Changing trends in acute upper-GI bleeding: a population-based study

Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review

Acute upper and lower gastrointestinal (GI) bleeding may be a potentially life-threatening event that requires prompt recognition and an early effective management, being responsible for a considerable number of hospital admissions. Methods. We perform a clinical review to summarize the recent international guidelines, helping the physician in clinical practice. Older people are a vulnerable subgroup of patients more prone to developing GI bleeding because of several comorbidities and polypharmacy, especially related to an increased use of antiplatelet and anticoagulant drugs. In addition, older patients may have higher peri-procedural risk that should be evaluated. The recent introduction of reversal strategies may help the management of GI bleeding in this subgroup of patients. In this review, we aimed to (1) summarize the epidemiology and risk factors for upper and lower GI bleeding, (2) describe treatment options with a focus on pharmacodynamics and pharmacokinetics of different proton pump inhibitors, and (3) provide an overview of the clinical management with flowcharts for risk stratification and treatment. In conclusion, GI is common in older patients and an early effective management may be helpful in the reduction of several complications.

Assessment, Resuscitation and Medical Management of Variceal and Nonvariceal Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) continues to be an important cause for emergency room visits and carries significant morbidity and mortality. Early resuscitative measures form the basis of the management of patients presenting with UGIB and can improve the outcomes of such patients including lowering mortality. In this review, using an evidence-based approach, we discuss the initial assessment and resuscitation of patients presenting with UGIB including identifying clues from history and physical examination to confirm UGIB, preendoscopic risk assessment tools, the role of early fluid resuscitation, utilization of blood products, use of pharmacologic interventions, and the optimal timing of endoscopy.

Peptic ulcer characteristics in oral opium and non-opium user patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a frequent medical issue. The primary risk factors for bleeding peptic ulcers are Helicobacter pylori infection and non-steroidal anti-inflammatory drugs. The association between acute gastric/duodenal ulcer and opium use has been previously proposed; however, there is no available data on endoscopic findings of patients with acute UGIB who use opium.

MATERIALS AND METHODS

In the present descriptive cross-sectional study, endoscopic data of 50 consecutive patients with oral opium use and 50 consecutive patients without any opium use who were admitted for UGIB were recorded. The size (5-10 mm, 11-20 mm, or more than 20 mm), number (single, double, or multiple), and location of the ulcers (esophagus, gastric corpus including the fundus and body, antrum, angulus, or duodenum) were examined by endoscopy in both groups.

RESULTS

Three or more ulcers were observed in 46% and 16% of patients with oral opium use and without opium use, respectively (P-value = 0.001). The rate of giant ulcers (> 20 mm) was significantly higher in patients who used oral opium (40% vs. 12%; P-value = 0.007). Esophageal ulcers were also more common in oral opium users (30%) than non-users (8%) with UGIB (P-value = 0.01). Nevertheless, the location of the ulcers between the two groups generally was not statistically different.

CONCLUSIONS

This study has demonstrated that multiple, large peptic ulcers in GIB are potential complications of oral opium use. This could aid the needed modifications in the treatment protocol for these patients.

Epidemiologic data on acute gastrointestinal bleeding in Albania: an overview of upper and lower GI bleeding

Background

Acute gastrointestinal bleeding (GIB) is a significant medical condition that poses a considerable burden on healthcare systems worldwide. To effectively manage and improve outcomes for patients, it is essential to have comprehensive epidemiologic data on GIB, including its various aspects such as upper and lower GIB, treatment modalities, and overall mortality rates.

Aim

The objective of this study is to present the first epidemiological data on acute gastrointestinal bleeding in our country, which includes a comprehensive analysis of upper and lower AGIB, as well as the use of endoscopic and surgical treatments, and an assessment of overall mortality rates for the year 2015.

Material and methods

A retrospective analysis of medical records and databases was conducted to gather epidemiologic data related to acute GIB cases during the specified period. Patient demographics, clinical characteristics, diagnostic findings, treatment approaches (including endoscopic and surgical interventions), and overall mortality rates were evaluated and analyzed.

Results

The study included a total of 926 patients with acute gastrointestinal bleeding during 2015. Among them, 70% presented with upper gastrointestinal bleeding (UGIB), while 30% had lower gastrointestinal bleeding (LGIB). The remaining cases involved both upper and lower GIB.

Regarding treatment modalities, 80% of patients with UGIB underwent endoscopic interventions, which included various techniques such as endoscopic hemostasis, band ligation, and sclerotherapy. On the other hand, 60% of patients with LGIB required surgical intervention due to the severity or complexity of their bleeding.

The overall mortality rate for acute GIB during the study period was calculated to be 8%. Subgroup analysis revealed that patients with UGIB had a mortality rate of 5%, while patients with LGIB had a mortality rate of 10%.

Conclusions

This study provides important epidemiologic data on acute gastrointestinal bleeding, focusing on upper and lower GIB, endoscopic and surgical treatment approaches, and overall mortality rates during the year 2015 in Albania. It refers to the first data, not published and gathered on this therapeutic field, that can be used as a reference for comparison in the latest publications and reports.

Our study results showed that the higher incidence of UGIB compared to LGIB highlights the need for focused attention on upper gastrointestinal pathologies as significant contributors to GIB cases. The utilization of endoscopic interventions as the primary treatment modality for UGIB indicates the effectiveness and importance of timely endoscopic evaluation and intervention in controlling bleeding and improving patient outcomes.

Based on the findings of this initial study, our future research endeavors were primarily focused on investigating patients within the upper gastrointestinal bleeding (UGIB) cohort.

Clinical Predictors of Gastrointestinal Bleeding Source before Computed Tomography Angiography

BACKGROUND

Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen.

METHODS

We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA.

RESULTS

We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB.

CONCLUSIONS

We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.

Utility of the CANUKA Scoring System in the Risk Assessment of Upper GI Bleeding

BACKGROUND

The Canada-United Kingdom-Adelaide (CANUKA) score was developed to stratify patients who experience upper gastrointestinal bleeding (UGIB) to predict who could be discharged from the emergency department. Our aim was to determine if the CANUKA score could be utilized for UGIB in-patients undergoing endoscopy in predicting adverse outcomes. We additionally sought to establish a CANUKA score cut point to predict adverse outcomes and in-hospital mortality and compare this to established scoring systems.

METHODS

Between January 1, 2018 to June 30, 2019 all patients who underwent upper endoscopy after admission for UGIB were identified. We assigned a CANUKA score and compared the area under the receiver operating curve to established scoring systems.

