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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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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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Sutton MM, Gregoski MJ, Rockey DC. Delay in post-endoscopic refeeding in patients with upper GI bleeding leads to increased hospital length of stay. Am J Med Sci 2024:S0002-9629(24)00010-7. [PMID: 38253257 DOI: 10.1016/j.amjms.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/26/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Patients with acute upper gastrointestinal bleeding (UGIB) are made NPO prior to endoscopy. It is standard practice in those found to have low risk lesions to immediately resume a usual diet. Here, we evaluated refeeding practices in hospitalized patients with UGIB after endoscopy. METHODS In this retrospective single-center cross-sectional study, we examined patients over the age of 18 with acute UGIB and low risk or no endoscopic lesion(s). Appropriate refeeding was categorically defined as resuming normal diet ≤ 4 h post-endoscopy. RESULTS Of 230 patients (mean age, 62 years; 57% female) with acute UGIB and low-risk lesions or no lesion(s), 96 [41% (95% CI: 35% to 48%)] received their usual diet within 4 h after EGD. For the remaining 134 patients, refeeding was delayed on average from 13 (NPO until regular diet) to 31 (NPO until liquid diet, then regular diet) hours. Baseline clinical features were identical in patients who received their regular diet within 4 h after EGD and those who did not. Hospital length of stay was shorter in patients receiving usual diets promptly (5.3 days vs. 6.4 days, p = 0.03). Patients in an ICU at the time of their endoscopy had a statistically significantly higher probability of not being refed appropriately [OR 2.371, 95% CI 1.191-4.722). CONCLUSIONS Inappropriate dietary restrictions are frequent in patients with UGIB caused by low risk lesions. This delay in refeeding leads to increased length of hospital stay - suggesting that appropriate refeeding is an opportunity to improve patient care.
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Affiliation(s)
- Michael M Sutton
- Department of Internal Medicine, Medical University of South Carolina, Charleston, S.C. USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, S.C. USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 908, Charleston, S.C. 29425, USA.
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Kishino T, Aoki T, Sadashima E, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Kaise M, Nagata N. Early feeding reduces length of hospital stay in patients with acute lower gastrointestinal bleeding: A large multicentre cohort study. Colorectal Dis 2023; 25:2206-2216. [PMID: 37787161 DOI: 10.1111/codi.16751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 10/04/2023]
Abstract
AIM No studies have compared the clinical outcomes of early and delayed feeding in patients with acute lower gastrointestinal bleeding (ALGIB). This study aimed to evaluate the benefits and risks of early feeding in a nationwide cohort of patients with ALGIB in whom haemostasis was achieved. METHODS We reviewed data for 5910 patients with ALGIB in whom haemostasis was achieved and feeding was resumed within 3 days after colonoscopy at 49 hospitals across Japan (CODE BLUE-J Study). Patients were divided into an early feeding group (≤1 day, n = 3324) and a delayed feeding group (2-3 days, n = 2586). Clinical outcomes were compared between the groups by propensity matching analysis of 1508 pairs. RESULTS There was no significant difference between the early and delayed feeding groups in the rebleeding rate within 7 days after colonoscopy (9.4% vs. 8.0%; p = 0.196) or in the rebleeding rate within 30 days (11.4% vs. 11.5%; p = 0.909). There was also no significant between-group difference in the need for interventional radiology or surgery or in mortality. However, the median length of hospital stay after colonoscopy was significantly shorter in the early feeding group (5 vs. 7 days; p < 0.001). These results were unchanged when subgroups of presumptive and definitive colonic diverticular bleeding were compared. CONCLUSION The findings of this nationwide study suggest that early feeding after haemostasis can shorten the hospital stay in patients with ALGIB without increasing the risk of rebleeding.
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Affiliation(s)
- Takaaki Kishino
- Department of Gastroenterology and Hepatology, Centre for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eiji Sadashima
- Department of Medical Research Institute, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Centre Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Centre Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Centre, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Centre for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Emergency and Critical Care Centre, Saiseikai Yokohama Tobu Hospital, Kanagawa, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Centre, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Centre, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
- Department of Gastroenterology and Hepatology, National Centre for Global Health and Medicine, Tokyo, Japan
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Busch RA, Collier BR, Kaspar MB. When Can we Feed after a Gastrointestinal Bleed? Curr Gastroenterol Rep 2022; 24:18-25. [PMID: 35147865 DOI: 10.1007/s11894-022-00839-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Gastrointestinal (GI) bleeding can carry minimal or significant risk for recurrent hemorrhage. Timing of feeding after GI bleeding remains an area of debate, and here we review the evidence supporting recommendations. RECENT FINDINGS Improved understanding of the pathophysiology of GI bleeding and the evolution of treatment strategies has significantly altered the management of GI bleeding and the associated propensity for rebleeding. Early feeding following peptic ulcer bleeding remains ill-advised for high risk lesions while early initiation of liquid diets following cessation of esophageal variceal bleeding is appropriate and shortens hospital stays. Time to feeding following GI bleeding is inherently based on the disease etiology, severity, and risk of recurrent hemorrhage. With evolving standards of care, rates of rebleeding following endoscopic hemostasis are decreasing. Some evidence exists for early feeding however, larger multi-center trials are needed to help optimize timing of feeding in higher risk lesions.
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Affiliation(s)
- Rebecca A Busch
- Department of Surgery, Division of Acute Care and Regional General Surgery, University of Wisconsin- Madison, Madison, WI, USA.
| | - Bryan R Collier
- Department of Surgery, Section of Acute Care Surgery, Virginia Technical Institute Carilion School of Medicine, Roanoke, VA, USA
| | - Matthew B Kaspar
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Thibault R, Abbasoglu O, Ioannou E, Meija L, Ottens-Oussoren K, Pichard C, Rothenberg E, Rubin D, Siljamäki-Ojansuu U, Vaillant MF, Bischoff SC. ESPEN guideline on hospital nutrition. Clin Nutr 2021; 40:5684-5709. [PMID: 34742138 DOI: 10.1016/j.clnu.2021.09.039] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 12/16/2022]
Abstract
In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.
