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Deliwala SS, Chandan S, Mohan BP, Khan S, Reddy N, Ramai D, Bapaye JA, Dahiya DS, Kassab LL, Facciorusso A, Chawla S, Adler D. Hemostatic spray (TC-325) vs. standard endoscopic therapy for non-variceal gastrointestinal bleeding: A meta-analysis of randomized controlled trials. Endosc Int Open 2023; 11:E288-E295. [PMID: 36968978 PMCID: PMC10038751 DOI: 10.1055/a-2032-4199] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/08/2023] [Indexed: 03/26/2023] Open
Abstract
Background and study aims
Hemospray (TC-325) is a mineral powder with adsorptive properties designed for use in various gastrointestinal bleeding (GIB) scenarios. We conducted a systematic review & meta-analysis of randomized controlled trials (RCTs) comparing TC-325 to standard endoscopic therapy (SET) for non-variceal GIB (NVGIB).
Methods
Multiple databases were searched through October 2022. Meta-analysis was performed using a random-effects model to determine pooled relative risk (RR) and proportions with 95 % confidence intervals (CI) for primary hemostasis, hemostasis failure, 30-day rebleeding, length of stay (LOS), and need for rescue interventions. Heterogeneity was assessed using I
2
%.
Results
Five RCTs with 362 patients (TC-325 178, SET 184) – 123 females and 239 males with a mean age 65 ± 16 years). The most common etiologies were peptic ulcer disease (48 %), malignancies (35 %), and others (17 %). Bleeding was characterized as Forrest IA (7 %), IB (73 %), IIA (3 %), and IIB (1 %). SET included epinephrine injection, electrocautery, hemoclips, or a combination. No statistical difference in primary hemostasis between TC-325 compared to SET, RR 1.09 (CI 0.95–1.25; I
2
43),
P =
0.2, including patients with oozing/spurting hemorrhage, RR 1.13 (CI 0.98–1.3; I
2
35),
P =
0.08. Failure to achieve hemostasis was higher in SET compared to TC-325, RR 0.30 (CI 0.12–0.77, I
2
0),
P =
0.01, including patients with oozing/spurting hemorrhage, RR 0.24 (CI 0.09 – 0.63, I
2
0),
P =
0.004. We found no difference between the two interventions in terms of rebleeding, RR 1.13 (CI 0.62–2.07, I
2
26),
P =
0.8 and LOS, standardized mean difference (SMD) 0.27 (CI, –0.20–0.74; I
2
62),
P =
0.3. Finally, pooled rate of rescue interventions (angiography) was statistically higher in SET compared to TC-325, RR 0.68 (CI 0.5–0.94; I
2
0),
P =
0.02.
Conclusions
Our analysis shows that for acute NV GIB, including oozing/spurting hemorrhage, TC-325 does not result in higher rates of primary hemostasis compared to SET. However, lower rates of failures were seen with TC-325 than SET. In addition, there was no difference in the two modalities when comparing rates of rebleeding and LOS.
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Affiliation(s)
- Smit S. Deliwala
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, United States
| | - Saurabh Chandan
- Gastroenterology & Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, United States
| | - Shahab Khan
- Harvard Medical School, Boston, Massachusetts, United States
| | - Nitin Reddy
- Department of Internal Medicine, PSG Institute of Medical Science, Coimbatore, Tamil Nadu, India
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, United States
| | - Jay A. Bapaye
- Department of Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan, United States
| | | | | | - Saurabh Chawla
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, United States
| | - Douglas Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, Colorado, United States
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2
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Romstad KK, Detlie TE, Søberg T, Thomas O, Ricanek P, Jahnsen ME, Lerang F, Jahnsen J. Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study). Scand J Gastroenterol 2022; 57:8-15. [PMID: 34663154 DOI: 10.1080/00365521.2021.1988701] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients. MATERIALS AND METHODS A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled. RESULTS Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients. CONCLUSIONS Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.
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Affiliation(s)
- Katrine Kauczynska Romstad
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trond Espen Detlie
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Taran Søberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Owen Thomas
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Marte Eide Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
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3
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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4
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Hemostatic spray powder TC-325 in the primary endoscopic treatment of peptic ulcer-related bleeding: multicenter international registry. Endoscopy 2021; 53:36-43. [PMID: 32459000 DOI: 10.1055/a-1186-5360] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. METHODS Data were collected prospectively (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion. RESULTS 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications. CONCLUSIONS This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.