RESULTS

Our data set included 641 patients, with a mean age of 59.5±14.5 years. A CANUKA score ≥10 was associated with an adverse outcome [unadjusted odds ratio, 3.08 (1.79, 5.27)]. No patients experienced an adverse outcome with a CANUKA score <4. No patients died with a CANUKA score <6. Those with a CANUKA score of <10 had an in-hospital mortality of 2.1% compared with 6.8% for those with a score ≥10 ( P =0.008). AIMS65 had the best area under the receiver operating characteristic curve (0.809) for predicting mortality.

CONCLUSIONS

The CANUKA score may serve utility as a predictor of adverse outcomes and mortality in patients admitted with UGIB undergoing endoscopy. Future studies, ideally prospective and multicenter, will be needed to validate its clinical utility.

The global epidemiology of upper and lower gastrointestinal bleeding in general population: A systematic review

BACKGROUND

Gastrointestinal bleeding (GIB) is a common and potentially life-threatening clinical event. To date, the literature on the long-term global epidemiology of GIB has not been systematically reviewed.

AIM

To systematically review the published literature on the worldwide epidemiology of upper and lower GIB.

METHODS

EMBASE^® and MEDLINE were queried from 01 January 1965 to September 17, 2019 to identify population-based studies reporting incidence, mortality, or case-fatality rates of upper GIB (UGIB) or lower GIB (LGIB) in the general adult population, worldwide. Relevant outcome data were extracted and summarized (including data on rebleeding following initial occurrence of GIB when available). All included studies were assessed for risk of bias based upon reporting guidelines.

RESULTS

Of 4203 retrieved database hits, 41 studies were included, comprising a total of around 4.1 million patients with GIB worldwide from 1980–2012. Thirty-three studies reported rates for UGIB, four for LGIB, and four presented data on both. Incidence rates ranged from 15.0 to 172.0/100000 person-years for UGIB, and from 20.5 to 87.0/100000 person-years for LGIB. Thirteen studies reported on temporal trends, generally showing an overall decline in UGIB incidence over time, although a slight increase between 2003 and 2005 followed by a decline was shown in 5/13 studies. GIB-related mortality data were available from six studies for UGIB, with rates ranging from 0.9 to 9.8/100000 person-years, and from three studies for LGIB, with rates ranging from 0.8 to 3.5/100000 person-years. Case-fatality rate ranged from 0.7% to 4.8% for UGIB and 0.5% to 8.0% for LGIB. Rates of rebleeding ranged from 7.3% to 32.5% for UGIB and from 6.7% to 13.5% for LGIB. Two main areas of potential bias were the differences in the operational GIB definition used and inadequate information on how missing data were handled.

CONCLUSION

Wide variation was seen in estimates of GIB epidemiology, likely due to high heterogeneity between studies however, UGIB showed a decreasing trend over the years. Epidemiological data were more widely available for UGIB than for LGIB.

Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study

GOALS

Aim of the study was to determine if patients with acute upper gastrointestinal bleeding (AUGIB) while on antithrombotic agents (ATs) are at higher risk for worse outcomes.

BACKGROUND

ATs are risk factors of AUGIB, but their impact on clinical outcomes is uncertain.

STUDY

Patients with AUGIB (nonvariceal, NV-AUGIB or variceal, V-AUGIB) in 50 Italian hospitals were prospectively enrolled from January 1, 2014 to December 31, 2015. Clinical data, laboratory tests, comorbidities, prognostic scores, received therapies, and outcomes (death, rebleeding, surgery/radiology, transfusions, length of hospitalization) were analyzed.

RESULTS

A total of 3324 patients (2764 NV-AUGIB, 83.2% and 560 V-AUGIB, 16.8%) were enrolled, 1399 (42.1%) on ATs. Patients taking ATs were older (75.4 vs. 62.8 y, P <0.001), had higher American Society of Anesthesiologists (ASA), Rockall and Glasgow-Blatchford scores ( P <0.001). At multivariate analysis considering comorbidities, ATs use resulted an independent protective factor against death [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.45-0.87, P =0.006]. Rebleeding (5.5% vs. 5.8%, P =0.71) and need for salvage surgery/radiology (4.2% vs. 4.8%, P =0.41) were similar in the 2 groups. Considering specific ATs, low-dose aspirin was the most powerful factor lowering the death risk (OR: 0.51, 95% CI: 0.33-0.81, P =0.004). While the generic use of AT therapy did not emerge as a statistically significant independent protective factor considering separately NV-AUGIB (OR: 0.80, 95% CI: 0.56-1.13, P =0.21) and V-AUGIB (OR: 0.40, 95% CI: 0.15-1.07, P =0.068), the protective effect of low-dose aspirin was confirmed for NV-AUGIB (OR: 0.62, 95% CI: 0.41-0.94, P =0.025).

CONCLUSIONS

ATs use is an independent protective factor against death in AUGIB. The protective effect is mainly derived from low-dose aspirin.

A multicenter prospective study of the treatment and outcome of patients with gastroduodenal peptic ulcer bleeding in Japan

Gastroduodenal peptic ulcers are the main cause of nonvariceal upper gastrointestinal bleeding (UGIB). We believe that recent advances in endoscopic techniques and devices for diagnosing upper gastrointestinal tract tumors have advanced hemostasis for UGIB. However, few prospective multicenter studies have examined how these changes affect the prognosis. This prospective study included 246 patients with gastroduodenal peptic ulcers treated at 14 participating facilities. The primary endpoint was in-hospital mortality within 4 weeks, and the secondary endpoints required intervention and refractory bleeding. Subsequently, risk factors affecting these outcomes were examined using various clinical items. Furthermore, the usefulness of the risk stratification using the Glasgow-Blatchford score, rockall score and AIMS65 based on data from the day of the first urgent endoscopy were examined in 205 cases in which all items were complete there are two periods. Thirteen (5%) patients died within 4 weeks; and only 2 died from bleeding. Significant risk factors for poor outcomes were older age and severe comorbidities. Hemostasis was required in 177 (72%) cases, with 20 cases of refractory bleeding (2 due to unsuccessful endoscopic treatment and 18 due to rebleeding). Soft coagulation was the first choice for endoscopic hemostasis in 57% of the cases and was selected in more than 70% of the cases where combined use was required. Rockall score and AIMS65 predicted mortality equally, and Glasgow-Blatchford score was the most useful in predicting the requirement for intervention. All scores predicted refractory bleeding similarly. Although endoscopic hemostasis for UGIB due to peptic ulcer had a favorable outcome, old age and severe comorbidities were risk factors for poor prognosis. We recommend that patients with UGIB should undergo early risk stratification using a risk scoring system.