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Affiliation(s)
- Ronan Thibault
- Unité de Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer Institute, NuMeCan, Rennes, France.
| | - Osman Abbasoglu
- Department of Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elina Ioannou
- Department of Nutrition, Limassol General Hospital, Cyprus
| | - Laila Meija
- Riga Stradins University, Pauls Stradins Clinical University Hospital, Latvia
| | - Karen Ottens-Oussoren
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Claude Pichard
- Unité de Nutrition, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabet Rothenberg
- Faculty of Health Sciences Kristianstad University Kristianstad Sweden, Sweden
| | - Diana Rubin
- Vivantes Netzwerk für Gesundheit GmbH, Humboldt Klinikum und Klinikum Spandau, Berlin, Germany
| | | | | | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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Tarar ZI, Zafar MU, Farooq U, Ghous G, Shoukat HMH, Kuwajima V. Does Performing Endoscopy Sooner Have an Impact on Outcomes in Patients With Acute Nonvariceal Upper Gastrointestinal Hemorrhage? A Systematic Review. Cureus 2021; 13:e16092. [PMID: 34367748 PMCID: PMC8330500 DOI: 10.7759/cureus.16092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Endoscopy is the cornerstone for the diagnosis and treatment of nonvariceal upper gastrointestinal bleeding. Regarding the management of nonvariceal bleeding, the administration of crystalloid solution and proton pump inhibitors before endoscopy is well established, but the optimal timing of endoscopy has been a matter of debate and a subject of many investigational studies. The need for urgent endoscopy arises to provide prompt redress to acute bleeding, decrease the length of stay, and lower mortality from ongoing bleeding. Objective This study aimed to determine if endoscopy performed within 24 hours of presentation improves outcomes in terms of mortality, hospital length of stay, and rebleeding in individuals presenting with nonvariceal upper gastrointestinal bleed with any risk. Methodology We performed a systematic review of two large databases (PubMed and Google Scholar) to incorporate all studies published after 2000. We included studies with nonvariceal upper gastrointestinal bleeding and excluded those reporting variceal gastrointestinal hemorrhage. Results We reviewed eight studies that qualified after meeting our inclusion and exclusion criteria. We divided these studies into three separate groups based on the timing of endoscopy. Only two studies found a difference in mortality that was statistically significant in patients who underwent endoscopy within 24 hours of presentation. One study showed lower mortality in a patient who underwent urgent endoscopy, but it did not reach statistical significance. Other studies did not show any statistical difference in mortality, hospital length of stay, and rebleeding rates. The studies showed conflicting evidence on the amount of blood transfusion, though urgent endoscopy was found to be difficult in few studies due to blood obscuring the lesion. Conclusions While data suggest that there is a potential benefit in performing endoscopy sooner, there is no concrete evidence to point to a particular time range. Before performing endoscopy, the American Society for Gastrointestinal Endoscopy (2012) recommends adequate resuscitation with crystalloid solutions, blood transfusions, and antisecretory and prokinetic agent therapy. More investigational studies are needed to formulate a time-sensitive flow sheet to approach endoscopy in patients with nonvariceal upper gastrointestinal bleeding. A strict criterion is also needed to delineate patients into low-risk and high-risk groups. Doing so would provide a systematic approach to help with mortality, rebleeding, and healthcare resource utilization.
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Affiliation(s)
| | | | - Umer Farooq
- Internal Medicine, Loyola Medicine, MacNeal Hospital, Berwyn, USA
| | - Ghulam Ghous
- Hematology/Oncology, University of Missouri, Columbia, USA
| | | | - Vanessa Kuwajima
- Gastroenterology and Hepatology, University of Missouri, Columbia, USA
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Optimal Timing of Feeding After Endoscopic Hemostasis in Patients With Peptic Ulcer Bleeding: A Randomized, Noninferiority Trial (CRIS KCT0001019). Am J Gastroenterol 2020; 115:548-554. [PMID: 32205642 DOI: 10.14309/ajg.0000000000000584] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The optimal duration of fasting after endoscopic hemostasis in patients with peptic ulcer bleeding has not yet been determined. We investigated the appropriate timing of feeding after endoscopic hemostasis in patients with high-risk peptic ulcer bleeding. METHODS This study was a randomized, single center, noninferiority trial. Between February 2014 and March 2019, consecutive patients with peptic ulcer bleeding were randomized to resume feeding either 24 or 48 hours after successful endoscopic hemostasis. A total of 209 eligible patients were included in the intention-to-treat analysis and 200 in the per-protocol (PP) analysis. The primary outcome measure was recurrent bleeding within 7 days of hemostasis. Noninferiority testing was performed in the PP population, and the noninferiority margin was set at 10%. Secondary outcomes included 30-day rebleeding and mortality, transfusion requirements, and length of hospital stay. RESULTS Recurrent bleeding rates at 7 days were 7.9% in the 24-hour group and 4.0% in the 48-hour group in the PP analysis; tests for noninferiority did not reach statistical significance (difference: 3.9%, 95% confidence interval [CI]: -2.7 to 10.5, P value for noninferiority = 0.034). The recurrent bleeding rates within 30 days were 10.9% and 4.0% in the 24- and 48-hour groups (difference: 6.9%, 95% CI: -0.5 to 14.2), and the 30-day mortality rates were 5.9% and 14.1%, respectively (difference: -8.2%, 95% CI: -16.5 to 0.1) in the PP analysis. The transfusion requirement and the length of hospital stay were similar between the 2 groups. DISCUSSION Early refeeding at 24 hours after endoscopic hemostasis is not noninferior to later refeeding at 48 hours for rebleeding in patients with high-risk peptic ulcer bleeding. Our results do not allow a recommendation of refeeding at 24 hours, rather than later refeeding in this population.
