastrointestinal bleeding (UGIB) without endoscopic findings have been established. We aimed to derive and validate a novel prediction score for in-hospital mortality. METHODS We conducted a three-stage, multicenter retrospective study. In the derivation stage, patients with nonvariceal UGIB at six institutions were enrolled to derive the prediction score by logistic regression analysis. External validation of the score was performed to analyze discrimination by patients at six other institutions. Then the performance of this score was compared with that of four existing scores. RESULTS We enrolled 1380 and 825 patients in the derivation and validation cohorts, respectively. A prediction score (CHAMPS-R Score) comprising seven variables (Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroids, and rebleeding) with equal-weight scores was established, with high discriminative ability in both derivation and validation cohorts (c statistic, 0.91 and 0.80, respectively). When rebeeding was excluded from the score (an onset model; CHAMPS Score), this score also achieved high discriminative ability (c statistic, 0.90 and 0.81, respectively). The prediction scores had significantly higher discriminative ability than the Glasgow Blatchford Score, AIMS65, ABC Score, and clinical Rockall Score in both cohorts (all, p < 0.05). CONCLUSIONS We derived and externally validated prediction scores for in-hospital mortality in patients with nonvariceal UGIB. The CHAMPS Score might be optimal for managing such patients. Its mobile application is freely available ( https://apps.apple.com/app/id1565716902 for iOS and https://play.google.com/store/apps/details?id=hatta.CHAMPS for Android).
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Affiliation(s)
- Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yasuhiko Abe
- Division of Endoscopy, Yamagata University Hospital, Yamagata, Japan
| | - Yusuke Onozato
- Department of Gastroenterology, Faculty of Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Yohei Ogata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Motoki Ohyauchi
- Department of Gastroenterology, Osaki Citizen Hospital, Osaki, Japan
| | - Hirotaka Ito
- Department of Gastroenterology, Osaki Citizen Hospital, Osaki, Japan
| | - Norihiro Hanabata
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yasumitsu Araki
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Takumi Yanagita
- Department of Gastroenterology, Ohta Nishinouchi Hospital, Kooriyama, Japan
| | - Hidemichi Imamura
- Department of Gastroenterology, Ohta Nishinouchi Hospital, Kooriyama, Japan
| | - Tsuyotoshi Tsuji
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Kae Sugawara
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Yohei Horikawa
- Department of Gastroenterology, Hiraka General Hospital, Yokote, Japan
| | - Shuichi Ohara
- Department of Gastroenterology, Tohoku Rosai Hospital, Sendai, Japan
| | - Yutaka Kondo
- Department of Gastroenterology, Tohoku Rosai Hospital, Sendai, Japan
| | - Takahiro Dohmen
- Department of Gastroenterology, Yuri Kumiai General Hospital, Yurihonjou, Japan
| | - Yoichi Kakuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tomohiro Nakamura
- Department of Health Record Informatics, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
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16
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Cañamares-Orbís P, Lanas Arbeloa Á. New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II. J Clin Med 2021; 10:3045. [PMID: 34300211 PMCID: PMC8303152 DOI: 10.3390/jcm10143045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, 22004 Huesca, Spain
| | - Ángel Lanas Arbeloa
- IIS Aragón, CIBERehd, 50009 Zaragoza, Spain;
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain
- University of Zaragoza, 500009 Zaragoza, Spain
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17
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Ryan K, Malacova E, Appleyard M, Brown AF, Song L, Grimpen F. Clinical utility of the Glasgow Blatchford Score in patients presenting to the emergency department with upper gastrointestinal bleeding: A retrospective cohort study. Emerg Med Australas 2021; 33:817-825. [PMID: 33543572 DOI: 10.1111/1742-6723.13737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) is a common presentation to EDs. Limited Australian data are available. Study aims were to assess mortality and re-bleeding rates in patients presenting with UGIB as risk-stratified by the Glasgow Blatchford Score (GBS). METHODS We conducted a retrospective medical chart review of all patients presenting with UGIB to a Brisbane tertiary hospital ED over a 12-month period. This descriptive study summarised the medical characteristics related to UGIB as risk-stratified by the GBS. Non-variceal bleeding was categorised as low-risk (GBS 0-2) or high-risk (GBS 3+). Variceal bleeding was not risk stratified. RESULTS A total of 211 patients presented with UGIB to the ED. The median age was 57 years, 67% were male. Mortality rates at 30 days were: 0% for GBS 0-2, 3% (95% confidence interval [CI] 0-6) for GBS 3+ and 10% (95% CI 0-21) for variceal groups. The overall 30-day re-bleeding rate was 4.3% (95% CI 2-7). High-risk patients accessed endoscopy according to international best practice of less than 24 h (GBS 3+, 23.7 h; variceal bleeding, 7.3 h). CONCLUSIONS Mortality and re-bleeding outcomes are similar to other international UGIB cohorts. Patients with a low-risk bleed were appropriately identified and discharged home. Those at higher risk were correctly identified and accessed timely endoscopy. The GBS demonstrated clinical utility in an Australian ED cohort of UGIB bleeding patients.
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Affiliation(s)
- Kimberley Ryan
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Eva Malacova
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Mark Appleyard
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anthony Ft Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Song
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Florian Grimpen
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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18
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Mille M, Engelhardt T, Stier A. Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers. Visc Med 2021; 37:52-62. [PMID: 33718484 PMCID: PMC7923890 DOI: 10.1159/000513689] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute peptic ulcer bleeding is still a major reason for hospital admission. Especially the management of bleeding duodenal ulcers needs a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers. Patient with these bleeding ulcers are often in a high-risk situation, which requires multidisciplinary treatment. SUMMARY This review provides a structured approach to modern management of bleeding duodenal ulcers and elucidates therapeutic practice in high-risk situations. Initial management including pharmacologic therapy, risk stratification, endoscopy, surgery, and transcatheter arterial embolization are reviewed and their role in the management of bleeding duodenal ulcers is critically discussed. Additionally, a future perspective regarding prophylactic therapeutic approaches is outlined. KEY MESSAGES Beside pharmacotherapeutic and endoscopic advances, bleeding management of high-risk duodenal ulcers is still a challenge. When bleeding persists or rebleeding occurs and the gold standard endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding. Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay. In the meantime, transcatheter arterial embolization is recommended as an alternative to surgery and more often replaces surgery in the management of failed endoscopic hemostasis. Future studies are needed to improve risk stratification and therefore enable a better selection of high-risk ulcers and optimal treatment. Additionally, the promising approach of prophylactic embolization in high-risk duodenal ulcers has to be further investigated to reduce rebleeding and improve outcomes in these patients.