A Novel Prediction Tool for Endoscopic Intervention in Patients with Acute Upper Gastro-Intestinal Bleeding

(1) Background: Predicting which patients with upper gastro-intestinal bleeding (UGIB) will receive intervention during urgent endoscopy can allow for better triaging and resource utilization but remains sub-optimal. Using machine learning modelling we aimed to devise an improved endoscopic intervention predicting tool. (2) Methods: A retrospective cohort study of adult patients diagnosed with UGIB between 2012−2018 who underwent esophagogastroduodenoscopy (EGD) during hospitalization. We assessed the correlation between various parameters with endoscopic intervention and examined the prediction performance of the Glasgow-Blatchford score (GBS) and the pre-endoscopic Rockall score for endoscopic intervention. We also trained and tested a new machine learning-based model for the prediction of endoscopic intervention. (3) Results: A total of 883 patients were included. Risk factors for endoscopic intervention included cirrhosis (9.0% vs. 3.8%, p = 0.01), syncope at presentation (19.3% vs. 5.4%, p < 0.01), early EGD (6.8 h vs. 17.0 h, p < 0.01), pre-endoscopic administration of tranexamic acid (TXA) (43.4% vs. 31.0%, p < 0.01) and erythromycin (17.2% vs. 5.6%, p < 0.01). Higher GBS (11 vs. 9, p < 0.01) and pre-endoscopy Rockall score (4.7 vs. 4.1, p < 0.01) were significantly associated with endoscopic intervention; however, the predictive performance of the scores was low (AUC of 0.54, and 0.56, respectively). A combined machine learning-developed model demonstrated improved predictive ability (AUC 0.68) using parameters not included in standard GBS. (4) Conclusions: The GBS and pre-endoscopic Rockall score performed poorly in endoscopic intervention prediction. An improved predictive tool has been proposed here. Further studies are needed to examine if predicting this important triaging decision can be further optimized.

The impact of red blood cell transfusion practices on inpatient mortality in variceal and non-variceal gastrointestinal bleeding patients: a 20-year US nationwide retrospective analysis

BACKGROUND

Previous studies in upper gastrointestinal (GI) bleeding have reported inconsistent outcomes about packed red blood cell (PRBC) transfusion practices.

AIM

To assess whether PRBC transfusion is more likely to be dangerous in variceal bleeding than in non-variceal bleeding due to concern of over-transfusion leading to elevated portal pressure.

METHODS

We used the Nationwide Inpatient Sample (1999-2018). We identified patients with upper GI bleeding using an algorithmic approach, categorising bleeding from non-variceal or variceal sources. Our primary outcome was all-cause inpatient mortality. To control for the severity of bleeding, we performed propensity matching of baseline features, including age, gender, the presence of shock, the need for ICU care and co-morbidities. We also examined PRBC transfusion, inpatient mortality and hospitalisation rates for both populations.

RESULTS

We included 10,228,524 upper GI bleeding discharges; 755,135 patients had variceal bleeding. After propensity matching, PRBC transfusion in variceal bleeders was associated with a 22% increase in inpatient mortality, whereas non-variceal bleeders had a 9% increase in inpatient mortality. Compared to non-variceal bleeders receiving blood transfusion, variceal bleeders had nearly four-fold higher odds of inpatient mortality (propensity-matched OR: 3.8; 95% CI: 3.7-3.8; p < 0.001). Notably, PRBC transfusion rates in both groups have declined since 2011, although it has remained higher in variceal bleeders. Mortality for upper GI bleeding has been declining since 1999.

CONCLUSIONS

Although decreased over the last decade, PRBC transfusion rates remain high for variceal bleeders. In addition, PRBC transfusion appears to be more detrimental in variceal bleeders than in non-variceal bleeders.

The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study

BACKGROUND

Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients.

OBJECTIVE

To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding.

DESIGN AND SETTING

Prospective cohort study in an emergency department in Bursa, Turkey.

METHODS

Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated.

RESULTS

A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001).

CONCLUSION

The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.

Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding

Objective

To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB).

Methods

A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed.

Results

In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively.

Conclusion

The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.

A Case of Upper Gastrointestinal Bleeding Due to Metastatic High-Grade B-Cell Lymphoma Successfully Treated With Chemotherapy

Upper gastrointestinal bleeding (UGIB) is a common and potentially life-threatening condition. Metastatic disease is an exceedingly rare cause of UGIB. We report the case of a 73-year-old man with high-grade B-cell lymphoma (HGBL) who presented for the initiation of chemotherapy and was found to be acutely anemic due to UGIB. An esophagogastroduodenoscopy (EGD) revealed multiple large, discrete, ulcerated, non-circumferential, and friable masses in the stomach. Biopsies were consistent with HGBL. The patient was urgently initiated on chemotherapy with the resolution of lesions on subsequent EGD. The rate of prevalence of gastric metastases is unknown, but it should be considered in patients with active malignancy who present with signs of UGIB.

Causes of gastrointestinal bleeding in oral anticoagulant users compared to non-users in a population-based study

BACKGROUND/AIMS

Causes of gastrointestinal bleeding (GIB) in patients on oral anticoagulants (OACs) are not well established. The aims of the study were to compare the causes of GIB in patients on OACs and those not on OAC therapy.

METHODS

A nationwide study of all GIB events in patients on OACs in Iceland from 2014-2019 was conducted. Bleeding events were obtained through ICD-10 codes and review of endoscopy databases, confirmed by review of medical records. For comparison, patients not on OACs from previous Icelandic population-based studies were used.

RESULTS

Among 752 GIB events in 12,005 patients on OACs, 273 (1.9%) had verified upper and 391 (2.7%) had verified lower GIB. For lower GIB, multivariate analysis showed that OAC users were more likely to have colonic polyps (OR 6.6, 95% CI: 2.4 - 17.8, p < .001) or colorectal cancer (OR 3.7, 95% CI: 2.0 - 7.0, p < .001) but less likely to have ischemic colitis (OR 0.11, 95% CI: 0.04 - 0.26, p < .001). For upper GIB, bleeding from mucosal erosions (OR 4.0 95% CI: 2.5 - 7.9, p < .001) and angiodysplasia (OR 3.6, 95%CI: 1.5 - 8.6, p = .003) were more common in OAC users.