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Kim SS, Kim KU, Kim SJ, Seo SI, Kim HS, Jang MK, Kim HY, Shin WG. Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal bleeding. Korean J Intern Med 2019; 34:288-295. [PMID: 29232942 PMCID: PMC6406092 DOI: 10.3904/kjim.2016.406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 07/06/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIMS Selecting patients with an urgent need for endoscopic hemostasis is difficult based only on simple parameters of presumed acute upper gastrointestinal bleeding. This study assessed easily applicable factors to predict cases in need of urgent endoscopic hemostasis due to acute upper gastrointestinal bleeding. METHODS The consecutively included patients were divided into the endoscopic hemostasis and nonendoscopic hemostasis groups. We reviewed the enrolled patients' medical records and analyzed various variables and parameters for acute upper gastrointestinal bleeding outcomes such as demographic factors, comorbidities, symptoms, signs, laboratory findings, rebleeding rate, and mortality to evaluate simple predictive factors for endoscopic treatment. RESULTS A total of 613 patients were analyzed, including 329 patients in the endoscopic hemostasis and 284 patients in the non-endoscopic hemostasis groups. In the multivariate analysis, a bloody nasogastric lavage (adjusted odds ratio [AOR], 6.786; 95% confidence interval [CI], 3.990 to 11.543; p < 0.0001) and a hemoglobin level less than 8.6 g/dL (AOR, 1.768; 95% CI, 1.028 to 3.039; p = 0.039) were independent predictors for endoscopic hemostasis. Significant differences in the morbidity rates of endoscopic hemostasis were detected between the group with no predictive factors and the group with one or more predictive factors (OR, 2.677; 95% CI, 1.920 to 3.733; p < 0.0001). CONCLUSION A bloody nasogastric lavage and hemoglobin < 8.6 g/dL were independent predictors of endoscopic hemostasis in patients with acute upper gastrointestinal bleeding.
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Affiliation(s)
| | | | | | | | | | | | | | - Woon Geon Shin
- Correspondence to Woon Geon Shin, M.D. Division of Gastroenterology, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, 150 Seongan-ro, Gangdong-gu, Seoul 05355, Korea Tel: +82-2-2225-2814 Fax: +82-2-478-6925 E-mail:
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10
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Affiliation(s)
- Loren Laine
- From the Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven - both in Connecticut
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11
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Fonseca J, Meira T, Nunes A, Santos CA. Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:128-32. [PMID: 25003265 DOI: 10.1590/s0004-28032014000200011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/20/2014] [Indexed: 11/22/2022]
Abstract
CONTEXT Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. OBJECTIVES The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. METHODS From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake. RESULTS From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. CONCLUSIONS Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.
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Affiliation(s)
- Jorge Fonseca
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Tânia Meira
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Ana Nunes
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Carla Adriana Santos
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
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Abstract
This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy.
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Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut 06520-8019, USA.
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13
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Primer consenso español sobre el tratamiento de la hemorragia digestiva por úlcera péptica. Med Clin (Barc) 2010; 135:608-16. [DOI: 10.1016/j.medcli.2010.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 01/26/2023]
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Chaparro M, Barbero A, Martín L, Esteban C, Espinosa L, de la Morena F, Sánchez A, Martín I, Santander C, Moreno-Otero R, Gisbert JP. Prospective evaluation of a clinical guideline recommending early patients discharge in bleeding peptic ulcer. J Gastroenterol Hepatol 2010; 25:1525-9. [PMID: 20796150 DOI: 10.1111/j.1440-1746.2010.06374.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM To validate an early discharge policy in patients admitted with upper gastrointestinal bleeding (UGIB) due to ulcers. METHODS Patients with gastroduodenal ulcer or erosive gastritis/duodenitis were included in a previous study aiming to develop a practice guideline for early discharge of patients with UGIB. Variables associated with unfavorable evolution were analyzed in order to identify patients with low-risk of re-bleeding. After that, a one-year prospective analysis of all UGIB episodes was carried out. RESULTS A total of 341 patients were identified in the retrospective study. Variables associated with unfavorable evolution were: systolic blood pressure < or = 100 mmHg, heart rate > or = 100 bpm, and a Forrest endoscopic classification of severe. 10% of patients were immediately discharged; however, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 34% of patients. A total of 77 patients were included in the prospective analysis. Although only 19.5% of patients were immediately discharged without complications, 29 patients (37.7%) were theoretically suitable for early discharge. CONCLUSIONS Patients with UGIB who have clean-based ulcers and are stable on admission can be safely discharged immediately after endoscopy. Implementation of the clinical practice guideline safely reduced hospital admission for those patients.
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Affiliation(s)
- María Chaparro
- Gastroenterology Unit, La Princesa University Hospital and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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15
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Abstract
Upper gastrointestinal bleeding from peptic ulcer disease is a common clinical event, resulting in considerable patient morbidity and significant health care costs. Inhibiting gastric acid secretion is a key component in improving clinical outcomes, including reducing rebleeding, transfusion requirements, and surgery. Raising intragastric pH promotes clot stability and reduces the influences of gastric acid and pepsin. Patients with high-risk stigmata for ulcer bleeding (arterial bleeding, nonbleeding visible vessels, and adherent clots) benefit significantly from and should receive high-dose intravenous proton pump inhibitors (PPIs) after successful endoscopic hemostasis. For patients with low-risk stigmata (flat spots or clean ulcer base), oral PPI therapy alone is sufficient. For oozing bleeding (an intermediate risk finding), successful endoscopic hemostasis and oral PPI are recommended. Using intravenous PPIs before endoscopy appears to reduce the frequency of finding high-risk stigmata on later endoscopy, but has not been shown to improve clinical outcomes. High-dose oral PPIs may be as effective as intravenous infusion in achieving positive clinical outcomes, but this has not been documented by randomized studies and its cost-effectiveness is unclear.
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Cho HS, Han DS, Ahn SB, Byun TJ, Kim TY, Eun CS, Jeon YC, Sohn JH. Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy. Gut Liver 2009; 3:266-70. [PMID: 20431759 PMCID: PMC2852733 DOI: 10.5009/gnl.2009.3.4.266] [Citation(s) in RCA: 7] [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: 04/07/2009] [Accepted: 08/17/2009] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIMS The optimal timing for interventional endoscopy in bleeding peptic ulcer disease is controversial. This study compared the outcomes between early endoscopy and delayed endoscopy in patients with bleeding peptic ulcer disease. METHODS We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer disease who visited the emergency room between May 2006 and September 2007. Patients were categorized into two groups: the early-endoscopy group (admitted during the daytime or at night with prompt endoscopic management) and the delayed-endoscopy group (admitted at night or during weekends, with endoscopic management delayed until the next day). We compared the clinical outcomes of endoscopy between the two groups. RESULTS There were 49 patients in the early-endoscopy group and 41 patients in the delayed-endoscopy group. Patient demographics, clinical characteristics, bleeding control modality, and Rockall score did not differ between the two groups. There were also no significant differences between the early- and delayed-endoscopy groups in the re-bleeding rate (3/49 vs 5/41, p=0.313), the duration of hospital stay (10.7 vs 9.3 days, p=0.437), and the total amount of blood transfused (3.4 vs 2.7 units, p=0.240). CONCLUSIONS The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease is not significantly affected by the timing of endoscopy.