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Affiliation(s)
- Markus Mille
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
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19
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Arai J, Kato J, Toda N, Kurokawa K, Shibata C, Kurosaki S, Funato K, Kondo M, Takagi K, Kojima K, Ohki T, Seki M, Tagawa K. Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers. BMC Gastroenterol 2021; 21:16. [PMID: 33407172 PMCID: PMC7789673 DOI: 10.1186/s12876-020-01580-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 12/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU. Methods In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis. Results Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7). Conclusion In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.
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Affiliation(s)
- Junya Arai
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Jun Kato
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Nobuo Toda
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan.
| | - Ken Kurokawa
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Chikako Shibata
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Shigeyuki Kurosaki
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kazuyoshi Funato
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Mayuko Kondo
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kaoru Takagi
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kentaro Kojima
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Takamasa Ohki
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Michiharu Seki
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kazumi Tagawa
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
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20
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Park SH, Mun YG, Lim CH, Cho YK, Park JM. C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis. Medicine (Baltimore) 2020; 99:e23689. [PMID: 33371112 PMCID: PMC7748191 DOI: 10.1097/md.0000000000023689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 11/15/2020] [Indexed: 01/26/2023] Open
Abstract
In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.
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Affiliation(s)
- Se Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
| | - Yoon Gwon Mun
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
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21
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Marmo R, Soncini M, de Franchis R. Patient's performance status should dictate transfusion strategy in nonvariceal acute upper gastrointestinal bleeding (NV-AUGIB): A prospective multicenter cohort study: Transfusion strategy in NV-AUGIB. Dig Liver Dis 2020; 52:1156-1163. [PMID: 32788141 DOI: 10.1016/j.dld.2020.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/29/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-variceal acute UGI bleeding (NV-AUGIB) is a frequent indication for transfusion, but the best hemoglobin threshold and target values for transfusion in relation to the patients' performance status are unknown. OBJECTIVE To identify threshold and target hemoglobin levels for transfusion favoring survival of patients with NV-AUGIB stratified by ASA score. DESIGN Prospective cohort study. SETTING 50 hospitals of the Italian National Health Service. PARTICIPANTS 2758 consecutive patients with NV-AUGIB admitted to 50 Italian hospitals from January 1st, 2014 to December 31st, 2015. Five hemoglobin cut-off values were evaluated. RESULTS 30-days mortality: overall: 5.4%; ASA 1-2 patients: 2.5%; ASA 3-4 patients: 10.8%. Mortality was higher when hemoglobin at admission was ≤ 7 g/dL in ASA 1-2 patients, and when it was ≤ 8 g/dL in ASA 3-4 patients. The hemoglobin levels after transfusion favouring survival were ≥ 8 g/dL in ASA 1-2, p <0.0001 and 9-10 g/dL in ASA 3-4 patients; p = 0.0002. CONCLUSIONS In patients with NV-AUGIB the physical performance status should dictate the transfusion strategy. In ASA 1-2 patients, admission hemoglobin values ≤ 7 g/dL should prompt transfusion, aiming at a target value of 8-9 g/dL; the corresponding figures for ASA 3-4 patients are: admission hemoglobin level ≤ 8 g/dL and target value of 9-10 g/dL.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Department, Presidio Ospedaliero Luigi Curto, ASL 3 Salerno, Via Luigi Curto , Polla (Salerno)
| | - Marco Soncini
- Medical Department, A. Manzoni Hospital, ASST Lecco, Via dell'Eremo, Lecco
| | - Roberto de Franchis
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy.
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22
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Ket SN, Sparrow RL, McQuilten ZK, Gibson PR, Brown GJ, Wood EM. Critical peptic ulcer bleeding requiring massive blood transfusion: outcomes of 270 cases. Intern Med J 2020; 51:2042-2050. [DOI: 10.1111/imj.15009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Shara N. Ket
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Rosemary L. Sparrow
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Zoe K. McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Peter R. Gibson
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Gregor J. Brown
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
- Epworth Hospital Richmond Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
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23
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Marmo R, Soncini M, Marmo C, Borbjerg Laursen S, Gralnek IM, Stanley AJ. Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study. Dig Liver Dis 2020; 52:561-565. [PMID: 32111388 DOI: 10.1016/j.dld.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding. AIMS To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding. METHODS A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward. PRIMARY OUTCOME 30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding. RESULTS Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01. CONCLUSION Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Unit, L. Curto Hospital, Polla, SA, Italy.
