Characteristics and outcomes of upper gastrointestinal hemorrhage in a tertiary referral hospital

A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting.

METHODS

This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted.

RESULTS

The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data.

CONCLUSION

Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.

Mallory-Weiss syndrome from giant gastric trichobezoar: A case report

BACKGROUND

Mallory-Weiss syndrome (MWS), representing a linear mucosal laceration at the gastroesophageal junction, is a quite frequent cause of upper gastrointestinal bleeding, usually induced by habitual vomiting. The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter, collectively inducing ischemic mucosal damage. Usually, MWS is associated with all vomiting conditions, but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies.

CASE SUMMARY

We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress, the latter of which deteriorated following her parents’ divorce. The patient, who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period, presented with a 2-mo history of habitual vomiting, hematemesis, and a slight depressive mood. Ultimately, a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair; this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred. The relative isolation in her living status without school attendance had worsened her compulsory habit. The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible. The patient underwent surgical intervention instead, which culminated in complete removal of the mass.

CONCLUSION

According to our knowledge, this is the first-ever described case of MWS due to an excessively large trichobezoar.

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

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.

Effect of acute upper gastrointestinal bleeding manifestations at admission on the in-hospital outcomes of liver cirrhosis: hematemesis versus melena without hematemesis

OBJECTIVES

Patients with acute upper gastrointestinal bleeding (AUGIB) often manifest as hematemesis and melena. Theoretically, hematemesis will carry worse outcomes of AUGIB. However, there is little real-world evidence. We aimed to compare the outcomes of hematemesis versus no hematemesis as a clinical manifestation of AUGIB at admission in cirrhotic patients.

METHODS

All cirrhotic patients with AUGIB who were consecutively admitted to our hospital from January 2010 to June 2014 were considered in this retrospective study. Patients were divided into hematemesis with or without melena and melena alone without hematemesis at admission. A 1:1 propensity score matching analysis was performed. Subgroup analyses were performed based on systemic hemodynamics (stable and unstable) and Child-Pugh class (A and B+C). Sensitivity analyses were conducted in patients with moderate and severe esophageal varices confirmed on endoscopy. Primary outcomes included five-day rebleeding and in-hospital death.

RESULTS

Overall, 793 patients were included. Patients with hematemesis at admission had significantly higher five-day rebleeding rate (17.4 versus 10.1%, P = 0.004) and in-hospital mortality (7.9 versus 2.4%, P = 0.001) than those without hematemesis. In the propensity score matching analyses, 358 patients were included with similar Child-Pugh score (P = 0.227) and MELD score (P = 0.881) between the two groups; five-day rebleeding rate (19.0 versus 10.6%, P = 0.026) and in-hospital mortality (8.4 versus 2.8%, P = 0.021) remained significantly higher in patients with hematemesis. In the subgroup and sensitivity analyses, the statistical results were also similar.

CONCLUSIONS

Hematemesis at admission indicates worse outcomes of cirrhotic patients with AUGIB, which is useful for the risk stratification of AUGIB.

Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms

BACKGROUND

Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation.

AIM

To investigate the incidence and risk factors of the MWT during esophageal ESD.

METHODS

From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored.

RESULTS

A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration.

CONCLUSION

The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis

Background

Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)?

Objectives

To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB.

Materials and methods

We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms “gastrointestinal bleeding”; “gastrointestinal hemorrhage”; “embolization”; “embolization, therapeutic”; and “surgery” were used ((“gastrointestinal bleeding” or “gastrointestinal hemorrhage”) and (“embolization” or “embolization, therapeutic”) and “surgery”)). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention.

Results

Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature.

Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I² = 43% [random effects]). Significant heterogeneity was found among the studies.

Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I² = 4% [fixed effects]).

Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I² = 26% [fixed effects]).

Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I² = 56% [random effects]). A great degree of heterogeneity was found among the studies.

Conclusions

The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials.

Limitations

The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.

Initial Assessment, Risk Stratification, and Early Management of Acute Nonvariceal Upper Gastrointestinal Hemorrhage

Inhospital mortality from nonvariceal upper gastrointestinal bleeding has improved with advances in medical and endoscopy therapy. Initial management includes resuscitation, hemodynamic monitoring, proton pump inhibitor therapy, and restrictive blood transfusion. Risk stratification scores help triage bleeding severity and provide prognosis. Upper endoscopy is recommended within 24 hours of presentation; select patients at lowest risk may be effectively treated as outpatients. Emergent endoscopy within 12 hours does not improve clinical outcomes, including mortality, rebleeding, or need for surgery, despite an increased use of endoscopic treatment. There may be a benefit to emergent endoscopy in patients with evidence of active bleeding.