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Affiliation(s)
- Hyun Seok Cho
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
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Sridhar S, Chamberlain S, Thiruvaiyaru D, Sethuraman S, Patel J, Schubert M, Cuartas-Hoyos F, Schade R. Hydrogen peroxide improves the visibility of ulcer bases in acute non-variceal upper gastrointestinal bleeding: a single-center prospective study. Dig Dis Sci 2009; 54:2427-33. [PMID: 19757051 PMCID: PMC2762049 DOI: 10.1007/s10620-009-0948-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 08/06/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute non-variceal upper gastrointestinal bleeding (ANVB) or hemorrhage (used interchangeably) is an emergency. Endoscopically applied hydrogen peroxide (H2O2) has been shown to improve visualization of the ulcer base. AIMS To test the hypothesis that ulcer base clot clearance with 3% H2O2 improves the visualization of ANVB lesions compared to water alone. METHODS In this single-center prospective study, 320 patients with ANVB were examined, of which 81 met the entry criteria for evaluation. All patients with ANVB underwent urgent endoscopy. Those with adherent clots on the ulcer base were sprayed with 250 ml of water, followed by up to 100 ml of 3% H2O2. The main outcome measurement was Kalloo"s Visual Scores of the ulcer base before and after water and H2O2. RESULTS Eighty-one patients with gastric ulcers (GU; 34) and duodenal ulcers (DU; 47) met the entry criteria. The mean improvement in grade from water to H2O2 was 2.04 (95% confidence interval [CI] (1.86, 2.23)). The mean volume of H2O2 used to clear clots was higher (70 ml) in patients who were negative for both Helicobacter pylori and non-steroidal anti-inflammatory drug (NSAID) use than in those who were positive for both (31 ml) (P = 0.00). More DU patients (72%) had visible vessels than GU patients (44%) (P = 0.01). CONCLUSIONS H2O2 improved the visualization of ulcer bases in ANVB. A smaller volume of H2O2 was required to clear clots in patients who used NSAIDs and had H. pylori infection. H2O2 identified more DU vessels. The use of H2O2 should be considered as a standard therapy in the management of clots in ANVB.
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Affiliation(s)
- Subbaramiah Sridhar
- Section of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, GA USA
| | - Sherman Chamberlain
- Section of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, GA USA
| | | | - Sankara Sethuraman
- Mathematics and Computer Science, Augusta State University, Augusta, GA USA
| | - Jigneshkumar Patel
- Section of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, GA USA
| | - Moonkyung Schubert
- Section of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, GA USA
| | | | - Robert Schade
- Section of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, GA USA
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Tajima A, Koizumi K, Suzuki K, Higashi N, Takahashi M, Shimada T, Terano A, Hiraishi H, Kuwayama H. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol 2008; 23 Suppl 2:S237-41. [PMID: 19120905 DOI: 10.1111/j.1440-1746.2008.05557.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Peptic ulcer disease (PUD) is one of the main lesions responsible for upper gastrointestinal (GI) bleeding, as well as esophageal varices and Mallory-Weiss tear. Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin are the major responsible causes. In cases of upper GI bleeding, urgent endoscopy is performed after stabilization of vital signs. There are several modalities for controlling bleeding in PUD, such as ethanol injection or hypertonic saline with epinephrine. Recurrent bleeding occurs in 20% of patients after endoscopic therapy. The combination of endoscopic intervention and a proton pump inhibitor (PPI) is necessary to achieve hemostasis of active bleeding. It has been reported that high-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h, then 40 mg/day orally for 1 week) can reduce recurrent bleeding, the need for surgery and mortality from hemorrhagic shock in patients with high-risk peptic ulcer bleeding, as compared with standard-dose omeprazole. The metabolism of PPIs is dependent upon P450 2C19 genotypes and the clinical usefulness of genotypic analysis remains to be determined.
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Affiliation(s)
- Akihiro Tajima
- Department of Gastroenterology, Dokkyo Medical University, Koshigaya Hospital, Koshigaya, Japan.
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cichoż-Lach H, Celiński K, Słomka M. Treatment of non-variceal upper gastrointestinal tract bleeding within our experience. ANNALES UMCS, MEDICINA 2008; 63:192-196. [DOI: 10.2478/v10079-008-0033-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
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Raju GS, Kaltenbach T, Soetikno R. Endoscopic mechanical hemostasis of GI arterial bleeding (with videos). Gastrointest Endosc 2007; 66:774-85. [PMID: 17905022 DOI: 10.1016/j.gie.2007.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 04/14/2007] [Indexed: 01/09/2023]
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Abstract
Acute upper gastrointestinal (UGI) bleeding is a common clinical problem that accounts for a large number of hospitalizations and results in substantial health care expenditures. Risk stratification after UGI hemorrhage involves the use of clinical and endoscopic parameters to predict the likelihood of rebleeding and death. This information can guide management decisions, such as the necessity of hospital admission, the application of endoscopic hemostatic therapy, and the length of inpatient stay. This concise review examines the current literature on risk stratification in UGI hemorrhage and attempts to integrate evidence-based data into the clinical decision-making process.
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Affiliation(s)
- Badih Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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22
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Abstract
Endoscopy plays a central role in the diagnosis and treatment of non-variceal upper gastrointestinal haemorrhage. Advances in endoscopic techniques, supported by an increasing body of high quality data, have rendered endoscopy the first-line diagnostic and therapeutic intervention for the patient presenting with an upper gastrointestinal haemorrhage. However, endoscopic intervention must be considered in the context of the overall management of the bleeding patient, often with significant comorbidities. Although parameters such as hospitalization duration, transfusion requirements and surgery rates have improved with advances in endoscopic therapy, mortality rates remain relatively static. This review addresses the current status of endoscopic intervention for non-variceal upper gastrointestinal haemorrhage. Additionally, an overview of important periprocedural management issues is presented.