| | - Marco Soncini
- Digestive Physiopathology Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | | | - Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ian Mark Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Family Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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24
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Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
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25
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Lazăr DC, Ursoniu S, Goldiş A. Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding. World J Clin Cases 2019; 7:2687-2703. [PMID: 31616685 PMCID: PMC6789381 DOI: 10.12998/wjcc.v7.i18.2687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nonvariceal upper digestive bleeding (NVUDB) represents a severe emergency condition and is associated with significant morbidity and mortality. Despite a decrease in the incidence due to the widespread use of potent therapy with proton pump inhibitors as well as the implementation of modern endoscopic techniques, the mortality rate associated with NVUDB is still high. AIM To identify the clinical, biological, and endoscopic parameters associated with a poor outcome in patients with NVUDB to allow the stratification of risk, which will lead to the implementation of the most accurate management. METHODS We performed a retrospective study including patients who were admitted to the Gastroenterology Department of Clinical Emergency County Hospital Timisoara, Romania, with a diagnosis of NVUDB between 1 January 2008 and 31 December 2016. All the data were collected from the patient's records, including demographic data, medication history, hemodynamic status, paraclinical tests, and endoscopic features as well as the methods of hemostasis, rate of rebleeding, need for surgery and death; we also assessed the Rockall score of the patients, length of hospitalization and associated comorbidities. All these parameters were evaluated as potential risk factors associated with rebleeding and death in patients with NVUDB. RESULTS We included a batch of 1581 patients with NVUDB, including 523 (33%) females and 1058 (67%) males with a median age of 66 years. The main cause of NVUDB was peptic ulcer (73% of patients). More than one-third of the patients needed endoscopic treatment. Rebleeding rate was 7.72%; surgery due to failure of endoscopic hemostasis was needed in 3.22% of cases; the in-hospital mortality rate was 8.09%, and the bleeding-episode-related mortality rate was 2.97%. Although our predictive models for rebleeding and death had a low sensitivity, the specificity was very high, suggesting a better discriminative capacity for identifying patients with better outcomes. Our results showed that the Rockall score was associated with both rebleeding and death; comorbidities such as respiratory conditions, liver cirrhosis and sepsis increased significantly the risk of in-hospital mortality (OR of 3.29, 2.91 and 8.03). CONCLUSION Our study revealed that the Rockall score, need for endoscopic therapy, necessity of transfusion and sepsis were risk factors for rebleeding. Moreover, an increased Rockall score and the presence of comorbidities were predictive factors for in-hospital mortality.
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Affiliation(s)
- Daniela Cornelia Lazăr
- Department of Internal Medicine I, University Medical Clinic, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
| | - Sorin Ursoniu
- Department of Public Health and Health Management, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
| | - Adrian Goldiş
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
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26
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Voulgaris T, Karagiannakis D, Siakavellas S, Kalogera D, Angelopoulos T, Chloupi E, Karamanolis G, Papatheodoridis G, Vlachogiannakos J. High prevalence of asymptomatic peptic ulcers diagnosed during screening endoscopy in patients with cirrhosis. Ann Gastroenterol 2019; 32:451-456. [PMID: 31474790 PMCID: PMC6686096 DOI: 10.20524/aog.2019.0399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/05/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) is more prevalent in cirrhotics and this may aggravate prognosis. We investigated the prevalence of PUD in cirrhotics and its potential association with Helicobacter pylori (H. pylori) infection, the underlying etiology and severity of liver disease, and other manifestations of portal hypertension (PH). METHODS We enrolled consecutive asymptomatic cirrhotic patients who underwent screening endoscopy in a tertiary hospital during a 12-month period. We recorded the presence of PUD and the endoscopic findings associated with PH. H. pylori infection was documented through either histology or CLO-test. The diagnosis of cirrhosis was based on elastography, liver biopsy or a combination of clinical, biochemical and imaging data. RESULTS One hundred patients (M/F: 54/46, mean age: 61±14 years) were included in the analysis. Viral hepatitis (37%) and alcohol (22%) were the most common causes of cirrhosis. Child-Pugh stage was A/B/C: 60/35/5. PUD was found in 19 patients (14 gastric, 5 duodenal). H. pylori infection was diagnosed in 54%. Varices were detected in 59% (39% needed treatment). PH gastropathy was present in 81% (severe in 33%). The presence of PUD was unrelated to the etiology and the severity of liver disease or to other endoscopic manifestations of PH. No correlation was found between PUD and H. pylori infection. CONCLUSIONS A high prevalence of PUD was observed in our cirrhotic patients, although they were asymptomatic and had no known risk factors of ulcerogenicity. The value of screening endoscopy for the early diagnosis and treatment of PUD in cirrhotics deserves further investigation.
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Affiliation(s)
- Theodoros Voulgaris
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Karagiannakis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Spyridon Siakavellas
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Despina Kalogera
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Theodoros Angelopoulos
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Elissavet Chloupi
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - George Karamanolis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - George Papatheodoridis
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - John Vlachogiannakos
- Academic Department of Gastroenterology and Hepatology, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
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27
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Endoscopic management of nonvariceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101608. [PMID: 31785733 DOI: 10.1016/j.bpg.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.
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28
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Bishay K, Tandon P, Fisher S, Yelle D, Carrigan I, Wooller K, Kelly E. Clinical Factors Associated with Mortality in Cirrhotic Patients Presenting with Upper Gastrointestinal Bleeding. J Can Assoc Gastroenterol 2019; 3:127-134. [PMID: 32395687 PMCID: PMC7204794 DOI: 10.1093/jcag/gwy075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 03/03/2019] [Indexed: 12/13/2022] Open
Abstract
Background Whether certain clinical or laboratory characteristics are able to differentiate cirrhotic patients with upper gastrointestinal bleeds (UGIB) at high-risk inpatient mortality is unknown. The objective of this study is to elucidate patient factors at presentation that are associated with in-hospital mortality. Methods A retrospective analysis of cirrhotic patients presenting with UGIB was performed. Baseline characteristics at admission including demographics, clinical and laboratory characteristics were collected. Factors associated with in-hospital mortality were evaluated with logistic regression analyses. The discriminative power of MELD score was evaluated with the use of area under the receiver operating characteristic (ROC) curve. Results One hundred and sixteen patients were included in this study. MELD score at presentation was higher in the death cohort (24.0 versus 14.8, P < 0.001) and remained significantly associated with mortality after multivariable adjustment (P < 0.001). ROC analysis of MELD score for death yielded an area under the curve of 0.88. At admission, the death group had lower systolic blood pressure (103 mmHg versus 123 mmHg, P=0.008 and more frequently presented with bright red blood per rectum (46.7% versus 11.9%, P = 0.003). Bilirubin and international normalized ratio were also higher, and albumin was lower in patients who died. Conclusions Among cirrhotic patients presenting with UGIB, the severity of symptoms and impairment in hepatic synthetic function is associated with in-hospital mortality. Admission MELD score may be useful in predicting in-hospital mortality.