The Cutting Edge: Doppler Probe in Guiding Endoscopic Hemostasis

This article examines use of the Doppler endoscopic probe (DEP) for risk stratification and as a guide to definitive hemostasis of nonvariceal upper gastrointestinal (NVUGI) bleeding and colonic diverticular hemorrhage. Studies report that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared with those without such SRH. Lesions with a persistently positive DEP signal after endoscopic hemostasis have a higher 30-day rebleeding rate. Studies document arterial blood flow underneath stigmata of recent hemorrhage as a risk factor for rebleeding of focal nonvariceal gastrointestinal lesions. With DEP probe as a guide, rates of definitive endoscopic hemostasis and clinical outcomes are improved compared with standard visually guided treatment.

A rational approach to the patient with hematochezia

PURPOSE OF REVIEW

Hematochezia is a common clinical presentation, with significant morbidity and economic burden. These patients often require costly interventions including hospitalization, blood transfusions, and radiologic or endoscopic procedures. The purpose of this review is to give a rational, concise approach to the patient with hematochezia, with special consideration of recent advances in the literature.

RECENT FINDINGS

Recent studies pertaining to hematochezia have evaluated risk stratification, endoscopic intervention, evaluation of small bowel bleeding, and management of anticoagulation.

SUMMARY

A step-wise approach to hematochezia helps determine the cause and provide the appropriate management of these patients. We propose five steps beginning with hemodynamic assessment and risk stratification, then focused history and physical examination, endoscopic intervention when warranted, and consideration of small bowel bleeding in selected instances.

Approach to the Patient With Hematochezia

The evaluation of the patient with hematochezia can be complex because of the broad differential diagnosis and the number of management strategies available. In this article, a simplified approach to the history and physical examination is presented, with management illustrated in a case-oriented manner.

What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding?

PURPOSE OF REVIEW

There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP).

RECENT FINDINGS

Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).

Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding

BACKGROUND AND AIM

Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB.

METHODS

During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis.

RESULTS

A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization.

CONCLUSION

In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB.

Outcome of acute upper gastrointestinal bleeding in patients with coronary artery disease: A matched case-control study

BACKGROUND/AIM

The risk of upper gastrointestinal bleeding (UGIB) increases in patients with coronary artery disease (CAD) due to the frequent use of antiplatelets. There is some data reporting on treatment outcomes in CAD patients presenting with UGIB. We aim to determine the clinical characteristics and outcomes of UGIB in patients with CAD, compared with non-CAD patients.

PATIENTS AND METHODS

We conducted a prospective multi-center cohort study (THAI UGIB-2010) that enrolled 981 consecutive hospitalized patients with acute UGIB. A matched case-control analysis using this database, which was collected from 11 tertiary referral hospitals in Thailand between January 2010 and September 2011, was performed.

RESULT

Of 981 hospitalized patients with UGIB, there were 61 CAD patients and 244 gender-matched non-CAD patients (ratio 1:4). UGIB patients with CAD were significantly older, and had more frequently used antiplatelets and warfarin than in non-CAD patients. Compared with non-CAD, the CAD patients had significantly higher Glasgow-Blatchford score, full and pre-endoscopic Rockall score and full. Peptic ulcer in CAD patients was identified more often than in non-CAD patients. UGIB patients with CAD and non-CAD had similar outcomes with regard to mortality rate, re-bleeding, surgery, embolization, and packed erythrocyte transfusion. However, CAD patients had longer duration of hospital stays than non-CAD patients. Two CAD patients died from cardiac arrest after endoscopy, whereas three non-CAD patients died from pneumonia and acute renal failure during their hospitalization.

CONCLUSION

In Thailand, patients presenting with UGIB, concomitant CAD did not affect clinical outcome of treatment, compared with non-CAD patients, except for longer hospital stay.

Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding

Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.

Accommodation in a refugee shelter as a risk factor for peptic ulcer bleeding after the Great East Japan Earthquake: a case-control study of 329 patients

BACKGROUND

We have reported that the total number of peptic ulcers (PUs) had increased 1.5-fold after the Great East Japan Earthquake compared with those of the previous year, and that hemorrhagic ulcers were more prominently increased by 2.2-fold. The aim of this study is to determine the risk factors for bleeding ulcers after the Great East Japan Earthquake.