CONCLUSIONS

A high proportion of GIB caused by colonic polyps and colorectal cancer among OAC patients indicates that OACs treatment may facilitate cancer diagnosis. The low proportion of ischemic colitis among those on OACs suggests that OACs provide a protective effect against ischemic colitis. OACs seem to increase the bleeding from angiodysplasia and mucosal erosive disease.

Anemia in cirrhosis: An underestimated entity

Anemia in a patient with cirrhosis is a clinically pertinent but often overlooked clinical entity. Relevant guidelines highlight the algorithmic approach of managing a patient of cirrhosis presenting with acute variceal hemorrhage but day-to-day management in hospital and out-patient raises multiple dilemmas: Whether anemia is a disease complication or a part of the disease spectrum? Should iron, folic acid, and vitamin B complex supplementation and nutritional advice, suffice in those who can perform tasks of daily living but have persistently low hemoglobin. How does one investigate and manage anemia due to multifactorial etiologies in the same patient: Acute or chronic blood loss because of portal hypertension and bone marrow aplasia secondary to hepatitis B or C viremia? To add to the clinician's woes the prevalence of anemia increases with increasing disease severity. We thus aim to critically analyze the various pathophysiological mechanisms complicating anemia in a patient with cirrhosis with an emphasis on the diagnostic flowchart in such patients and proposed management protocols thereafter.

The Current Portrayal of Non-Variceal Upper Gastrointestinal Bleeding in a Portuguese Tertiary Center

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important healthcare problem whose epidemiology and outcomes have been changing throughout the years. The main goal of this study was to characterize the current demographics, etiologies, and risk factors of NVUGIB.

Methods

Analysis of clinical, endoscopic, and outcome data from patients who were admitted for NVUGIB between January 2016 and January 2019 in an emergency department of a tertiary hospital center.

Results

A total of 522 patients were included, with a median age of 71 years, mainly men, with multiple comorbidities. Most patients were directly admitted, while the others were transferred from other hospitals. Peptic ulcer disease was the most common cause of NVUGIB and it was followed by tumor bleeding. Esophagogastroduodenoscopy was performed within <12 h after hospital admission in 51.9%. In-hospital rebleeding occurred in 6.9% and overall mortality was 4.2%. Transferred patients had superior Glasgow-Blatchford score (GBS), required more blood transfusion, endoscopic and surgical interventions, and presented higher rebleeding rate, with similar mortality. Complete Rockall score (CRS) and GBS were predictors of endoscopic therapy. Surgery need was only related to CRS. Patients who rebled had superior pre-endoscopic Rockall score (RS), CRS, and GBS. Mortality was increased in patients with higher RS and CRS.

Discussion/Conclusion

Ageing and increasing comorbidities have not been related to worse outcomes in NVUGIB. These findings seem to be the consequence of the correct use of both diagnostic and therapeutic tools in an organized and widely accessible healthcare system.

The outcomes of emergency hospital admissions with non-malignant upper gastrointestinal bleeding in England between 2003 and 2015

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant mortality. Despite developments in endoscopic and clinical management, only minor improvements in outcomes have been reported.

METHODS

This was a retrospective cohort study of patients with non-malignant UGIB emergency admissions in England between 2003 and 2015, using Hospital Episode Statistics. Multilevel logistic regression analysis examined the associations with mortality.

RESULTS

242 796 patients with an UGIB admission were identified (58.8 % men; median age 70 [interquartile range (IQR) 53 - 81]). Between 2003 and 2015, falls occurred in both 30-day mortality (7.5 % to 7.0 %; P < 0.001) and age-standardized mortality (odds ratio (OR) 0.74, 95 % confidence interval [CI] 0.69 - 0.80; P < 0.001), including from variceal bleeding (OR 0.63, 95 %CI 0.45 - 0.87; P < 0.005). Increasing co-morbidity (Charlson score > 5, OR 2.94, 95 %CI 2.85 - 3.04; P < 0.001), older age (> 83 years, OR 6.50, 95 %CI 6.09 - 6.94; P < 0.001), variceal bleeding (OR 2.03, 95 %CI 1.89 - 2.18; P < 0.001), and a weekend admission (Sunday, OR 1.18, 95 %CI 1.12 - 1.23; P < 0.001) were associated with 30-day mortality. Of deaths at 30 days, 8.9 % were from ischemic heart disease (IHD) and the cardiovascular age-standardized mortality rate following UGIB was high (IHD deaths within 1 year, 1188.4 [95 %CI 1036.8 - 1353.8] per 100 000 men in 2003).

CONCLUSIONS

Between 2003 and 2015, 30-day mortality among emergency admissions with non-malignant UGIB fell by 0.5 % to 7.0 %. Mortality was higher among UGIB admissions at the weekend, with important implications for service provision. Patients with UGIB had a much greater risk of subsequently dying from cardiovascular disease and addressing this risk is a key management step in UGIB.

Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding

OBJECTIVES

Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding.

MATERIALS AND METHODS

Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021.

RESULTS

There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively.

CONCLUSIONS

When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.

Prophylactic transcatheter arterial embolization reduces rebleeding in non-variceal upper gastrointestinal bleeding: A meta-analysis

BACKGROUND

Despite the improvement in the endoscopic hemostasis of non-variceal upper gastrointestinal bleeding (NVUGIB), rebleeding remains a major concern.

AIM

To assess the role of prophylactic transcatheter arterial embolization (PTAE) added to successful hemostatic treatment among NVUGIB patients.

METHODS

We searched three databases from inception through October 19^th, 2020. Randomized controlled trials (RCTs) and observational cohort studies were eligible. Studies compared patients with NVUGIB receiving PTAE to those who did not get PTAE. Investigated outcomes were rebleeding, mortality, reintervention, need for surgery and transfusion, length of hospital (LOH), and intensive care unit (ICU) stay. In the quantitative synthesis, odds ratios (ORs) and weighted mean differences (WMDs) were calculated with the random-effects model and interpreted with 95% confidence intervals (CIs).

RESULTS

We included a total of 3 RCTs and 9 observational studies with a total of 1329 patients, with 486 in the intervention group. PTAE was associated with lower odds of rebleeding (OR = 0.48, 95%CI: 0.29–0.78). There was no difference in the 30-d mortality rates (OR = 0.82, 95%CI: 0.39–1.72) between the PTAE and control groups. Patients who underwent PTAE treatment had a lower chance for reintervention (OR = 0.48, 95%CI: 0.31–0.76) or rescue surgery (OR = 0.35, 95%CI: 0.14–0.92). The LOH and ICU stay was shorter in the PTAE group, but the difference was non-significant [WMD = -3.77, 95%CI: (-8.00)–0.45; WMD = -1.33, 95%CI: (-2.84)–0.18, respectively].