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Affiliation(s)
- Kirles Bishay
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stacey Fisher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dominique Yelle
- Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Carrigan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Krista Wooller
- Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Kelly
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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29
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Hajiagha Mohammadi AA, Reza Azizi M. Prognostic factors in patients with active non-variceal upper gastrointestinal bleeding. Arab J Gastroenterol 2019; 20:23-27. [PMID: 30770260 DOI: 10.1016/j.ajg.2019.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/22/2018] [Accepted: 01/08/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND STUDY AIMS Acute upper gastrointestinal bleeding is one of the main causes of hospitalisation. The purpose of this study was to determine the prognostic factors in non-variceal upper gastrointestinal bleeding. PATIENTS AND METHODS Clinical outcomes, demographic and laboratory variables of the subjects were collected from the HIS software and national code with the SQL format from three hospitals in Qazvin. The data were linked to the database software designed by the author. Clinical and upper endoscopic findings of patients' records were collected through a questionnaire form in the designed software database. RESULTS In this study, 29.2% of patients with favourable outcome and 64.2% of patients with unfavourable clinical outcomes had a history of anticoagulant drug use before hospitalisation (p < 0.001). The prevalence of chronic cardiovascular disease, chronic liver disease, chronic lung disease, diabetes and dialysis was higher in subjects with poor clinical outcomes than those with a favourable clinical outcome. 53.1% of subjects with favourable clinical outcome and 90.5% of subjects with undesirable clinical outcomes received packed red blood cell transfusion (p < 0.001). 16.1% of subjects with desirable clinical outcome and 86.3% of subjects with undesirable clinical outcomes received endoscopic haemostatic treatment which was statistically significant (p < 0.001). CONCLUSION Undesirable clinical outcome in patients with acute non-variceal upper gastrointestinal bleeding has a significant statistical association with longer hospitalisation, chronic underlying disease, anticoagulant administration, packed red blood cell infusion, higher Forrest stage, low systolic blood pressure, higher age, low haemoglobin, low platelet count, high INR and high BUN at the onset of diagnosis.
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Affiliation(s)
- Ali Akbar Hajiagha Mohammadi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mohammad Reza Azizi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.
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30
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Alzoubaidi D, Lovat LB, Haidry R. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterol 2019; 10:35-42. [PMID: 30651955 PMCID: PMC6319149 DOI: 10.1136/flgastro-2017-100901] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/10/2018] [Accepted: 01/21/2018] [Indexed: 02/04/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK
- GI Services, University College London Hospital, London, UK
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31
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Wu KH, Shih HA, Hung MS, Hsiao CT, Chen YC. The association between blood urea nitrogen to creatinine ratio and mortality in patients with upper gastrointestinal bleeding. Arab J Gastroenterol 2018; 19:143-147. [PMID: 30522883 DOI: 10.1016/j.ajg.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/12/2018] [Accepted: 11/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Azotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients. PATIENTS AND METHODS This study was conducted prospectively at a university-affiliated teaching hospital with approximate 70,000 annual emergency department (ED) visits. Data from a total of 258 adult UGIB patients were collected between March 1, 2011 and March 1, 2012. Cox regression analysis was used to identify risk factors for 30-day mortality. RESULTS Malignancy and Rockall score were associated with increased risk of 30-day mortality (Unadjusted hazard ratio (HR): 3.87, 95% CI: 1.59-9.41, p = 0.0029; HR: 1.31, 95% CI: 1.02-1.71, p = 0.0476, respectively). However, BUN/Cr > 30 was associated with lower risk of 30-day mortality (HR: 0.32, 95% CI: 0.11-0.97, p = 0.0441). CONCLUSIONS A BUN/Cr ratio of >30 was found to be an independent risk factor for mortality and may be useful for pre-endoscopic assessment. Development of future risk scoring systems might warrant consideration of including BUN/Cr ratio as a parameter for estimating risk.
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Affiliation(s)
- Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Hsin-An Shih
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Ming-Szu Hung
- Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan; Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan.
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Gweon TG, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180022] [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: 11/22/2022] Open
Affiliation(s)
- Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jinsu Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Cipolletta L, Cipolletta F, Granata A, Ligresti D, Barresi L, Tarantino I, Traina M. What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding? ACTA ACUST UNITED AC 2018; 16:363-375. [PMID: 30229463 DOI: 10.1007/s11938-018-0192-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. RECENT FINDINGS Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.
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Affiliation(s)
- Livio Cipolletta
- Endoscopy Unit, Ruesch Clinic, Via San Domenico, 24, 80127, Naples, Italy.
| | - Fabio Cipolletta
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
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Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology 2018; 67:1458-1471. [PMID: 28714072 DOI: 10.1002/hep.29370] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/18/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The presence of cirrhosis increases the mortality of patients with peptic ulcer bleeding (PUB). Both acute variceal bleeding (AVB) and PUB are associated with substantial mortality in cirrhosis. This multicenter cohort study was performed to assess whether the mortality of patients with cirrhosis with PUB is different from that of those with AVB. Patients with cirrhosis and acute gastrointestinal bleeding were consecutively included and treated with somatostatin and proton pump inhibitor infusion from admission and with antibiotic prophylaxis. Emergency endoscopy with endoscopic therapy was performed within the first 6 hours. 646 patients with AVB and 144 with PUB were included. There were baseline differences between groups, such as use of gastroerosive drugs or β-blockers. Child-Pugh and Model for End-Stage Liver Disease MELD scores were similar. Further bleeding was more frequent in the AVB group than those in the PUB group (18% vs. 10%; odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.29-0.88). However, mortality risk at 45 days was similar in both groups (19% in the AVB group vs. 17% in the PUB group; OR = 0.85; 95% CI = 0.55-1.33; P = 0.48). Different parameters, such as Child-Pugh score, acute kidney injury, acute on chronic liver failure, or presence of shock or bacterial infection, but not the cause of bleeding, were related to the risk of death. Only 2% of the PUB group versus 3% of the AVB group died with uncontrolled bleeding (P = 0.39), whereas the majority of patients in either group died from liver failure or attributed to other comorbidities. CONCLUSION Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).