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5
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Romstad KK, Detlie TE, Søberg T, Ricanek P, Jahnsen ME, Lerang F, Jahnsen J. Gastrointestinal bleeding due to peptic ulcers and erosions - a prospective observational study (BLUE study). Scand J Gastroenterol 2020; 55:1139-1145. [PMID: 32931710 DOI: 10.1080/00365521.2020.1819405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Acute upper gastrointestinal bleeding is a well-recognized complication of peptic ulcers and erosions. The aim of this study was to assess the incidence rate and identify risk factors for this complication in southeastern Norway. MATERIALS AND METHODS Between March 2015 and December 2017, a prospective observational study was conducted at two Norwegian hospitals with a total catchment area of approximately 800,000 inhabitants. Information regarding patient characteristics, comorbidities, drug use, H. pylori status and 30-day mortality was recorded. RESULTS A total of 543 adult patients were included. The incidence was 30/100,000 inhabitants per year. Altogether, 434 (80%) of the study patients used risk medication. Only 46 patients (8.5%) used proton pump inhibitors (PPIs) for more than 2 weeks before the bleeding episode. H. pylori testing was performed in 527 (97%) patients, of whom 195 (37%) were H. pylori-positive. The main comorbidity was cardiovascular disease. Gastric and duodenal ulcers were found in 183 (34%) and 275 (51%) patients, respectively. Simultaneous ulcerations at both locations were present in 58 (10%) patients, and 27 (5%) had only erosions. Overall, the 30-day mortality rate was 7.6%. CONCLUSIONS The incidence of upper gastrointestinal bleeding due to peptic ulcers and erosions was found to be lower than previously demonstrated in comparable studies, but the overall mortality rate was unchanged. The consumption of risk medication was high, and only a few patients had used prophylactic PPIs. Concurrent H. pylori infection was present in only one-third of the patients. CLINICAL TRIAL REGISTRATION Bleeding Ulcer and Erosions Study 'BLUE Study', ClinicalTrials.gov Identifier. NCT03367897.
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Affiliation(s)
- Katrine Kauczynska Romstad
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trond Espen Detlie
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Taran Søberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Marte Eide Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
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6
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Hussein M, Alzoubaidi D, Serna ADL, Weaver M, Fernandez-Sordo JO, Rey JW, Hayee B, Despott E, Murino A, Moreea S, Boger P, Dunn J, Mainie I, Graham D, Mullady D, Early D, Ragunath K, Anderson J, Bhandari P, Goetz M, Kiesslich R, Coron E, de Santiago ER, Gonda T, Lovat LB, Haidry R. Outcomes of Hemospray therapy in the treatment of intraprocedural upper gastrointestinal bleeding post-endoscopic therapy. United European Gastroenterol J 2020; 8:1155-1162. [PMID: 32588788 DOI: 10.1177/2050640620938549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient's quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. METHODS Data was prospectively collected on the use of Hemospray from 16 centres (January 2016-November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. RESULTS A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0-9). The median Rockall score was six (interquartile range 5-7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. CONCLUSION Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.