CONCLUSION

PTAE is associated with lower odds of rebleeding and any reintervention in NVUGIB. However, further RCTs are needed to have a higher level of evidence.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

The "Hub and Spoke" model has no effect on mortality in acute upper gastrointestinal bleeding: A prospective multicenter cohort study

BACKGROUND

the lack of standardized pathways for patients with gastrointestinal bleeding may have led to differences in their management and inequity to medical care access. The "Hub & Spoke" model was adopted to fill this gap in many disciplines, but, to our knowledge, no data exist on its efficacy on mortality in GI bleeding. We aimed to evaluate if the "Hub & Spoke" organizational model has an impact on mortality risk from UGIB.

METHODS

from January 2014 to December 2015, 3324 consecutive patients admitted for UGIB in 50 Italian hospitals were enrolled (1977 patients in hospitals within the "Hub & Spoke" network for digestive hemorrhagic emergency and 1347 in hospitals outside the "Hub & Spoke" network). Clinical, endoscopic and organizational data were recorded.

RESULTS

we observed no differences in mortality between patients admitted to hospitals included or not included in the "Hub & Spoke" network (5.2% vs 6.1%, p = 0.3). On multivariate analysis, admission in gastroenterology wards (OR 0.61, p = 0.001) or an academic hospital (OR 0.65, p < 0.056) were independent protective factors while being in "Hub & Spoke" organization system did not affect mortality (OR 1.09, p = 0.57).

CONCLUSION

the "Hub & Spoke" model per sé does not impact on mortality while being treated in academic hospital or gastroenterology wards improved survival.

Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.

Seasonal variation of peptic ulcer disease, peptic ulcer bleeding, and acute pancreatitis: A nationwide population-based study using a common data model

Although gastrointestinal diseases are reported at various times throughout the year, some particular seasons are associated with a higher incidence of these diseases. This study aimed to identify the seasonal variations of peptic ulcer (PU), peptic ulcer bleeding (PUB), and acute pancreatitis (AP) in South Korea.We conducted a retrospective, observational cohort study of all subjects aged >18 years between 2012 and 2016 using the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. We assessed the overall seasonal variations of PU, PUB, and AP and further analyzed seasonal variations according to age and sex subgroups.In total, 14,626 patients with PU, 3575 with PUB, and 9023 with AP were analyzed for 5 years. A clear seasonal variation was noted in PU, with the highest incidence rate during winter, the second highest during spring, the third highest during summer, and the lowest incidence during autumn for 5 years (P < .001). PUB also showed significant seasonal fluctuations, with winter peak for 4 years, except 1 year, which had a spring peak (P < .001). However, AP showed no clear seasonal variations (P = .090). No significant differences in the seasonal variation of PU, PUB, and AP were observed according to sex and age subgroups (<60 years vs ≥60 years).Seasonal variation of PU and PUB should be considered when determining allocation of available health care resources.

Divergent trends of hospitalizations for upper and lower gastrointestinal bleeding based on population prescriptions of aspirin, proton pump inhibitors and Helicobacter pylori eradication therapy: Trends of upper and lower gastrointestinal bleeding

BACKGROUND

With the increasing use of medications that alter the risk of gastrointestinal bleeding (GIB), comprising aspirin, proton pump inhibitors (PPIs), and Helicobacter pylori eradication therapies, the trends of GIB are evolving.

OBJECTIVE

The aim of this study is to determine and predict the trends of GIB and to evaluate the effects of population prescriptions of these medications on GIB incidences.

METHODS

We retrieved patients hospitalized for GIB in all public hospitals in Hong Kong between 2009 and 2019. Monthly age- and sex-standardized GIB data were fitted and predicted, based on population prescriptions of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, other antiplatelet drugs, PPIs, and H. pylori therapies, using autoregressive integrated moving average model for time series analysis.

RESULTS

The incidence of upper GIB (UGIB) showed a clear declining trend while lower GIB (LGIB) decreased slightly. Older population (>80 years) had the greatest decline in UGIB but was associated with an increase in LGIB. Prescriptions of PPIs and aspirin increased significantly with time. PPIs prescriptions were negatively associated with UGIB incidence (coefficient log(PPIs) -4.58; 95% confidence interval [CI]: -5.69, -3.47). H. pylori eradication in the previous month showed a nonsignificant trend on UGIB (coefficient -0.14; 95% CI: -0.30, 0.02). In contrast, aspirin increased the incidences of UGIB (coefficient 0.06; 95% CI: 0.04, 0.07) and LGIB (coefficient 0.04; 95% CI: 0.03, 0.05). NSAIDs, anticoagulants, and other antiplatelet drugs were not significantly associated with the trend of either UGIB or LGIB. UGIB is predicted to decline continuously but LGIB is projected to rise, particularly with increasing use of aspirin.

CONCLUSIONS

UGIB incidences were decreasing and had been surpassed by LGIB. Based on population prescriptions of aspirin and PPIs, divergent trends of upper and lower GIB are expected, especially in elderly.

Role of Video Capsule in Small Bowel Bleeding

Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.

Outcomes of upper gastrointestinal bleeding are similar between direct oral anticoagulants and vitamin K antagonists

BACKGROUND

The increased risk of upper gastrointestinal bleeding (UGIB) related to direct oral anticoagulants (DOACs) as compared to vitamin K antagonists (VKA) remains debated.

AIMS

To describe the epidemiology and outcomes of UGIB in patients treated with oral anticoagulants.

METHODS

A prospective, multicentre study in French general hospitals enrolled all consecutive patients with UGIB during one year. Patients treated with oral anticoagulants were retrieved from the cohort. Main outcomes were mortality and rebleeding during the first 6 weeks and need for non-endoscopic treatment (surgery or interventional radiology).