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Affiliation(s)
- Alba Ardevol
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Ibañez-Sanz
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquim Profitos
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Carles Aracil
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Josep M Castellvi
- Department of Gastroenterology, Hospital de Mataró, Barcelona, Spain
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Cachero
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Diana Horta
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Josep Miñana
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Oana Pavel
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Eva Dueñas
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Meritxell Casas
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | | | - Jose Castellote
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Candid Villanueva
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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Characteristics and outcomes of gastroduodenal ulcer bleeding: a single-centre experience in Lithuania. GASTROENTEROLOGY REVIEW 2018; 12:277-285. [PMID: 29358997 PMCID: PMC5771452 DOI: 10.5114/pg.2017.72103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 10/29/2016] [Indexed: 11/29/2022]
Abstract
Introduction Despite the optimal use of combined endoscopic haemostasis and pharmacologic control of acid secretion in the stomach, mortality in patients with peptic ulcer bleeding (PUB) has remained constant. Recent data has shown that the majority of patients with PUB die of non-bleeding-related causes. Aim To provide an overview of our experience of PUB management, with emphasis on the effect of age, gender, comorbidities, and drug use on the characteristics and outcomes of gastroduodenal ulcer bleeding. Material and methods We retrospectively reviewed the medical records of all patients admitted with the primary diagnosis of acute, chronic or unspecified gastric and/or duodenal ulcer with haemorrhage during 2008–2012. Results Two hundred and nineteen patients were identified. 46.6% of patients were ≥ 65 years old (elderly) and 53.4% were < 65 years old (young). The young patients were more likely to have duodenal ulcers and liver failure at admission. Previous use of medications was more regularly observed in gastric ulcer patients than in duodenal ulcer patients. Rebleeding occurred in 43 (19.6%) patients and death in 5 (2.3%) patients. Increased risk of mortality in our patients was associated with age ≥ 65 years (RR = 2.21; 95% CI: 1.90–2.56; p = 0.021). Conclusions Management of peptic ulcer bleeding should aim at reducing the risk of multiorgan failure and cardiopulmonary death instead of focusing merely on successful haemostasis.
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Yang EH, Cheng HC, Wu CT, Chen WY, Lin MY, Sheu BS. Peptic ulcer bleeding patients with Rockall scores ≥6 are at risk of long-term ulcer rebleeding: A 3.5-year prospective longitudinal study. J Gastroenterol Hepatol 2018; 33:156-163. [PMID: 28497645 DOI: 10.1111/jgh.13822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/20/2017] [Accepted: 05/09/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Patients with high Rockall scores have increased risk of rebleeding and mortality within 30 days after peptic ulcer bleeding, but long-term outcomes deserve follow-up after cessation of proton pump inhibitors. The paper aimed to validate whether patients with high Rockall scores have more recurrent ulcer bleeding in a 3.5-year longitudinal cohort. METHODS Between August 2011 and July 2014, 368 patients with peptic ulcer bleeding were prospectively enrolled after endoscopic hemostasis to receive proton pump inhibitors for at least 8 to 16 weeks. These subjects were categorized into either a Rockall scores ≥6 group (n = 257) or a Rockall scores <6 group (n = 111) and followed up until July of 2015 to assess recurrent ulcer bleeding. RESULTS The proportion of patients with rebleeding during the 3.5-year follow-up was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 vs. 3.63 per 100 person-year, P = 0.004, log-rank test). Among patients with Rockall scores ≥6, activated partial thromboplastin time prolonged ≥1.5-fold (P = 0.045), American Society of Anesthesiologists physical status class ≥III (P = 0.02), and gastric ulcer (P = 0.04) were three additional independent factors found to increase rebleeding risk. The cumulative rebleeding rate was higher in patients with Rockall scores ≥6 with more than or equal to any two additional factors than in those with fewer than two additional factors (15.69 vs. 7.63 per 100 person-year, P = 0.012, log-rank test). CONCLUSIONS Patients with Rockall scores ≥6 are at risk of long-term recurrent peptic ulcer bleeding. The risk can be independently increased by the presence of activated partial thromboplastin time prolonged ≥1.5-fold, American Society of Anesthesiologists class ≥III, and gastric ulcer in patients with Rockall scores ≥6.
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Affiliation(s)
- Er-Hsiang Yang
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chi Cheng
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Tai Wu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ying Chen
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Ying Lin
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bor-Shyang Sheu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
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Kawasaki K, Nakamura S, Kurahara K, Nagasue T, Yanai S, Harada A, Yaita H, Fuchigami T, Matsumoto T. Continuing use of antithrombotic medications for patients with bleeding gastroduodenal ulcer requiring endoscopic hemostasis: a case-control study. Scand J Gastroenterol 2017; 52:948-953. [PMID: 28532190 DOI: 10.1080/00365521.2017.1328989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to compare clinical characteristics and outcomes of bleeding gastroduodenal ulcer between patients taking antithrombotic medications and those not taking antithrombotic medications. METHODS We performed a case-control study of 346 patients with endoscopically verified bleeding gastroduodenal ulcer, which included 173 cases taking antithrombotic medications throughout peri-bleeding period and 173 age- and sex-matched controls not taking antithrombotic medications. RESULTS The cases showed less frequent Helicobacter pylori (H. pylori) infections (45.1% versus 60.7%, p = .005), more frequent duodenal location (31.8% versus 19.1%, p = .009), and more frequent rebleeding (13.9% versus 5.8%, p = .02) than the controls. Multivariate analysis revealed that duodenal location (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.37-6.65) and use of antithrombotic medications (OR 2.47, 95% CI 1.13-5.77) were independent factors for rebleeding. However, there were no differences in clinical outcomes, including final successful endoscopic hemostasis, need for surgical intervention, and mortality between cases and controls. Thromboembolic events did not occur in any cases and controls during the periendoscopic period. CONCLUSIONS Low prevalence of H. pylori infection, frequent duodenal location, and high rebleeding rate are characteristics of patients with bleeding gastroduodenal ulcer under antithrombotic medications. Continuation of antithrombotic medications can be accepted for bleeding gastroduodenal ulcer.