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Affiliation(s)
- Mohamed Hussein
- Division of Surgery and Interventional Science, 4919University College London (UCL), London, UK
| | - Durayd Alzoubaidi
- Division of Surgery and Interventional Science, 4919University College London (UCL), London, UK
| | - Alvaro de la Serna
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Michael Weaver
- Department of Gastroenterology, Washington University School of Medicine, USA
| | | | - Johannes W Rey
- Department of Gastroenterology, Klinikum Osnabruck, Germany
| | - Bu'Hussain Hayee
- Department of Gastroenterology, Kings College London, London, UK
| | - Edward Despott
- Department of Gastroenterology, The 158987Royal Free Hospital, London, UK
| | - Alberto Murino
- Department of Gastroenterology, The 158987Royal Free Hospital, London, UK
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Phil Boger
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Jason Dunn
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust Hospitals, London, UK
| | - Inder Mainie
- Department of Gastroenterology, Belfast Trust, Belfast, UK
| | - David Graham
- Department of Gastroenterology, 4919University College London Hospital (UCLH), London, UK
| | - Dan Mullady
- Department of Gastroenterology, Nottingham University Hospitals, Nottingham, UK
| | - Dayna Early
- Department of Gastroenterology, Nottingham University Hospitals, Nottingham, UK
| | - Krish Ragunath
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Martin Goetz
- Department of Gastroenterology, Tübingen University Hospital, Germany
| | - Ralf Kiesslich
- Department of Gastroenterology, Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Emmanuel Coron
- Department of Gastroenterology, Centre Hospitalier Universitaire, Nantes, France
| | | | - Tamas Gonda
- Department of Gastroenterology, Columbia University Medical Centre, New York, USA
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, 4919University College London (UCL), London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, 4919University College London (UCL), London, UK.,Department of Gastroenterology, 4919University College London Hospital (UCLH), London, UK
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7
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Guo CG, Cheung KS, Zhang F, Chan EW, Chen L, Wong IC, Leung WK. Incidences, temporal trends and risks of hospitalisation for gastrointestinal bleeding in new or chronic low-dose aspirin users after treatment for Helicobacter pylori: a territory-wide cohort study. Gut 2020; 69:445-452. [PMID: 31101690 DOI: 10.1136/gutjnl-2019-318352] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The risk of GI bleeding (GIB) in aspirin users after Helicobacter pylori (HP) eradication remains poorly defined. We characterised the incidences and temporal trends of hospitalisations for all GIB in aspirin users after HP eradication therapy. DESIGN Based on a territory-wide health database, we identified all patients who had received the first course of clarithromycin-based triple therapy between 2003 and 2012. Patients were divided into three cohorts according to aspirin use: new users (commenced after HP eradication), chronic users (commenced before and resumed after HP eradication) and non-users. The primary outcome was to determine the risk of hospitalisation for GIB. RESULTS We included 6985 new aspirin users, 5545 chronic users and 48 908 non-users. The age-adjusted and sex-adjusted incidence of hospitalisation for all GIB in new, chronic and non-users was 10.4, 7.2 and 4.6 per 1000 person-years, respectively. Upper and lower GIB accounted for 34.7% and 45.3% of all bleeding, respectively. Compared with chronic users, new users had a higher risk of GIB (HR with propensity score matching: 1.89; 95% CI 1.29 to 2.70). Landmark analysis showed that the increased risk in new aspirin users was only observed in the first 6 months for all GIB (HR 2.10, 95% CI 1.41 to 3.13) and upper GIB (HR 2.52, 95% CI 1.38 to 4.60), but not for lower GIB. CONCLUSION New aspirin users had a higher risk of GIB than chronic aspirin users, particularly during the initial 6 months. Lower GIB is more frequent than upper GIB in aspirin users who had HP eradicated.
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Affiliation(s)
- Chuan-Guo Guo
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Ka Shing Cheung
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Feifei Zhang
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong
| | - Lijia Chen
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Ian Ck Wong
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong.,UCL School of Pharmacy, UCL, London, UK
| | - Wai K Leung
- Department of Medicine, University of Hong Kong, Hong Kong, China
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8
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A randomized controlled trial of the effects of local tranexamic acid on mortality, rebleeding, and recurrent endoscopy need in patients with upper gastrointestinal hemorrhage. Eur J Gastroenterol Hepatol 2020; 32:26-31. [PMID: 31567714 DOI: 10.1097/meg.0000000000001555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent used to control bleeding in different circumstances. We conducted a randomized controlled trial to assess the efficacy and safety of locally administered TXA in upper gastrointestinal hemorrhage. METHODS This single-center, double-blind, randomized controlled trial was performed in a tertiary emergency department (ED) in patients presenting with upper gastrointestinal bleeding symptoms between 2016 and 2018. The patients received either 2000 mg of 5% TXA in 100 mL of isotonic saline solution or 100 mL isotonic saline (control group) via the nasogastric route. As a composite outcome, recurrent endoscopy need, rebleeding, surgery need, recurrent admission to the ED, and mortality parameters were evaluated at the end of a one-month period. RESULTS During the study period, 78 patients were randomized into the TXA group, and 79 patients were randomized into the isotonic saline group. The majority of the bleedings (61%) were in Forrest class 3, and the most frequent cause was peptic ulcer disease. The composite outcome occurred in 25 of the TXA patients (32.1%) and 23 of the isotonic saline patients (29.1%); no statistically significant difference was found between the groups (P = 0.690). In addition, no statistically significant differences were observed between the TXA and control groups regarding mortality (10.3 vs 12.7%; P = 0.637), recurrent ED admission (17.9 vs 12.7%; P = 0.357), or thromboembolic complications (3.8 vs 1.3%; P = 0.367). CONCLUSION Locally administered TXA confers no additional benefit over standard care in patients with upper gastrointestinal hemorrhage.