RESULTS

Among the 2498 patients included, 475 (19%) had an oral anticoagulant, mostly with VKA (267 patients [56.2%]). Baseline characteristics were similar between the groups except for renal failure and cirrhosis that were more prevalent in the VKA group. Gastroscopy was normal in 73 patients (15.3%); peptic lesions were the main cause of UGIB (n = 233, 49%). Endoscopic treatment was performed in 128 patients (26.9%), leading to bleeding resolution in 74% (n = 95). Mortality rate at 6 weeks was 12.4% (59 patients), and was higher in the VKA group compared to DOACs (16.1% vs 7.8%, P < 0.01). By multivariate analysis, only the Charlson index ≥ 5 and UGIB occurrring in in-patients were independently associated with mortality. Rebleeding (56 patients [11.8%]) and need for non-endoscopic treatment (18 patients [3.8%]) were not associated with the type of anticoagulant.

CONCLUSION

DOACs do not alter outcomes of UGIB as compared to VKA. Comorbidities and associated treatment are the most important factors worsening the prognosis of UGIB.

Patient safety in an endoscopy unit: an observational retrospective analysis of reported incidents

INTRODUCTION

Patient safety is a serious public health with serious implications on morbidity, mortality, and quality of life of patients, in addition to negatively affecting the public image of healthcare institutions and professionals. It requires further investigation, especially in specialties lacking published data, such as endoscopy.

OBJECTIVE

To analyze patient safety incidents reported in a gastrointestinal endoscopy unit of a tertiary hospital in southern Brazil.

METHODS

This retrospective, cross-sectional study quantitatively described patient safety incidents related to endoscopic procedures. The sample consisted of reports of incidents that occurred from 2015 to 2017. The data were descriptively analysed, and the study was approved by the relevant research ethics committee.

RESULTS

Overall, 42,863 endoscopic procedures were performed and 167 reports were submitted in the period, accounting for a prevalence of incidents of 0.38%. Most incidents did not result in unnecessary harm to patients (76.6%). The most prevalent incidents were those related to patient identification, followed by those related to pathology exams, exam reports, gastrointestinal perforations, skin lesions, falls and medication errors. The rate of adverse events (harm to patient) in patients undergoing any endoscopic procedure was 0.06%.

CONCLUSIONS

The incidence of unnecessary harm (adverse event) associated with any endoscopic procedure was relatively low in this study. However, the identification of reported incidents is crucial for evaluating and improving the quality of care provided to patients.

High- versus low-dose proton pump inhibitors post endoscopic hemostasis in hemodialysis cases with peptic ulcer bleeding

Post-endoscopic hemostasis treatment is not adequately addressed in high-risk patients on regular hemodialysis (HD) with emergency peptic ulcer bleeding. This study aimed to compare post-endoscopic high- versus low-dose proton pump inhibitors (PPIs) for peptic ulcer bleeding in patients undergoing regular HD. This prospective study comprised 200 patients on regular hemodialysis having emergency peptic ulcer bleeding confirmed at endoscopy and managed with endoscopic hemostasis. Half of the patients received high-dose intensive regimen and the other half received the standard regimen. Patients who were suspected to have recurrent bleeding underwent a second endoscopy for bleeding control. The primary outcome measure was rate of recurrent bleeding during period of hospitalization that was detected through second endoscopy. Rebleeding occurred in 32 patients ; 15 in the High-Dose Cohort and 17 in the Low-Dose Control (p = 0.700). No significant differences between the two dose cohorts regarding the time of rebleeding (p = 0.243), endoscopic hemostasis mode (p = 1.000), and need for surgery (p = 0.306). The highdose regimen Inhospital mortality in high-dose group was 9.0% compared to 8.0% in the low-dose group (p = 0.800). Apart from the pre-hemostatic Forrest classification of ulcers, there were no significant differences between patients with re-bleeding ulcers (n=32) and those with non-rebleeding (n=168). Rebleeding was more common in class Ia, i.e. spurting bleeders (p < 0.001). Endoscopic hemostasis followed by the standard low-dose PPI regimen of 40 mg daily IV boluses is safe and effective option for bleeding peptic ulcers in the high-risk patients under regular hemodialysis.

C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis

In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.

The management of acute lower gastrointestinal bleeding using a Sengstaken-Blakemore tube

INTRODUCTION

Acute lower gastrointestinal haemorrhage can potentially be life-threatening. We present a case of a massive rectal bleed which was managed successfully with a balloon tamponade device designed for upper gastrointestinal haemorrhage.

PRESENTATION OF CASE

A 75-year-old gentleman, with a history of human immunodeficiency virus and cirrhosis with portal hypertension, presented with bright red rectal bleeding. Investigations showed a low haemoglobin level (74 g/L) and deranged clotting. Oesophago-gastro-duodenoscopy demonstrated no fresh or altered blood. Flexible sigmoidoscopy revealed active bleeding from a varix within the anterior rectal wall 4 cm from the anal verge. Efforts to stop the bleeding, including endoscopic clips, adrenaline injection and rectal packing, were unsuccessful and the patient became haemodynamically unstable. A Sengstaken-Blakemore tube was inserted per rectum and the gastric balloon was inflated to tamponade the lower rectum. The oesophageal balloon was then inflated to hold the gastric balloon firmly in place. A computed tomography angiogram demonstrated no evidence of haemorrhage with balloon tamponade. After 36 h, the balloon was removed with no further episodes of bleeding.

DISCUSSION

The application of a balloon tamponade device should be considered in the management algorithm for acute lower gastrointestinal bleed. Advantages include its rapid insertion, immediate results and ability to measure further bleeding after the catheter has been placed.

CONCLUSION

Sengstaken-Blakemore tube per rectum may effectively control massive low rectal bleeding when alternative methods have been unsuccessful.

Use of proton pump inhibitors in dialysis patients: a double-edged sword?

Large cohort-based studies have shown that proton pump inhibitors (PPIs) are linked to rare but multiple and varied secondary events when used in the general population. Although clinicians accept the negative effects of PPIs on renal function, there is a lack of available data regarding the potential consequences of their use by dialysis patients in whom the risk of gastrointestinal bleeding is quite high. This review aims to highlight the risks and benefits of PPIs use in dialysis patients. To summarize, the benefit on the reduction of high digestive bleeding seems certain, but without any beneficial impact on overall survival. The impact on quality of life seems to be significant. The data on the occurrence of peritonitis during PPIs treatment are very contradictory. There is evidence regarding the occurrence of hypomagnesaemia in haemodialysis patients with PPIs; which may lead to increase bone fragility. New data show an increased cardiovascular risk and even a risk of death linked to the use of PPIs on dialysis. Several mechanisms of IPP toxicity are advanced to explain these findings.

Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study

BACKGROUND

There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding.

AIMS

To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding.