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Affiliation(s)
- Keisuke Kawasaki
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan.,b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Shotaro Nakamura
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
| | - Koichi Kurahara
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Tomohiro Nagasue
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Shunichi Yanai
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
| | - Akira Harada
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Hiroki Yaita
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Tadahiko Fuchigami
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Takayuki Matsumoto
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
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Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol. J Trauma Acute Care Surg 2017; 83:41-46. [PMID: 27779592 DOI: 10.1097/ta.0000000000001295] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Effective multidisciplinary management of gastrointestinal bleeding (GIB) requires effective communication. We instituted a protocol to standardize communication practices with the hypothesis that outcomes would improve following protocol initiation. METHODS We performed a retrospective cohort analysis of 442 patients who required procedural management of acute GIB at our institution during a 50-month period spanning 25 months before and 25 months after implementation of a multidisciplinary communication protocol. The protocol stipulates that when a patient with severe GIB is identified, a conference call is coordinated among the gastroenterology, interventional radiology, and acute care surgery teams. A consensus plan is generated and then reassessed following procedural interventions and changes in patients' status. Patients' characteristics, management strategies, and outcomes were compared before and after protocol initiation. RESULTS Patient populations before and after protocol initiation were similar in age, comorbidities, outpatient use of antiplatelet/anticoagulant medications, admission vital signs, and admission laboratory values. The median interval between admission and the first procedure was significantly shorter in the protocol group (40 vs 47 hours, p = 0.046). The proportion of patients who received packed red blood cell transfusions decreased following protocol initiation (41% vs 50%, p = 0.018). Median hospital length of stay was significantly shorter in the protocol group (5.0 vs 6.0 days, p = 0.014). Readmissions with GIB were decreased after protocol implementation (8% vs. 15%, p = 0.023). CONCLUSION Implementation of a multidisciplinary protocol for management of acute GIB was associated with earlier intervention, fewer packed red blood cell transfusions, shorter hospital length of stay, and fewer readmissions with GIB. Future research should seek to establish causal relationships between communication practices and outcomes. LEVEL OF EVIDENCE Therapeutic study, level III.
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40
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Thongbai T, Thanapirom K, Ridtitid W, Rerknimitr R, Thungsuk R, Noophun P, Wongjitrat C, Luangjaru S, Vedkijkul P, Lertkupinit C, Poonsab S, Ratanachu-ek T, Hansomburana P, Pornthisarn B, Mahachai V, Treeprasertsuk S. Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding. ASIAN BIOMED 2017; 10:115-122. [DOI: 10.5372/1905-7415.1002.471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2025]
Abstract
Abstract
Background
Acute upper gastrointestinal bleeding (UGIB) is a common gastrointestinal disease emergency and a cause of morbidity and mortality.
Objectives
To assess the clinical outcomes and explore predictive factors for mortality of elderly patients with acute UGIB.
Methods
During the study period from January 2010 to September 2011, we prospectively enrolled 981 patients presenting with UGIB from 11 hospitals (mean age ± standard deviation (SD), 59.4 ± 14.9 years; range, 17–94 years; including 661 men). Of these 981 patients, 499 (50.9%) were elderly. Basic demographic data and clinical findings, and Rockall scores were collected and calculated.
Results
We studied 499 elderly patients. Their mean age ± SD was 71.63 ± 7.65 years. The 30-day mortality rate was 9% and rebleeding was just 1%. Regression analysis showed a pulse rate >100 beats per min at first visit, red blood in a nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL were independent predictive factors of 30-day mortality.
Conclusions
Peptic ulcer bleeding is a major cause of acute UGBI in the elderly. We recommend patients with predictive factors of mortality, pulse rate >100 beats per min at first visit, red blood in nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL be closely monitored and treated promptly. Reducing mortality from peptic ulcer bleeding should focus on preventing peptic ulcer occurrence as a result of ulcerogenic medications.
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Affiliation(s)
- Thirada Thongbai
- Division of Gastroenterology , Bangkok Metropolitan Administration General Hospital , Bangkok 10100 , Thailand
| | - Kessarin Thanapirom
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Rattikorn Thungsuk
- Division of Gastroenterology , Sawanpracharak Hospital , Nakhon Sawan 60000 , Thailand
| | - Phadet Noophun
- Division of Gastroenterology , Surin Hospital , Surin 32000 , Thailand
| | - Chatchawan Wongjitrat
- Division of Gastroenterology , HRH Princess Maha Chakri Sirindhorn Medical Center–MSMC Hospital , Nakhon Nayok 26120 , Thailand
| | - Somchai Luangjaru
- Division of Gastroenterology , Maharat Nakhonratchasima Hospital , Nakhon Ratchasima 30000 , Thailand
| | - Padet Vedkijkul
- Division of Gastroenterology , Maharaj Nakhonsithammarat Hospital , Nakhon Sithammarat 80000 , Thailand
| | - Comson Lertkupinit
- Division of Gastroenterology , Chonburi Hospital , Chonburi 20000 , Thailand
| | - Swangphong Poonsab
- Division of Gastroenterology , Bangkok Hospital , Bangkok 10310 , Thailand
| | | | | | - Bubpha Pornthisarn
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Thammasat University Hospital , Pathum Thani 12120 , Thailand
| | - Varocha Mahachai
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
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Hypoalbuminemia in the outcome of patients with non-variceal upper gastrointestinal bleeding. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016. [DOI: 10.1016/j.rgmxen.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Gené E, Calvet X. ¿Sonda nasogástrica en el paciente con hemorragia digestiva alta? GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:497-9. [DOI: 10.1016/j.gastrohep.2015.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/30/2015] [Accepted: 12/21/2015] [Indexed: 12/26/2022]
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González-González JA, Vázquez-Elizondo G, Monreal-Robles R, García-Compean D, Borjas-Almaguer OD, Hernández-Velázquez B, Maldonado-Garza HJ. Hypoalbuminemia in the outcome of patients with non-variceal upper gastrointestinal bleeding. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2016; 81:183-189. [PMID: 27567195 DOI: 10.1016/j.rgmx.2016.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/20/2016] [Accepted: 03/29/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIM The role of serum albumin level in patients with non-variceal upper gastrointestinal bleeding (NVUGB) has not been extensively studied. Our aim was to evaluate the role of serum albumin on admission in terms of in-hospital mortality in patients with NVUGB. MATERIALS AND METHODS Patients admitted with NVUGB during a 4-year period were prospectively included. Demographic, clinical, and laboratory data were collected. ROC curve analysis was used to determine the cutoff value for serum albumin on admission that made a distinction between deceased patients and survivors with respect to serum albumin on admission, as well as its overall performance compared with the Rockall score. RESULTS 185 patients with NVUGB were evaluated. Men predominated (56.7%) and a mean age of 59.1±19.9 years was found. Mean serum albumin on admission was 2.9±0.9g/dl with hypoalbuminemia (< 3.5g/dl) detected on admission in 71.4% of cases. The ROC curve found that the best value for predicting hospital mortality was an albumin level of 3.1g/dl (AUROC 0.738). Mortality in patients with albumin ≥ 3.2g/dl was 1.2% compared with 11.2% in patients with albumin<3.2g/dl (P=.009; OR 9.7, 95%CI 1.2-76.5). There was no difference in overall performance between the albumin level (AUORC 0.738) and the Rockall score (AUROC 0.715) for identifying mortality. CONCLUSIONS Patients with hypoalbuminemia presenting with NVUGB have a greater in-hospital mortality rate. The serum albumin level and the Rockall score perform equally in regard to identifying the mortality rate.
