Trends in Upper Gastrointestinal Bleeding in Patients on Primary Prevention Aspirin: A Nationwide Emergency Department Sample Analysis, 2016-2020

Functional disability after clinically significant extracranial bleeding: a secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) Trial

BACKGROUND

Clinically significant extracranial bleeding, defined as bleeding at any site other than the brain or spinal cord requiring either a hospital admission >24 hours, red blood cell transfusion, surgery for hemostasis, or resulting in death, is a common side effect of antithrombotic agents. Compared to intracranial bleeding, the impact of clinically significant extracranial bleeding on long-term outcomes, including functional independence, has been poorly studied.

OBJECTIVES

To determine if clinically significant extracranial bleeding impacts the development of functional disability in healthy older adults.

METHODS

We performed a secondary analysis of the Aspirin in Reducing Events in the Elderly trial. The primary outcome of this study was incident dependence in the Katz Activities of Daily Living (ADLs), defined as being unable to perform or requiring assistance with any ADLs or being admitted to a long-term care facility.

RESULTS

A total of 18 982 participants were included in the analysis, of which 547 (2.9%) developed clinically significant extracranial bleeding during study follow-up. In adjusted analyses, clinically significant extracranial bleeding was significantly associated with the development of incident ADL dependence (hazard ratio [HR], 2.46; 95% CI, 1.97-3.07). This finding was similar for gastrointestinal (HR, 2.29; 95% CI, 1.72-2.08) and nongastrointestinal extracranial bleeds (HR, 2.68; 95% CI, 1.96-3.69). The association with increased risk of incident ADL dependence remained significant in secondary analysis of groups randomized to either aspirin (HR, 2.15; 95% CI, 1.57-2.94) or placebo (HR, 2.84; 95% CI, 2.09-3.86).

CONCLUSION

Clinically significant extracranial bleeding was associated with the development of incident ADL dependence in otherwise healthy older adults.

Incidentally Discovered Duodenal Gastrointestinal Stromal Tumour (GIST): Operative Treatment and Problems After Surgery-A Case Report and Literature Review

Background: Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours of the digestive tract that can involve any part of the tract. The tumours can be harmless or life-threatening. Materials and Methods: A case report of a surgeon who fell in a Finnish sauna, and he immediately felt that some ribs were broken. Magnetic resonance imaging and ultrasound showed three fractured ribs and an intrasplenic haematoma. Contrast-enhanced computed tomography (CT) demonstrated a small intrasplenic anomaly but no haematoma. Incidentally, an incidentaloma in the left adrenal gland was diagnosed. Three months later, a control CT scan was performed. The radiological findings on the adrenal gland and laboratory examinations matched those of a benign adenoma. Incidentally, a small duodenal tumour was diagnosed. At the same time, anaemia (haemoglobin: 104 g/L) and iron deficiency (ferritin: 8 μg/L) were noticed. An esophagogastroduodenoscopy showed an intramural tumour localised after the bulb-descending junction. Because the tumour was submucosal, the pathological diagnosis failed. Three months later, a radical surgical resection of the tumour with a resection margin of 2 mm and primary closing of the duodenum was performed. Pathological examination showed a well-circumscribed submucosal mesenchymal tumour with spindle cells. A tumour-free margin was uncertain. Immunohistochemistry findings showed a GIST. Due to the uncertain margin, an esophagogastroduodenoscopy control was planned at 2 years postoperatively. The patient disagreed with the decision and ordered a private control CT 3 months after the operation. The new CT found no local recurrence or metastasis. The patient contacted the head surgeon of the clinic, who ordered a 1-year postoperative CT. The 1-year follow-up CT finding agreed with the previous findings. Conclusion: The aftertreatment of a radical-operated GIST is extremely important if histologic examination of the tumour-free margin is uncertain. In that case, CT controls should be considered once a year for at least 3 years.

Tranexamic Acid With Acid Suppression Versus Acid Suppression Alone as Therapy for Upper Gastrointestinal Bleeding: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Studies have reported the benefits of tranexamic acid (TXA) in controlling bleeding across various conditions. However, the effect of TXA in upper gastrointestinal bleeding (UGIB) remains controversial, and its therapeutic impact when combined with acid suppression, particularly proton pump inhibitors (PPIs), which are considered first-line therapy for bleeding peptic ulcers, has not been reported.