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Affiliation(s)
- Vu Kwan
- Department of Gastroenterology, Concord Hospital, Sydney, New South Wales, Australia
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23
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Abstract
Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.
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Affiliation(s)
- Mark H Flasar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland Medical Center, and Veterans Affairs, Maryland Health Care System, 10 North Greene Street, Baltimore, MD 21201, USA.
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24
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Abstract
Because there are many causes of acute abdominal pain, a systematic approach by the evaluating physician is necessary to narrow the differential diagnosis. It is vital that the physician have an understanding of the mechanisms of pain generation and be familiar with the presentations of common diseases that cause abdominal pain. Recognizing the red flags in the history and physical examination and the initial imaging and laboratory findings helps to determine which patients may have a serious underlying disease process, and therefore warrant more expedited evaluation and treatment.
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Affiliation(s)
- Mark H Flasar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland Medical Center, Baltimore, MD 21201, USA.
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25
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Gisbert JP, Legido J, Castel I, Trapero M, Cantero J, Maté J, Pajares JM. Risk assessment and outpatient management in bleeding peptic ulcer. J Clin Gastroenterol 2006; 40:129-34. [PMID: 16394873 DOI: 10.1097/01.mcg.0000196187.19426.03] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AIMS 1) To review clinical and endoscopic variables in patients hospitalized for upper gastrointestinal bleeding (UGIB) due to peptic gastroduodenal lesions over a period of 3 years; 2) to identify factors associated with unfavorable evolution; and 3) to evaluate characteristics of patients discharged immediately after endoscopy. METHODS A 3-year retrospective analysis of all UGIB episodes was performed. Patients with gastroduodenal ulcer or erosive gastritis/duodenitis at endoscopy were included. The prognostic value of several clinical, endoscopic, and analytical variables was assessed. Persistence or recurrence of bleeding, surgery, and mortality were considered as outcome variables (evolution was classified as "unfavorable" when any of these was observed). RESULTS A total of 341 patients were identified, with a mean age of 62 years. Melena was the most frequent UGIB presentation (70%). Forty-five percent had associated diseases, and 45% were taking gastroerosive drugs. Duodenal ulcer was the most frequent cause of UGIB (48%), followed by gastric ulcer (32%). The evolution of UGIB was unfavorable in 7% of cases. Variables associated with unfavorable evolution in the multivariate analysis were: systolic blood pressure < or = 100 mm Hg, heart rate > or = 100 bpm, and a Forrest endoscopic classification of severe. Only 10% of patients were immediately discharged, with no subsequent complications. However, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 115 patients (34%) without subsequent complications. CONCLUSIONS A number of clinical and endoscopic variables (blood pressure, heart rate, and endoscopic stigmata of bleeding) with prognostic value have been identified. These are easy to obtain and apply in clinical practice and allow an accurate estimation of the evolution of UGIB. This diagnostic strategy identifies a relatively high proportion of UGIB patients who can be managed on an outpatient basis.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Madrid, Spain.
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26
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Parente F, Anderloni A, Bargiggia S, Imbesi V, Trabucchi E, Baratti C, Gallus S, Bianchi Porro G. Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey. World J Gastroenterol 2005; 11:7122-30. [PMID: 16437658 PMCID: PMC4725080 DOI: 10.3748/wjg.v11.i45.7122] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Revised: 05/08/2005] [Accepted: 05/12/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital. METHODS All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered. RESULTS Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy. CONCLUSION Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.
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Affiliation(s)
- Fabrizio Parente
- Gastroenterology Unit, A. Manzoni Hospital, Via delloEremo 9-11, 23900 Lecco, Italy.
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Brullet E, Campo R, Calvet X, Guell M, Garcia-Monforte N, Cabrol J. A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection. Gastrointest Endosc 2004; 60:15-21. [PMID: 15229419 DOI: 10.1016/s0016-5107(04)01314-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer. METHODS Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge. RESULTS A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001). CONCLUSIONS Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.
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Affiliation(s)
- Enric Brullet
- Endoscopy Unit, UDIAT-CD, Hospital de Sabadell, Corporació Parc Taulí, Insitut Universitari Parc Taulí, UAB, Sabadell, Spain
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Bjorkman DJ, Zaman A, Fennerty MB, Lieberman D, Disario JA, Guest-Warnick G. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointest Endosc 2004; 60:1-8. [PMID: 15229417 DOI: 10.1016/s0016-5107(04)01287-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Urgent endoscopy in patients with acute upper-GI bleeding identifies many patients who may be safely treated without hospitalization. The aim of this multicenter trial was to determine whether urgent endoscopy effectively decreases health care resource utilization in a real-life setting where primary care providers determine the course of care. METHODS Ninety-three outpatients with acute upper-GI bleeding were randomized to either urgent endoscopy (before hospitalization) or elective endoscopy after admission. The results of urgent endoscopy and a recommendation regarding patient disposition were provided to the attending physician. Medical outcomes and resource utilization were measured. RESULTS The timing of endoscopy did not affect resource utilization or patient outcomes. Length of stay was similar (urgent endoscopy, OR 3.98 days: 95% CI[2.84, 5.11] vs. elective endoscopy, OR 3.26 days: 95% CI[2.32, 4.21], p=0.45). The mean number of days in an intensive care unit was the same (1.2 days). The urgent endoscopy group had more high-risk endoscopic lesions (15 vs. 9; p=0.031). Outpatient care was recommended for 19 patients (40%). Only 4 patients were discharged. CONCLUSIONS Urgent endoscopy did not reduce hospitalization or resource utilization because the results of early endoscopy did not impact the decision by attending physicians regarding admission. For early (triage) endoscopy to impact resource utilization, the results of endoscopy must change subsequent patient care.
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Affiliation(s)
- David J Bjorkman
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah 84132-2101, USA
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30
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Abstract
Nonvariceal UGI bleeding is one of the most common emergencies that gastroenterologists encounter, and continues to be a significant cause of morbidity and mortality. The keys to management are rapid resuscitation and stabilization; appropriate triage based on pre-endoscopic risk factors; early endoscopy to achieve prompt diagnosis and implement hemostatic therapy to high-risk lesions; and aggressive antisecretory therapy (in the case of peptic ulcer bleeding) to reduce the risk of continued or recurrent bleeding.