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Affiliation(s)
- J A González-González
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México.
| | - G Vázquez-Elizondo
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
| | - R Monreal-Robles
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
| | - D García-Compean
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
| | - O D Borjas-Almaguer
- Departamento de Medicina Interna, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
| | - B Hernández-Velázquez
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
| | - H J Maldonado-Garza
- Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, México
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Successful Endoscopic Hemostasis Is a Protective Factor for Rebleeding and Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2016; 61:2011-8. [PMID: 26923946 DOI: 10.1007/s10620-016-4082-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 02/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Rebleeding and mortality rates remain high in patients with nonvariceal upper gastrointestinal bleeding. AIM To identify clinical and endoscopic risk factors for rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding. METHODS This study was performed in patients with nonvariceal upper gastrointestinal bleeding who underwent upper endoscopic procedures between July 2006 and February 2013. Clinical and endoscopic characteristics were compared among patients with and without rebleeding and mortality. Logistic regression analysis was performed to determine independent risk factors for rebleeding and mortality. RESULTS After excluding 64 patients, data for 689 patients with nonvariceal upper gastrointestinal bleeding were analyzed. Peptic ulcer (62.6 %) was by far the most common source of bleeding. Endoscopic intervention was performed within 24 h in 99.0 % of patients, and successful endoscopic hemostasis was possible in 80.7 % of patients. The 30-day rebleeding rate was 13.1 % (n = 93). Unsuccessful endoscopic hemostasis was found to be the only independent risk factor for rebleeding (odds ratio 79.6; 95 % confidence interval 37.8-167.6; p = 0.000). The overall 30-day mortality rate was 3.2 % (n = 23). Unsuccessful endoscopic hemostasis (odds ratio 4.9; 95 % confidence interval 1.7-13.9; p = 0.003) was also associated with increased 30-day mortality in patients with nonvariceal upper gastrointestinal bleeding. CONCLUSIONS Successful endoscopic hemostasis is an independent protective factor for both rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.
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The Novel Scoring System for 30-Day Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2016; 61:2002-10. [PMID: 26921080 DOI: 10.1007/s10620-016-4087-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/13/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although the mortality rates for non-variceal upper gastrointestinal bleeding (NVUGIB) have recently decreased, it remains a significant medical problem. AIM The main aim of this prospective multicenter database study was to construct a clinically useful predictive scoring system by using our predictors and compare its prognostic accuracy with that of the Rockall scoring system. METHODS Data were collected from consecutive patients with NVUGIB. Logistic regression analysis was performed to identify the independent predictors of 30-day mortality. Each independent predictor was assigned an integral point proportional to the odds ratio (OR) and we used the area under the curve to compare the discrimination ability between the new predictive model and the Rockall score. RESULTS The independent predictors of mortality included age >65 years [OR 2.627; 95 % confidence interval (CI) 1.298-5.318], hemodynamic instability (OR 2.217; 95 % CI 1.069-4.597), serum blood urea nitrogen level >40 mg/dL (OR 1.895; 95 % CI 1.029-3.490), active bleeding at endoscopy (OR 2.434; 95 % CI 1.283-4.616), transfusions (OR 3.811; 95 % CI 1.640-8.857), comorbidities (OR 3.481; 95 % CI 1.405-8.624), and rebleeding (OR 10.581; 95 % CI 5.590-20.030). The new predictive model showed a high discrimination capability and was significantly superior to the Rockall score in predicting the risk of death (OR 0.837;95 % CI 0.818-0.855 vs. 0.761; 0.739-0.782; P = 0.0123). CONCLUSIONS The new predictive score was significantly more accurate than the Rockall score in predicting death in NVUGIB patients. We need to prospectively validate the accuracy of this score for predicting mortality in NVUGIB patients.