METHODS

We systematically searched PubMed, Embase, and Google Scholar from January 1987 to June 2024 using predefined keywords to identify RCTs meeting our inclusion criteria, including details of TXA dosage, route of administration, and choice of acid suppressants. Data from selected trials were extracted, and a meta-analysis was performed using random-effects modeling.

RESULTS

Six trials with 709 participants were included. Baseline patient characteristics in the selected trials were balanced. The rebleeding rate, mortality, need for blood transfusion, units of blood transfused, and need for salvage therapy were compared. The TXA with acid suppression group significantly reduced the risk of rebleeding (RR: 0.63, 95% CI: 0.41-0.96), units of blood transfused (mean difference: -1.08, 95% CI: -1.44 to -0.71), and the need for salvage therapy (RR: 0.28, 95% CI: 0.12-0.64). No significant difference was observed in mortality rate (RR: 0.74) and need for blood transfusion (RR: 1.01) between the two groups, but outcomes favored the TXA and acid suppression group.

CONCLUSIONS

We suggest combining TXA with acid suppression as a first-line therapy for UGIB patients. Further trials should be conducted to determine the optimal dose and route of TXA administration for better care.

Long-Term Effects of Low-Dose Aspirin on Gastrointestinal Symptoms and Bleeding Complications in Patients with Type 2 Diabetes

BACKGROUND

Low-dose aspirin for primary prevention is determined by the balance of risks of cardiovascular events and adverse effects. We assessed the long-term gastrointestinal symptoms or bleeding with low-dose aspirin in diabetic patients.

METHODS

The Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial was a randomized clinical trial to evaluate the efficacy and safety of low-dose aspirin in patients with type 2 diabetes. As a post hoc analysis, we investigated the incidence of upper gastrointestinal symptoms or bleeding in aspirin (100 mg enteric-coated aspirin or 81 mg buffered aspirin daily) and no-aspirin groups within and beyond 3 years.

RESULTS

Of 2535 patients (mean age 65 years, 55% male) followed for a median of 11.2 years, 1258 were included in the aspirin group (951 enteric-coated, 208 buffered, 99 unknown) and 1277 were included in the no-aspirin group. The cumulative incidence of upper gastrointestinal symptoms or bleeding was higher in the aspirin group than the no-aspirin group (8.8% vs. 5.7% at 18 years; p < 0.0001). The increased risk in the aspirin group was prominent within 3 years, and the hazard ratio (HR) [95% confidence interval (CI)] of the aspirin group was 7.10 [3.21-15.7], but attenuated beyond 3 years (HR 1.20 [0.76-1.89]). In 1159 patients in the aspirin group, the cumulative incidence was lower in the enteric-coated than in the buffered aspirin groups (2.9% vs. 7.3%; p = 0.003) within 3 years, and the adjusted HR of enteric-coated aspirin was 0.38 [0.20-0.72] compared with the buffered aspirin group.

CONCLUSION

The upper gastrointestinal symptoms or bleeding of low-dose aspirin within 3 years, and the aspirin formulations, were relevant for decision making of initiation and continuation of low-dose aspirin for primary prevention.

Detection of Gastrointestinal Bleeding With Large Language Models to Aid Quality Improvement and Appropriate Reimbursement

BACKGROUND & AIMS

Early identification and accurate characterization of overt gastrointestinal bleeding (GIB) enables opportunities to optimize patient management and ensures appropriately risk-adjusted coding for claims-based quality measures and reimbursement. Recent advancements in generative artificial intelligence, particularly large language models (LLMs), create opportunities to support accurate identification of clinical conditions. In this study, we present the first LLM-based pipeline for identification of overt GIB in the electronic health record (EHR). We demonstrate 2 clinically relevant applications: the automated detection of recurrent bleeding and appropriate reimbursement coding for patients with GIB.

METHODS

Development of the LLM-based pipeline was performed on 17,712 nursing notes from 1108 patients who were hospitalized with acute GIB and underwent endoscopy in the hospital from 2014 to 2023. The pipeline was used to train an EHR-based machine learning model for detection of recurrent bleeding on 546 patients presenting to 2 hospitals and externally validated on 562 patients presenting to 4 different hospitals. The pipeline was used to develop an algorithm for appropriate reimbursement coding on 7956 patients who underwent endoscopy in the hospital from 2019 to 2023.

