Diagnosis and treatment of acute gastrointestinal haemorrhage in a small district hospital

Effects of fibrinolytic inhibitors on mortality from upper gastrointestinal haemorrhage

OBJECTIVE

To see whether fibrinolytic inhibitors are of value when given to patients with upper gastrointestinal haemorrhage.

DESIGN

Meta-analysis of six randomised double blind placebo controlled trials. Two methods used for obtaining an overall estimate of effect, including a random effects model incorporating any heterogeneity of outcome in the estimate of the overall treatment effect.

SETTING

Inpatient care in hospitals in the United Kingdom, Sweden, and Australia.

PATIENTS

1267 Patients admitted to hospital with primary diagnosis of acute upper gastrointestinal haemorrhage. Five of the six trials included a high proportion of elderly patients. Most patients were bleeding from peptic ulcers in the stomach and duodenum (43-88%) or gastric erosions (4-23%). A variable proportion had a degree of clinical shock at entry.

INTERVENTIONS

Tranexamic acid 3-6 g/day given intravenously for two or three days followed by 3-6 g/day by mouth for a further three to five days (four trials) or 4.5-12 g/day by mouth for two to seven days (two trials).

END POINTS

Frequency of recurrent haemorrhage, need for surgery, and death.

MAIN RESULTS

Treatment with tranexamic acid was associated with a 20-30% reduction in the rate of rebleeding, a 30-40% reduction (95% confidence interval 10% to 60%) in mortality.

CONCLUSIONS

Treatment with tranexamic acid may be of value to patients considered to be at risk of dying after an upper gastrointestinal haemorrhage.

The antifibrinolytic properties of cimetidine

The mucosal fibrinolytic activity was estimated in 24 patients with duodenal ulcer and in 11 patients with gastric ulcer. The fibrinolytic activity was estimated in biopsy specimens taken during gastroscopy. Specimens were taken in the corpus, in the antrum, and in the duodenal mucosa. In patients with duodenal ulcer the fibrinolytic activity was significantly higher in the corpus and antrum mucosa, whereas no difference was observed in the duodenal mucosa compared with controls. Gastric ulcer patients had, compared with controls, significantly higher activity in the corpus mucosa only. Fourteen patients with duodenal ulcer and five with gastric ulcer were treated with 1 g cimetidine daily for 4 weeks. The mucosal fibrinolytic activity was estimated before and after treatment in the above-mentioned regions. A significant reduction was observed after treatment in patients with duodenal ulcer, both in the corpus and in the duodenal mucosa, whereas no difference was seen in the duodenum. In patients with gastric ulcer a reduction was observed in the corpus mucosa only. The fibrinolytic activity estimated was plasminogen activator, and not other proteases, in all estimations.

Cimetidine--an antifibrinolytic agent?

The mucosal fibrinolytic activity was estimated in 14 patients with duodenal ulcer before and after 4 weeks' treatment with cimetidine. A significant reduction in fibrinolytic activity in the corpus and antrum mucosa was found after treatment. In patients with healed ulcer after treatment, the activity was lower than in patients with unhealed ulcers, but no significance was proved. Similarly, in five patients with gastric ulcer, reduction in fibrinolytic activity was found after cimetidine treatment but in the corpus mucosa only. The fibrinolytic activity in the mucosa is caused by plasmin. Whether this antifibrinolytic property of cimetidine is of any importance in the treatment of ulcer disease is still unknown.

Local inhibition of the fibrinolytic system in patients with massive upper gastrointestinal hemorrhage

The effect or oral tranexamic acid on massive upper gastrointestinal hemorrhage was evaluated in a randomized double-blind study. Totally 50 patients entered the trial and seven were excluded, leaving 22 placebo treated and 21 tranexamic acid treated for analysis. The groups were comparable regarding sex, age, diagnosis, and initial laboratory data. Transfusions requirements and operation frequency did not differ. Mortality was slightly reduced and death delayed in tranexamic acid treated patients.

Acute upper gastro-intestinal haemorrhage : A review of 71 cases

Seventy-one patients with acute upper gastro-intestinal haemorrhage were studied with particular reference to investigations, diagnosis, and history of ingestion of gastro-intestinal irritants. A high incidence of superficial mucosal lesions was found, and the importance of early investigation in the diagnosis of these lesions is stressed. Endoscopy was found to be superior to barium meal in the diagnosis of all sources of haemorrhage except duodenal ulcer. The incidence of multiple lesions was found to be 12.7%, and the value of direct visualisation of bleeding points by endoscopy is emphasised. Almost 16% of the patients underwent urgent surgery, but the mortality rate for the series as a whole was only 2.8%.