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Sinclair M, Smith N, McPherson S. Improving the care of patients with gastrointestinal bleeding. Br J Hosp Med (Lond) 2016; 77:322-3. [PMID: 27269745 DOI: 10.12968/hmed.2016.77.6.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Martin Sinclair
- Consultant Upper Gastrointestinal Surgeon in the Department of Surgery, Ipswich Hospital NHS Trust, Ipswich
| | - Neil Smith
- Deputy Chief Executive, NCEPOD, London EC1M 4DZ
| | - Simon McPherson
- Consultant Vascular and Interventional Radiologist in the Department of Radiology, Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds
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47
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Kim JW, Park HJ, Jang JY, Oh CH, Shim JJ, Lee CK, Chang YW. When Should Antiplatelet Agents Be Resumed After Successful Endoscopic Hemostasis in Patients with Peptic Ulcer Bleeding? Dig Dis Sci 2016; 61:1611-21. [PMID: 26846117 DOI: 10.1007/s10620-016-4052-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/21/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND During treatment for peptic ulcer bleeding (PUB), it is imperative to determine the effect of antiplatelet agents on recurrent bleeding in order to balance risks and benefits. AIMS We compared the rate of recurrent bleeding in antiplatelet users and non-users. METHODS This retrospective study analyzed prospectively collected data from PUB patients treated by endoscopic modalities between August 2007 and December 2014. We evaluated and compared the rate of recurrent bleeding within 30 days in antiplatelet users and non-users; we also categorized antiplatelet users into continuation (≤3 days) and withdrawal (>3 days) groups. RESULTS A total of 490 patients were enrolled in the study, 302 (61.6 %) and 188 (38.4 %) in the non-user and antiplatelet user groups, respectively. The recurrent bleeding rate among antiplatelet users (10.1 %) was significantly higher than that among non-users (5.0 %; p = 0.029). Among 188 antiplatelet users, 51 (27.1 %) and 137 (72.9 %) were assigned to the continuation and withdrawal groups, respectively. The rate of recurrent bleeding did not differ significantly between groups (11.7 vs. 5.9 %, p = 0.241). Multivariate analysis revealed chronic kidney disease as a risk factor [odds ratio (OR) 2.890, 95 % confidence interval (CI) 1.079-7.742, p = 0.035]. However, antiplatelet use (OR 1.691, 95 % CI 0.813-3.517, p = 0.160) was not. CONCLUSIONS This study highlights the need for clinicians to consider underlying diseases in antiplatelet users under the appropriate antiplatelet therapy during the post-hemostasis period. Furthermore, the optimal time to resume antiplatelet agents may be 3 days after successful endoscopic hemostasis in patients with PUB.
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Affiliation(s)
- Jung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea
| | - Hyun Jin Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea
| | - Jae-Young Jang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea.
| | - Chi Hyuk Oh
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - Jae-Jun Shim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea
| | - Chang Kyun Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea
| | - Young Woon Chang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemoongu, Seoul, 130-702, Republic of Korea
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Do NSAIDs and ASA Cause More Upper Gastrointestinal Bleeding in Elderly than Adults? Gastroenterol Res Pract 2016; 2016:8419304. [PMID: 26880898 PMCID: PMC4736379 DOI: 10.1155/2016/8419304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/09/2015] [Indexed: 01/26/2023] Open
Abstract
Purpose. NSAIDs and ASA may cause upper gastrointestinal bleeding (UGIB) both in adults and in elderly. There is no study that compares this increased bleeding risk between adult and elderly subjects. Methods. A total of 524 patients with UGIB were included in this study. The data of patients were, respectively, analyzed. Results. NSAIDs and ASA-associated UGIB rates were similar between <65 years (345 patients) (group 1) and ≥65 years (179 patients) (group 2) (28.4% versus 23.5%, p = 0.225 and 13% versus 19%, p = 0.071, resp.). Warfarin-associated UGIB was found significantly higher in group 2 than group 1. Elderly patients with NSAID-associated UGIB had significantly higher length of stay (LoS) and CoH than adult patients with NSAID-associated UGIB (p = 0.002 and 0.001, resp.). Elderly patients with ASA-associated UGIB had significantly higher CoH than adult patients with NSAID-associated UGIB. Conclusions. Using NSAIDs without gastroprotective drugs or using ASA with gastroprotective drugs in elderly patients is as safe as in adult patients. Not only should adding gastroprotective drugs to ASA or NSAID be based on their risk of UGIB, but the cost of hospitalization of ASA or NSAID-associated UGIB should be considered.
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Monteiro S, Gonçalves TC, Magalhães J, Cotter J. Upper gastrointestinal bleeding risk scores: Who, when and why? World J Gastrointest Pathophysiol 2016; 7:86-96. [PMID: 26909231 PMCID: PMC4753192 DOI: 10.4291/wjgp.v7.i1.86] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/02/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.
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50
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Lee YJ, Min BR, Kim ES, Park KS, Cho KB, Jang BK, Chung WJ, Hwang JS, Jeon SW. Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding. Korean J Intern Med 2016; 31:54-64. [PMID: 26767858 PMCID: PMC4712435 DOI: 10.3904/kjim.2016.31.1.54] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/28/2014] [Accepted: 11/13/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency that can be life threatening. This study evaluated predictive factors of 30-day mortality in patients with this condition. METHODS A prospective observational study was conducted at a single hospital between April 2010 and November 2012, and 336 patients with symptoms and signs of gastrointestinal bleeding were consecutively enrolled. Clinical characteristics and endoscopic findings were reviewed to identify potential factors associated with 30-day mortality. RESULTS Overall, 184 patients were included in the study (men, 79.3%; mean age, 59.81 years), and 16 patients died within 30 days (8.7%). Multivariate analyses revealed that comorbidity of diabetes mellitus (DM) or metastatic malignancy, age ≥ 65 years, and hypotension (systolic pressure < 90 mmHg) during hospitalization were significant predictive factors of 30-day mortality. CONCLUSIONS Comorbidity of DM or metastatic malignancy, age ≥ 65 years, and hemodynamic instability during hospitalization were predictors of 30-day mortality in patients with NVUGIB. These results will help guide the management of patients with this condition.
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Affiliation(s)
- Yoo Jin Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Bo Ram Min
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Eun Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Correspondence to Eun Soo Kim, M.D. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: +82-53-250-8096 Fax: +82-53-250-7442 E-mail:
| | - Kyung Sik Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang Bum Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Byoung Kuk Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Seok Hwang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Woo Jeon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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