METHODS

Clinical data of all peptic ulcer subjects endoscopically detected at the 7 major hospitals in the middle of the stricken area during the 3 months after the earthquake were retrospectively collected. Based on endoscopic and laboratory findings, peptic ulcer cases were divided into 227 bleeding ulcer cases and 102 non-bleeding controls. Other than ordinary risk factors for bleeding ulcers, the refugee shelter was included in the analysis as a unique confounder after the earthquake. Multiple logistic regression analyses were used to adjust for potential confounders.

RESULTS

Eighty-seven (27%) of 329 PUs emerged from refuge shelters, and the majority (76 of 87) of PUs occurring in such shelters was the bleeding type. Multivariate regression showed that residence in a shelter was a strong risk factor for ulcer bleeding with OR (95% CI): 4.4 (2.1-9.6, p < 0.0001), independent of the progressiveness of ulcer diseases.

CONCLUSIONS

Accommodation in a refugee shelter can be a strong risk factor for ulcer bleeding after a large-scale disaster. Since acid-suppressive drugs are supposed to decrease the risk for stress-induced ulcer bleeding, our results will encourage effective use of a limited medical resource in such catastrophic events.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

A systematic review of transarterial embolization versus emergency surgery in treatment of major nonvariceal upper gastrointestinal bleeding

Background

Emergency surgery or transarterial embolization (TAE) are options for the treatment of recurrent or refractory nonvariceal upper gastrointestinal bleeding. Surgery has the disadvantage of high rates of postoperative morbidity and mortality. Embolization has become more available and has the advantage of avoiding laparotomy in this often unfit and elderly population.

Objective

To carry out a systematic review and meta-analysis of all studies that have directly compared TAE with emergency surgery in the treatment of major upper gastrointestinal bleeding that has failed therapeutic upper gastrointestinal endoscopy.

Methods

A literature search of Ovid MEDLINE, Embase, and Google Scholar was performed. The primary outcomes were all-cause mortality and rates of rebleeding. The secondary outcomes were length of stay and postoperative complications.

Results

A total of nine studies with 711 patients (347 who had embolization and 364 who had surgery) were analyzed. Patients in the TAE group were more likely to have ischemic heart disease (odds ratio [OR] =1.99; 95% confidence interval [CI]: 1.33, 2.98; P=0.0008; I²=67% [random effects model]) and be coagulopathic (pooled OR =2.23; 95% CI: 1.29, 3.87; P=0.004; I²=33% [fixed effects model]). Compared with TAE, surgery was associated with a lower risk of rebleeding (OR =0.41; 95% CI: 0.22, 0.77; P<0.0001; I²=55% [random effects]). There was no difference in mortality (OR =0.70; 95% CI: 0.48, 1.02; P=0.06; I²=44% [fixed effects]) between TAE and surgery.

Conclusion

When compared with surgery, TAE had a significant increased risk of rebleeding rates after TAE; however, there were no differences in mortality rates. These findings are subject to multiple sources of bias due to poor quality studies. These findings support the need for a well-designed clinical trial to ascertain which technique is superior.

Risk stratification of upper GI bleeding with an esophageal capsule

BACKGROUND

Analysis of upper GI bleeding (UGIB) presentations to our institutions suggests that many patients admitted for endoscopic investigation could be managed safely as outpatients.

OBJECTIVE

To learn whether an esophageal capsule could identify a low-risk group of patients with UGIB who could safely wait for elective EGD.

DESIGN

Diagnostic, nonrandomized, single-blind (investigator) study.

SETTING

Three tertiary-care referral centers.

PATIENTS

Eighty-three consecutive adult patients referred for management of UGIB.

INTERVENTION

A capsule endoscopy (CE) was performed before EGD for the investigation and management of UGIB.

MAIN OUTCOME MEASUREMENTS

Detection rates of UGIB source and identification of a low-risk group of patients who would have been suitable for outpatient EGD based on CE findings.

RESULTS

In total, 62 of 83 patients (75%) had a cause for bleeding identified. Findings were concordant across both modalities in 34 patients (55%). Twenty-one patients (38%) with positive EGD results had negative CE results, 7 of whom were due to lack of duodenal visualization alone. However, 7 of 28 patients (25%) with normal EGD results had positive CE results. The subgroup of patients with duodenal visualization on CE, 23 of 25 (92%), were concordant with EGD for low-risk lesions that would have been suitable for outpatient management.

LIMITATIONS

Low duodenal visualization rates with CE and low concordance between EGD and CE.

CONCLUSION

Although CE is not currently ready to be used as a triage tool, when duodenal visualization was achieved CE correlated well with EGD findings and identified 92% of patients who may have been managed as outpatients.

Transfusion strategies for acute upper gastrointestinal bleeding

BACKGROUND

The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.

METHODS

We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.

RESULTS

A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.

CONCLUSIONS

As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).