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Affiliation(s)
- Christopher S Huang
- Section of Gastroenterology, Boston Medical Center, 88 East Newton Street, D-408, Boston, MA 02118, USA
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Feu F, Brullet E, Calvet X, Fernández-Llamazares J, Guardiola J, Moreno P, Panadès A, Saló J, Saperas E, Villanueva C, Planas R. [Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:70-85. [PMID: 12570891 DOI: 10.1016/s0210-5705(03)79046-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- F Feu
- Societat Catalana de Digestologia. Barcelona. España.
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Kovacs TOG, Jensen DM. Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding. Med Clin North Am 2002; 86:1319-56. [PMID: 12510456 DOI: 10.1016/s0025-7125(02)00079-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endoscopy has become the first and primary diagnostic and therapeutic modality in the management of patients with severe gastrointestinal bleeding. Panendoscopy, push enteroscopy, and colonoscopy provide the diagnostic, prognostic, and therapeutic elements to improve patient outcomes and to reduce morbidity and mortality from severe GI hemorrhage. Recent improvements in endoscopic hemostatic techniques and in imaging modalities using wireless capsule endoscopy suggest that diagnostic and therapeutic endoscopy will be even more important in determining patient outcomes in the future.
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Affiliation(s)
- Thomas O G Kovacs
- Division of Digestive Diseases, Department of Medicine, University of California at Los Angeles, School of Medicine, CURE Digestive Diseases Research Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Pardo A, Durández R, Hernández M, Pizarro A, Hombrados M, Jiménez A, Planas R, Quintero E. Impact of physician specialty on the cost of nonvariceal upper GI bleeding care. Am J Gastroenterol 2002; 97:1535-42. [PMID: 12094879 DOI: 10.1111/j.1572-0241.2002.05695.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Upper GI bleeding (UGIB) is a common medical emergency that leads to a high consumption of medical resources and costs. We aimed to analyze the influence of physician specialty on the costs of nonvariceal UGIB care. METHODS We retrospectively assessed 350 nonvariceal UGIB episodes that were primarily cared for by gastroenterologists (n = 142), internists (n = 67), or surgeons (n = 141). Gastroenterologists followed evidence-based clinical protocols that included early endoscopy and early hospital discharge for uncomplicated bleeding. A risk score system was used to control for severity of illness. Linear regression analyses were performed to find out predictors of costs and the influence of specialist care on length of stay (LOS). RESULTS The overall mean hospital cost was significantly lower in patients cared for by gastroenterologists (EUR 1,630) than in those managed by internists (EUR 3,745, p < 0.001) or surgeons (EUR 2,513, p < 0.05). The mean LOS was the variable with highest influence on total cost. Patients cared for by gastroenterologists had a mean LOS significantly shorter (7.3 days) than that of those treated by internists (16.2 days, p < 0.001) or surgeons (11 days, p < 0.001). Hospital costs and LOS differences were maintained when adjusting for severity of illness. In caring for low risk patients, nongastroenterologists had a higher probability of having a hospital stay longer than 4 days (odds ratio = 18.4, Cl = 4.6-73.6, p < 0.001). CONCLUSION The implementation of specific evidence-based protocols by gastroenterologists reduces length of hospital stay and saves medical costs in patients with nonvariceal UGIB, especially those at low risk.
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Affiliation(s)
- Alberto Pardo
- Gastroenterology Department, University Hospital of Canary Islands, Tenerife, Spain
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Gisbert JP, Llorca I, Cantero J, Pajares JM. [Clinical and endoscopic prognostic factors in patients with bleeding peptic ulcer]. Med Clin (Barc) 2002; 118:481-6. [PMID: 11975884 DOI: 10.1016/s0025-7753(02)72427-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The main objectives of this study were to review the clinic and endoscopic variables of patients with upper gastrointestinal bleeding (UGB) due to peptic gastroduodenal lesions who were evaluated in our hospital during one year, to identify the characteristics associated with a negative evolution of the UGB and to analyse the characteristics of those patients who were discharged immediately after the endoscopy was performed. PATIENTS AND METHOD A one-year retrospective analysis of all UGB episodes was performed. Patients having gastroduodenal ulcer or erosive gastritis/duodenitis at endoscopy were included. The prognostic value of several clinic, laboratory and endoscopic variables was evaluated. Persistence or recurrence of bleeding, surgery and mortality were considered as outcome variables (the variable evolution was categorized as negative when any of these was observed). RESULTS 156 patients were identified, with a mean (SD) age of 61 (17) years. Melena was the most frequent UGB presentation (79%). 46% patients had associated diseases and 50% were taking gastroerosive drugs. Duodenal ulcer was the commonest cause of UGB (52%), followed by gastric ulcer (30%). The evolution of UGB was negative in 7% cases. Variables associated with a negative evolution in the multivariate analysis were: age, red hematemesis, systolic blood pressure >= 100 mmHg, heart rate >= 100 b.p.m. and a more severe Forrest endoscopic classification. 11% patients were discharged immediately, without complications afterwards. If predictive variables obtained in the multivariate analysis would have been applied, hospitalization would have been avoided in 59 patients (38%) without subsequent complications. CONCLUSIONS A number of clinic and endoscopic variables (UGB presentation form, blood pressure, heart rate, and Forrest endoscopic classification) with prognostic value have been identified in this study. These variables are easy to obtain and apply in clinical practice, allowing a precise estimate of the UGB evolution. Thus, a relatively high number of patients with UGB susceptible of ambulatory treatment and management can be reliably identified.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo. Hospital Universitario de la Princesa. Madrid. Spain
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35
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Elta GH. Acute Nonvariceal Upper Gastrointestinal Hemorrhage. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:147-152. [PMID: 11879595 DOI: 10.1007/s11938-002-0062-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Upper endoscopy to assess the risk of rebleeding in patients with nonvariceal upper gastrointestinal bleeding may be used for triage, allowing outpatient care of selected patients and leading to significant cost savings. Over the last 10 years, hospitalization days required for upper gastrointestinal bleeding have decreased significantly and the majority of patients with upper gastrointestinal bleeding undergo endoscopy within 24 hours of admission. Twenty percent to 35% of these endoscopies include endoscopic hemostatic therapy. Endoscopic treatment is recommended for actively bleeding (ie, spurting or oozing) visible vessels and nonbleeding visible vessels that are raised and cannot be washed off. Endoscopic methods can be divided into thermal (multipolar coagulation, heater probe, argon plasma coagulator, Nd:YAG laser) and nonthermal (eg, injection therapy); both types are effective. A combination of injection and thermal therapy with initial injection to slow the bleeding or "clear the field" followed by coagulation of the identified vessel is popular. Bleeding recurs in 15% of patients. A recent randomized controlled trial of repeat endoscopic treatment versus surgery for patients with recurrent ulcer bleeding concluded that endoscopic retreatment is superior to surgery. Most peptic ulcer rebleeding occurs within the first 3 days of presentation. A comparison of omeprazole and placebo therapy in high-risk ulcer patients with bleeding stigmata at endoscopy who were not treated endoscopically found that high-dosage omeprazole (40 mg twice a day) significantly lowered the rates of further bleeding and surgical intervention. Although unlikely to replace endoscopic therapy, this study demonstrated the efficacy of potent acid suppression, perhaps due to stabilization of clotting activity. A recent placebo-controlled trial of high-dosage parenteral omeprazole after endoscopic treatment of bleeding peptic ulcers demonstrated a substantial reduction in the risk of rebleeding.