METHODS

A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward.

PRIMARY OUTCOME

30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding.

RESULTS

Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01.

CONCLUSION

Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.

The Effect of Octreotide in Acute Nonvariceal Upper Gastrointestinal Bleeding: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Nonvariceal upper gastrointestinal bleeding (NUGIB) is a common cause of hospitalization and is associated with considerable mortality and morbidity. Octreotide has been shown to be an effective treatment in the control of variceal UGIB. Theoretically, octreotide could be effective in the treatment of other types of bleeding ulcers.

METHODS

This randomized, double-blind, placebo-controlled trial was carried out on patients with NVUGIB who had been admitted to two referral centers in Shiraz, Iran. Patients were randomized to two groups: Group A (n = 58) received octreotide and Group B (n = 58) received a placebo. Patients in both groups received pantoprazole 40 mg as an initial dose, then 40 mg every 12 h intravenously. In addition to the pantoprazole, patients in Group A received 100 μg octreotide subcutaneously every 8 h for 72 h or until they were discharged. Patients in Group B received pantoprazole and a placebo at the same dose schedule.

FINDINGS

There were no statistically significant differences between Groups A and B in terms of mortality (0 vs. 5.17%; P = 0.21,) rebleeding rate (5.17% vs. 1.72%; P = 0.5), blood transfusion requirement (1.65 ± 0.47 units vs. 1.70 ± 0.45 units; P = 0.45), length of hospital stay (1.96 ± 1.00 days vs. 1.65 ± 0.84 days; P = 0.44), and need for surgery (1.72% vs. 1.72%; P = 0.7).

CONCLUSION

The results showed that use of subcutaneous octreotide as an adjuvant treatment did not have a beneficial effect on the treatment of NVUGIB.

Prospective cost analysis of early video capsule endoscopy versus standard of care in non-hematemesis gastrointestinal bleeding: a non-inferiority study

Background and aim: A non-inferiority cost analysis was performed to assess if the early capsule approach would incur higher costs than the standard of care approach in patients presenting with non-hematemesis gastrointestinal bleeding.Methods: A prospective non-inferiority cost analysis was performed on patients receiving either an early video capsule as the first diagnostic procedure or an endoscopic procedure as determined by gastroenterology staff that were not involved in the study. Primary outcome was total direct costs incurred in both groups.Results: Forty-five patients and 42 patients were enrolled into the early capsule and standard of care arms, respectively. There was no difference in total direct cost per inpatient case in both groups ($7,362 vs $7,148, p = 0.77 [CI = -2,285-2,315, equivalent margin = -$3,100]). Localization of a bleeding source after the first diagnostic procedure was identified more frequently in the early capsule group (69.2% vs 27.9%, p = 0.0003). If patients were discharged after their last non-diagnostic evaluation, then length of stay could be decreased by 50% in both groups (58.5 to 31.6 h, p = 0.02 in the early capsule group and 69.4 to 39.2 h in the standard of care group p = 0.001). Projections indicate the fastest a patient with non-diagnostic evaluations could be discharged is 0.88 days in the early capsule group vs 1.63 days in the standard of care group (p = 0.0005).Discussion: In patients with non-hematemesis bleeding, video capsule endoscopy may be a more efficient diagnostic approach than the standard of care approach, since it detects bleeding significantly more often without an increase in healthcare costs.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated.

AIM

To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB.

METHODS

This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups.

RESULTS

A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.

CONCLUSION

In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Upper Gastrointestinal Bleeding due to Metastatic Endometrial Adenocarcinoma

Upper gastrointestinal bleeding (UGIB) is a life-threatening complication and a commonly encountered diagnosis requiring hospitalization. It is defined as bleeding proximal to the ligament of Treitz with the most common cause being peptic ulcer disease. There are multiple causes of UGIB and each of them presents its own unique diagnostic and management challenges. We present a rare case of UGIB due to endometrial adenocarcinoma metastatic to the third part of the duodenum. Most common sites of metastasis from endometrial adenocarcinoma are pelvic and paraaortic lymph nodes, and it is very rare for endometrial cancer to metastasize in gastrointestinal tract and then present as UGIB.

Rising Events and Improved Outcomes of Gastrointestinal Bleed With Shock in USA: A 12-year National Analysis

OBJECTIVE

Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock.

METHODS

We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products.

RESULTS

GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%).

CONCLUSIONS

GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.

Novel Application of Balloon Tamponade in Management of Acute Lower Gastrointestinal Hemorrhage

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital.

Changing epidemiology and etiology of upper and lower gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) develops in the oesophagus, stomach or duodenum and has an incidence of 47/100,000. Lower GIB (LGIB) develops in the small bowel, colon or anorectum and has an incidence of 33/100,000. Where the incidence of UGIB has fallen, driven by helicobacter pylori eradication and the use of proton pump inhibitors, the incidence of LGIB may be increasing. Interventions such as early endoscopy, risk assessment and national guidelines have improved clinical outcomes but have had limited impact on the economic burden of GIB. Previously LGIB was thought to be less severe than UGIB, but contemporary data suggest that patients with LGIB tend to have a longer length of hospital stay and may be at higher risk of death or re-bleeding.

Is upper gastrointestinal bleeding still a life-threatening condition?

Background: Upper gastrointestinal bleeding is a common clinical problem and one of the main reasons for emergency hospitalization. It is associated with an overall mortality rate of 2% to 13%, despite advances in medical therapy. First-choice management is conservative treatment with endoscopic hemostasis. Aim of the study: The aim of the study was to examine the epidemiological and clinical characteristics of patients with upper gastrointestinal bleeding with a focus on the course of hospitalization based on the etiology Material and methods: A retrospective study was conducted in the Department of Surgery at the 4th Military Teaching Hospital in the years 2011–2016, comprising a total of 200 hospitalizations. 150 (75%) of the study group were men, and the mean age was 63.6±15.8 years. Results: Patients most frequently presented with melena (n=105; 53.1%) and hematemesis (n=79; 40%) or coffee ground vomiting (n=57; 28.7%). . 138 (69%) of hemorrhages were managed with endoscopic hemostasis, and in 43 (21.5%) of cases conservative treatment was adequate. In 12 (6%) of cases, laparotomy was the first-choice therapy and in 7 (3.5%) cases, surgery was performed after an attempt at endoscopic treatment had failed. The sources of bleeding were: gastric ulcer – 58 (29%), duodenal ulcer – 48 (24%), esophageal varices – 31 (15.5%), gastric tumor – 15 (7.5%), Mallory-Weiss syndrome – 10 (5%), and Dieulafoy’s lesion – 3 (1.5%). 16 (8%) of the hospitalizations were fatal. Conclusions: Upper gastrointestinal bleeding still has a high mortality rate (8%). It more frequently affects men and the elderly. Gastric and duodenal ulcers are the most common etiologies of bleeding. Esophageal varices and neoplasms are also a significant source of bleeding. Despite the progress in the pharmacological treatment of peptic ulcers, the complications resulting from gastrointestinal bleeding continue to be a serious clinical problem.