RESULTS

The LLM-based pipeline accurately detected melena (positive predictive value, 0.972; sensitivity, 0.900), hematochezia (positive predictive value, 0.900; sensitivity, 0.908), and hematemesis (positive predictive value, 0.859; sensitivity, 0.932). The EHR-based machine learning model identified recurrent bleeding with area under the curve of 0.986, sensitivity of 98.4%, and specificity of 97.5%. The reimbursement coding algorithm resulted in an average per-patient reimbursement increase of $1299 to $3247 with a total difference of $697,460 to $1,743,649.

CONCLUSIONS

An LLM-based pipeline can robustly detect overt GIB in the EHR with clinically relevant applications in detection of recurrent bleeding and appropriate reimbursement coding.

Evaluation of Aspirin Prescribing and Gastrointestinal Bleeding in Adults 60 Years of Age and Older in a Large, Academic Health System

Background National guidelines no longer recommend adults 60 years of age and older to begin treatment with low-dose daily aspirin for primary prevention of atherosclerotic cardiovascular disease (CVD) due to a lack of proven net benefit and a higher risk of bleeding. Objective The objective of this cross-sectional retrospective analysis was to evaluate the appropriateness of low-dose aspirin prescribing and subsequent gastrointestinal bleeding in older persons receiving primary care in a large academic health system. Setting Large, academic health system within Colorado. Patients Patients with an active order for daily low-dose aspirin as of July 1, 2021, were assessed for appropriateness based on indication (primary vs secondary prevention) and use of a concomitant proton-pump inhibitor (PPI). Incident gastrointestinal bleeds (GIBs) in the subsequent 12 months and GIB risk factors were also evaluated. Results A total of 19,525 patients were included in the analysis. Eighty-nine percent of patients identified as White and 54% identified as male. Of the total cohort, 44% had CVD and 19% were co-prescribed a PPI. GIB occurred in 247 patients (1.27%) within the subsequent year. Risk factors significantly associated with a GIB within 1 year included: history of GIB, history of peptic ulcer disease, other esophageal issue (esophagitis, Barrett's esophagus, Mallory Weiss tears, etc.), 75 years of age or older, and history of gastroesophageal reflux disease. Conclusion This evaluation found that many older persons at this institution may be inappropriately prescribed aspirin, providing opportunities for pharmacists to improve medication safety by deprescribing aspirin among primary prevention patients or potentially co-prescribing a PPI in secondary prevention patients.

The impact of aspirin use on outcomes in patients with inflammatory bowel disease: Insights from a national database

BACKGROUND

Inflammatory bowel disease (IBD) is an inflammatory disorder that can increase the risk of mortality. Aspirin is an anti-inflammatory drug used for primary prevention of cardiovascular events. A single center analysis previously reported that aspirin use did not impact major outcomes in IBD. In this study, we aim to assess the impact of aspirin use on mortality and other outcomes in patients with IBD using national data.

METHODS

National inpatient sample (NIS) 2016-2020 was used to identify adult patients with IBD. Data were collected on patient demographics, hospital characteristics, and comorbidities. The outcomes studied were in-hospital mortality, sepsis, shock, Intensive Care Unit (ICU) admission, and need for surgery. Multivariate logistic regression analysis was performed.

RESULTS

A total of 1,524,820 IBD hospitalizations were included. Of these, 137,430 (9%) were long-term aspirin users. The majority of the patients in the aspirin group were aged > 65 years (34.11%), female (56.37%), White (78.83%) and had Medicare insurance (36.77%). Aspirin users had a lower incidence of in-hospital mortality (1.6% vs 1.4%, P = 0.06), sepsis (2.5% vs 2.9%, P < 0.001), shock (2.9% vs 3.4%, P < 0.001), ICU admission (2.6% vs 2.9%, P < 0.001), need for surgery (2.1% vs 4.2%, P < 0.001). After adjusting for confounders, aspirin was associated with a reduction in mortality (adjusted odds ratio: 0.49, 95%CI 0.45-0.55, P < 0.001).

CONCLUSION

Our study reports that aspirin use among patients with IBD was associated with a lower risk of death, sepsis, and shock. Aspirin use may have a protective effect in patients with IBD. Further studies are needed to confirm these results.