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Affiliation(s)
- Grace H. Elta
- Division of Gastroenterology, University of Michigan, 3912 Taubman Center, Box 0362, Ann Arbor, MI 48109-0362, USA.
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Abstract
There is now a multitude of technologic and pharmacologic options available to clinicians caring for patients with gastrointestinal (GI) bleeding; however, drugs and technology are no substitute for understanding and properly executing the basic management principles of GI bleeding. This article focuses on the most common causes of GI bleeding and emphasizes the importance of the primary care provider's role in the management of these patients. Also, by answering questions we are commonly asked as gastroenterology consultants, we hope to provide insight into current diagnostic and therapeutic options and the most appropriate use of these options.
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Affiliation(s)
- J D Pianka
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Almela P, Benages A, Peiró S, Minguez M, Peña A, Pascual I, Mora F. Outpatient management of upper digestive hemorrhage not associated with portal hypertension: a large prospective cohort. Am J Gastroenterol 2001; 96:2341-8. [PMID: 11513172 DOI: 10.1111/j.1572-0241.2001.04087.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the safety of outpatient management of upper GI hemorrhage (UGIH) not associated with portal hypertension. METHODS A prospective cohort of 983 subjects who went to the Accident & Emergency Department (A&ED) of a University hospital in Valencia (Spain), for UGIH not associated with portal hypertension during 1994 to 1997 were evaluated. After evaluation in the A&ED, 216 patients (22%) were discharged and referred for outpatient follow-up, but 15 patients could not be located thus, reducing the follow-up to 201 subjects. The main outcome measures were rebleeding within 10 days, emergency surgery within 15 days, and mortality for any cause during the 30 days after the initial hemorrhaging episode. RESULTS UGIH in subjects under outpatient care were less severe than those subjects in the hospitalized group. Hemorrhaging recurred in 7.3% of inpatients versus 0.5% of outpatients (p < 0.01); emergency surgery was required in 5.6% of the hospitalized patients and 0.5% of the outpatients (p < 0.01); a total of 20 deaths occurred in the hospitalized group (2.6%), while three (1.5%) occurred in outpatients (p = 0.26). After adjusting for several significant risk factors, outpatient management was not associated with outcomes that were worse. CONCLUSIONS Treatment under an outpatient regime is a safe alternative for a large percentage of selected patients with UGIH not associated with portal hypertension.
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Affiliation(s)
- P Almela
- Servicio de Gastroenterología, Hospital Clinico-Universitario, Universitat de València, Spain
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38
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Gisbert JP, Pajares JM. [Bleeding peptic ulcer. Can the prognosis be accurately estimated and the hospitalization prevented?]. Med Clin (Barc) 2001; 117:227-32. [PMID: 11481099 DOI: 10.1016/s0025-7753(01)72069-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Madrid, Spain.
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Abstract
Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.
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Affiliation(s)
- J J Farrell
- Harvard Medical School, Boston, Massachusetts, USA
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40
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Wassef W, Obando J, Sharma A. Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting. J Intensive Care Med 2001. [DOI: 10.1046/j.1525-1489.2001.00105.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Wassef W, Obando J, Sharma A. Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting. J Intensive Care Med 2001. [DOI: 10.1177/088506660101600301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.
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Affiliation(s)
- Wahid Wassef
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
| | - Jorge Obando
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
| | - Ashish Sharma
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
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Surgical Management of Peptic Ulcer Disease in the Helicobacter Era—Management of Bleeding Peptic Ulcer. Surg Laparosc Endosc Percutan Tech 2001. [DOI: 10.1097/00129689-200102000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chak A, Cooper GS, Lloyd LE, Kolz CS, Barnhart BA, Wong RC. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest Endosc 2001; 53:6-13. [PMID: 11154481 DOI: 10.1067/mge.2001.108965] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Esophagogastroduodenoscopy (EGD) is generally indicated for the management of patients admitted to intensive care units (ICUs) with upper gastrointestinal (GI) hemorrhage but its impact in community practice has not been measured. Thus, the effectiveness of 3 EGD factors, viz., accurate initial diagnosis, performance within 24 hours of admission (early EGD), and appropriate intervention, was examined. METHODS Records of 214 patients admitted to the ICU of 10 metropolitan hospitals with upper GI hemorrhage were reviewed. Unadjusted and severity-adjusted associations of the 3 EGD factors with length of hospital stay, length of ICU stay, readmission to ICU, recurrent bleeding, surgery, and death were evaluated. RESULTS Inaccurate diagnosis occurred in 10% of patients at initial EGD and was associated with significant increases in risk of recurrent bleeding (70% vs. 11%, p < 0.001), rate of surgery (20% vs. 4%, p < 0.05), length of hospital stay (median 7.5 vs. 5 days, p < 0.005), length of ICU stay (median 4 vs. 2 days, p < 0.005), and rate of readmission to ICU (20% vs. 0.6%, p < 0.001). These associations persisted after adjusting for severity of illness. Early EGD performed in 82% of patients was associated with significant severity-adjusted reductions in hospital (-33%: 95% CI [-45%, -18%]) and ICU (-20%: 95% CI [-24%, -3%]) stay. Appropriate intervention at initial EGD, performed in 84% of patients, was associated with reductions in severity-adjusted length of ICU stay (-18%: 95% CI [-32%, 0%]) and rate of recurrent bleeding (odds ratio = 0.37, 95% CI [0.13, 1.06]). CONCLUSIONS Early, accurate EGD with appropriate therapeutic intervention is effective as practiced in the community and is associated with improved outcomes for patients with upper GI hemorrhage admitted to the ICU. Inaccurate diagnosis at initial EGD is uncommon but has a significant adverse association with all outcome measures.