Clinical experience with ferric carboxymaltose in the management of anemia in acute gastrointestinal bleeding

OBJECTIVE

The aim of this study was to assess the efficacy and safety of intravenous ferric carboxymaltose (FCM) following hospitalization for acute gastrointestinal bleeding (AGIB) in the context of a restrictive transfusion strategy.

PATIENTS AND METHODS

A retrospective single-center study analyzed patients with AGIB (excluding AGIB secondary to portal hypertension) administered a single FCM dose with or without blood transfusion.

RESULTS

Eighty-six episodes in 84 patients were analyzed. Seventy-nine patients had upper AGIB. Nineteen episodes were associated with hemodynamic instability. FCM was administered during hospitalization as a single dose of 1000 mg iron in 84/86 episodes and as a single dose of 500 mg iron in two episodes, with blood transfusion in 60/86 (69.8%) episodes. The mean hemoglobin (Hb) was 9.0 g/dl at admission, 7.6 g/dl at the lowest in-hospital value, 9.4 g/dl at discharge, and 12.7 g/dl at follow-up (mean: 55 days postdischarge) (P<0.001 for follow-up vs. all other timepoints). The lowest mean in-hospital Hb value was 7.2 and 8.8 g/dl, respectively, in patients with transfusion+FCM versus FCM alone; the mean Hb was 12.4 versus 13.7 g/dl at follow-up. In patients administered FCM alone, the mean Hb at follow-up in the subpopulations aged older than or equal to 75 years (n=33), Charlson comorbidity index of at least 3 (n=48), and Hb of up to 10 g/dl at admission (n=47) were 12.6, 13.1, and 13.3 g/dl, respectively. No adverse effects were detected.

CONCLUSION

Treatment with FCM for AGIB is associated with a good erythropoietic response and anemia correction after hospitalization, even in severe episodes or when transfusion is needed. FCM is safe and well tolerated, and may support a restrictive transfusion policy.

Lower Endoscopic Diagnostic Yields Observed in Non-hematemesis Gastrointestinal Bleeding Patients

BACKGROUND

Location of bleeding can present a diagnostic challenge in patients without hematemesis more so than those with hematemesis.

AIM

To describe endoscopic diagnostic yields in both hematemesis and non-hematemesis gastrointestinal bleeding patient populations.

METHODS

A retrospective analysis on a cohort of 343 consecutively identified gastrointestinal bleeding patients admitted to a tertiary care center emergency department with hematemesis and non-hematemesis over a 12-month period. Data obtained included presenting symptoms, diagnostic lesions, procedure types with diagnostic yields, and hours to diagnosis.

RESULTS

The hematemesis group (n = 105) took on average 15.6 h to reach a diagnosis versus 30.0 h in the non-hematemesis group (n = 231), (p = 0.005). In the non-hematemesis group, the first procedure was diagnostic only 53% of the time versus 71% in the hematemesis group (p = 0.02). 25% of patients in the non-hematemesis group required multiple procedures versus 10% in the hematemesis group (p = 0.004). Diagnostic yield for a primary esophagogastroduodenoscopy was 71% for the hematemesis group versus 50% for the non-hematemesis group (p = 0.01). Primary colonoscopies were diagnostic in 54% of patients and 12.5% as a secondary procedure in the non-hematemesis group. A primary video capsule endoscopy yielded a diagnosis in 79% of non-hematemesis patients (n = 14) and had a 70% overall diagnostic rate (n = 33).

CONCLUSION

Non-hematemesis gastrointestinal bleeding patients undergo multiple non-diagnostic tests and have longer times to diagnosis and then compared those with hematemesis. The high yield of video capsule endoscopy in the non-hematemesis group suggests a role for this device in this context and warrants further investigation.

Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: Using propensity score matching

BACKGROUND AND AIM

Recently, the application of hemostatic powder to the bleeding site has been used to treat active upper gastrointestinal bleeding (UGIB). We aimed to assess the effectiveness of the polysaccharide hemostatic powder (PHP) in patients with non-variceal UGIB.

METHODS

We reviewed prospectively collected 40 patients with UGIB treated with PHP therapy between April 2016 and January 2017 (PHP group) and 303 patients with UGIB treated with conventional therapy between April 2012 and October 2014 (conventional therapy group). We compared the rate of successful hemostasis and the rebleeding between the two groups after as well as before propensity score matching using the Glasgow-Blatchford score and Forrest classification.

RESULTS

Thirty patients treated with the PHP and 60 patients treated with conventional therapy were included in the matched groups. Baseline patient characteristics including comorbidities, vital signs, and bleeding scores were similar in the matched groups. The rate of immediate hemostasis and 7-day and 30-day rebleeding were also similar in the two groups before and after matching. In the subgroup analysis, no significant differences in immediate hemostasis or rebleeding rate were noted between PHP in monotherapy and PHP combined with a conventional hemostatic method. At 30 days after the therapy, there were no significant PHP-related complications or mortality.

CONCLUSIONS

Given its safety, the PHP proved feasible for endoscopic treatment of UGIB, having similar effectiveness as that of conventional therapy. The PHP may become a promising hemostatic method for non-variceal UGIB.

Endoscopic Management of Nonvariceal, Nonulcer Upper Gastrointestinal Bleeding

Nonvariceal, nonulcer upper gastrointestinal hemorrhage (UGIH) is a less common cause for acute upper gastrointestinal bleeding. However, nonvariceal, nonulcer UGIH is an important entity to identify and treat appropriately to prevent bleeding-related morbidity and mortality. Over the past 40 years, there has been a revolution in gastrointestinal endoscopy and a similar revolution in the management of UGIH. The aim of this article is to focus on the endoscopic management of nonvariceal, nonulcer UGIH, with a focus on the newer diagnostic and treatment modalities currently available.

CT for Evaluation of Acute Gastrointestinal Bleeding

Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. ^©RSNA, 2018.