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Affiliation(s)
- A Chak
- Division of Gastroenterology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44106-1736, USA
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45
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Podila PV, Ben-Menachem T, Batra SK, Oruganti N, Posa P, Fogel R. Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway. Am J Gastroenterol 2001; 96:208-19. [PMID: 11197254 DOI: 10.1111/j.1572-0241.2001.03477.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To develop a clinical care pathway for the management of patients with acute upper or lower nonvariceal GI hemorrhage (GIH) who do not require immediate surgical intervention. To test the effectiveness and safety of the pathway in improving the efficiency of care for patients with acute GIH. METHODS A multidisciplinary team developed the evidence-based GIH clinical care pathway by consensus techniques. In a quasiexperimental design, pathway outcomes were measured prospectively during the first 8 months of pathway implementation, and compared to similar time periods in the 2 prior yr. Effectiveness measures were the number of patients <65 yr of age admitted for GIH and the hospital length of stay for all patients. Thirty-day safety outcomes were the rates of recurrent GIH, mortality, and readmission to hospital for any reason. RESULTS Of 368 patients studied after pathway implementation, 81 (22%) were managed as outpatients. The number of admissions for pathway patients <65 yr of age was significantly lower compared to 691 prepathway patients (p < 0.002). Mean length of stay (+/- 95% CI) for pathway inpatients was 3.5 (3.1, 3.9) days, compared to 5.3 (4.9, 5.7) and 4.6 (4.2, 5) days in the 2 prepathway yr, respectively (p < 0.001). Multivariable regression controlling for admission vital signs, comorbid conditions, age, and the etiology of GIH confirmed that admission after pathway implementation was an independent predictor of a reduced length of hospital stay. There were no significant between-year differences in the 30-day rates of recurrent GIH, mortality, or hospital readmission. CONCLUSION A multidisciplinary clinical care pathway may improve the efficiency of caring for patients with acute upper or lower nonvariceal GIH. Decreasing the number of admissions for GIH and reducing the hospital length of stay can be achieved without increasing the number of adverse outcomes.
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Affiliation(s)
- P V Podila
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan 48202, USA
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46
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Abstract
Acute gastrointestinal bleeding is a significant worldwide medical problem. Despite modern measures for diagnosis and treatment, morbidity and mortality rates associated with gastrointestinal bleeding remain largely unchanged. Aggressive medical resuscitation while initiating an evaluation to localize the site of blood loss remains the key to successful management of acute gastrointestinal bleeding. A multidisciplinary approach with early involvement of a gastroenterologist, surgeon, and radiologist can be extremely helpful in the management of these patients. With the logical and direct approach to the evaluation of patients with gastrointestinal bleeding described in this article, most episodes can be managed successfully.
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Affiliation(s)
- M A Fallah
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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47
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Savides TJ, Jensen DM. Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin North Am 2000; 29:465-87, vii. [PMID: 10836190 DOI: 10.1016/s0889-8553(05)70123-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.
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Affiliation(s)
- T J Savides
- Department of Clinical Medicine, University of California, San Diego, USA.
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48
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Abstract
Aging is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. Important management issues considered include hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy.
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Affiliation(s)
- J J Farrell
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
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49
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Lee JG, Turnipseed S, Romano PS, Vigil H, Azari R, Melnikoff N, Hsu R, Kirk D, Sokolove P, Leung JW. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50:755-61. [PMID: 10570332 DOI: 10.1016/s0016-5107(99)70154-9] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. METHODS All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. RESULTS We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group. CONCLUSIONS Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.
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Affiliation(s)
- J G Lee
- Division of Gastroenterology, General Medicine, and Emergency Medicine, UC Davis Medical Center, Sacramento, California 95817, USA.
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Cebollero-Santamaria F, Smith J, Gioe S, Van Frank T, Mc Call R, Airhart J, Perrillo R. Selective outpatient management of upper gastrointestinal bleeding in the elderly. Am J Gastroenterol 1999; 94:1242-7. [PMID: 10235201 DOI: 10.1111/j.1572-0241.1999.01073.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We sought to determine whether elderly patients with upper gastrointestinal bleeding can be safely managed as outpatients. We were also interested in determining the etiology of bleeding peptic ulcer disease in this population. METHODS Eighty-four patients (65 yr of age and older) were studied during a 23-month period. Urgent outpatient endoscopy was performed and clinical as well as endoscopic criteria were applied to determine the need for hospital admission. Patients with endoscopic findings that indicated a low risk for rebleeding were not admitted if they lacked one major or three minor predefined clinical criteria. All enrollees were followed after discharge from the clinic or hospital for 4 wk with hematocrit determination and clinical assessments. The main outcome measures were the number of patients who met our predefined clinical and endoscopic criteria for outpatient versus inpatient care and the differences in the rebleeding rates in these two groups. RESULTS Twenty-four (29%) patients were treated as outpatients; none rebled. In contrast, seven (12%) of the 60 inpatients had one or more rebleeding episodes (p = 0.002). Bleeding from peptic ulcer disease was associated with use of nonsteroidal antiinflammatory medications in 81% of patients. CONCLUSIONS Selective outpatient management of elderly patients with upper gastrointestinal bleeding can be done safely and has the potential to lead to reduced health care expenditures. Over-the-counter nonsteroidal antiinflammatory drugs are the most frequent cause of bleeding peptic ulcer disease in this population.
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Affiliation(s)
- F Cebollero-Santamaria
- Section of Gastroenterology and Hepatology, Alton Ochsner Medical Institutions, New Orleans, Louisiana, USA
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