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Role of Helicobacter pylori in Upper Gastrointestinal Bleeding Among Ischemic Stroke Hospitalizations: A Nationwide Study of Outcomes. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1030029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Helicobacter pylori (H. pylori) is a well-recognized risk factor for upper gastrointestinal bleeding (UGIB). The exposure to tissue plasminogen activator (tPA), anti-platelets, and anticoagulants increases the risk of UGIB in acute ischemic stroke (AIS) patients, the risk stratification of H. pylori infection is not known. In this retrospective cross-sectional study, we aimed to evaluate the relationship between H. pylori and GIB in patients hospitalized with AIS. Methods: In the nationwide data, hospitalization for AIS was identified by primary diagnosis using International Classification of Diseases, clinical modification (ICD-9-CM) codes. Subgroup of patients with GIB and H. pylori were identified in AIS cohort. A stepwise multivariable logistic regression model was fitted to evaluate the outcome of upper GIB and role of H. Pylori in UGIB. Results: Overall 4,224,924 AIS hospitalizations were identified, out of which 18,629 (0.44%) had UGIB and 3122 (0.07%) had H. pylori. The prevalence of H. pylori-induced UGIB among UGIB in AIS was 3.05%. The prevalence of UGIB was markedly elevated among the H. pylori infection group (18.23% vs. 0.43%; p < 0.0001) compared to the non-H. pylori group. In multivariable regression analysis, H. pylori was associated with markedly elevated odds of UGIB (aOR:27.75; 95%CI: 21.07–36.55; p < 0.0001). Conclusion: H. pylori infection had increased risk-adjusted occurrence of UGIB amongst the AIS hospitalized patients. H. pylori testing may improve risk stratification for UGIB and lower the health care cost burden in stroke hospitalization.
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Brenner A, Afolabi A, Ahmad SM, Arribas M, Chaudhri R, Coats T, Cuzick J, Gilmore I, Hawkey C, Jairath V, Javaid K, Kayani A, Mutti M, Nadeem MA, Shakur-Still H, Stanworth S, Veitch A, Roberts I. Tranexamic acid for acute gastrointestinal bleeding (the HALT-IT trial): statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Trials 2019; 20:467. [PMID: 31362765 PMCID: PMC6668177 DOI: 10.1186/s13063-019-3561-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/08/2019] [Indexed: 12/29/2022] Open
Abstract
Background Acute gastrointestinal (GI) bleeding is an important cause of mortality worldwide. Bleeding can occur from the upper or lower GI tract, with upper GI bleeding accounting for most cases. The main causes include peptic ulcer/erosive mucosal disease, oesophageal varices and malignancy. The case fatality rate is around 10% for upper GI bleeding and 3% for lower GI bleeding. Rebleeding affects 5–40% of patients and is associated with a four-fold increased risk of death. Tranexamic acid (TXA) decreases bleeding and the need for blood transfusion in surgery and reduces death due to bleeding in patients with trauma and postpartum haemorrhage. It reduces bleeding by inhibiting the breakdown of fibrin clots by plasmin. Due to the methodological weaknesses and small size of the existing trials, the effectiveness and safety of TXA in GI bleeding is uncertain. The Haemorrhage ALleviation with Tranexamic acid – Intestinal system (HALT-IT) trial aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding. Methods The HALT-IT trial is an international, randomised, double-blind, placebo-controlled trial of tranexamic acid in 12,000 adults (increased from 8000) with acute upper or lower GI bleeding. Eligible patients are randomly allocated to receive TXA (1-g loading dose followed by 3-g maintenance dose over 24 h) or matching placebo. The main analysis will compare those randomised to TXA with those randomised to placebo on an intention-to-treat basis, presenting the results as effect estimates (relative risks) and confidence intervals. The primary outcome is death due to bleeding within 5 days of randomisation and secondary outcomes are: rebleeding; all-cause and cause-specific mortality; thromboembolic events; complications; endoscopic, radiological and surgical interventions; blood transfusion requirements; disability (defined by a measure of patient’s self-care capacity); and number of days spent in intensive care or high-dependency units. Subgroup analyses for the primary outcome will consider time to treatment, location of bleeding, cause of bleed and clinical Rockall score. Discussion We present the statistical analysis of the HALT-IT trial. This plan was published before the treatment allocation was unblinded. Trial registration Current Controlled Trials, ID: ISRCTN11225767. Registered on 3 July 2012; Clinicaltrials.gov, ID: NCT01658124. Registered on 26 July 2012. Electronic supplementary material The online version of this article (10.1186/s13063-019-3561-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Adefemi Afolabi
- Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, Queen Elizabeth Road, Ibadan, 200001, Nigeria
| | - Syed Masroor Ahmad
- Department of Medicine Unit III, Jinnah Postgraduate Medical Centre, Rafiq Shaheed Road, Karachi, 75510, Pakistan
| | - Monica Arribas
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Timothy Coats
- Department of Cardiovascular Sciences, University of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ, UK
| | | | - Christopher Hawkey
- Faculty of Medicine and Health Sciences, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Muttiullah Mutti
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Department of Medicine, Services Hospital Unit III, Medical Unit III, Jail Road, Lahore, Pakistan
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | - Andrew Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Upper gastrointestinal hemorrhage is associated with poor outcomes among patients with acute cholangitis: a nationwide analysis. Eur J Gastroenterol Hepatol 2019; 31:586-592. [PMID: 30741727 DOI: 10.1097/meg.0000000000001378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acute cholangitis (AC) and upper gastrointestinal hemorrhage (UGIH) are common emergencies encountered by gastroenterologists. We aimed to evaluate the impact of UGIH on in-hospital mortality, morbidity and resource utilization among patients with AC. PATIENTS AND METHODS Adult admissions with a principal diagnosis of AC were selected from the National Inpatient Sample 2010-2014. The exposure of interest was significant UGIH (requiring red blood cell transfusion). The primary outcome was in-hospital mortality. Secondary outcomes were significant UGIH's incidence, morbidity (shock, prolonged mechanical ventilation and total parenteral nutrition), and resource utilization (length of hospital stay and total hospitalization charges and costs). Confounders were adjusted for using propensity matching and multivariate regression analysis. RESULTS A total of 50 375 admissions were included in the analysis, 747 of whom developed significant UGIH. After adjusting for confounders, the adjusted odds ratio (aOR) of in-hospital mortality for patients who developed UGIH was 7.1 (95% confidence interval: 2.1-23.9, P<0.01) compared with those who did not. Significant UGIH was associated with substantial increase in morbidity [shock: aOR: 4.1 (2.1-9.3), P<0.01, prolonged mechanical ventilation: aOR: 5.8 (2.2-12.4), P<0.01, total parenteral nutrition: aOR: 4.7 (1.9-10.7), P<0.01], and resource utilization [mean adjusted difference in: length of hospital stay: 7.01 (4.72-9.29), P<0.01 and total hospitalization charges: $81 818 ($58 109-$105 527), P<0.01 and costs: $25 230 ($17 805-$32 653), P<0.01]. Similar results were obtained using multivariate regression analysis. CONCLUSION Onset of significant UGIH among patients hospitalized with AC has a detrimental effect on in-hospital mortality, morbidity and resource utilization.
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12
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Kim D, Jo S, Lee JB, Jin Y, Jeong T, Yoon J, Park B. Comparison of the National Early Warning Score+Lactate score with the pre-endoscopic Rockall, Glasgow-Blatchford, and AIMS65 scores in patients with upper gastrointestinal bleeding. Clin Exp Emerg Med 2018; 5:219-229. [PMID: 30571901 PMCID: PMC6301866 DOI: 10.15441/ceem.17.268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 10/10/2017] [Indexed: 12/23/2022] Open
Abstract
Objective We compared the predictive value of the National Early Warning Score+Lactate (NEWS+L) score with those of other parameters such as the pre-endoscopic Rockall score (PERS), Glasgow-Blatchford score (GBS), and albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 years score (AIMS65) among patients with upper gastrointestinal bleeding (UGIB). Methods We conducted a retrospective study of patients with UGIB during 2 consecutive years. The primary outcome was the composite of in-hospital death, intensive care unit admission, and the need for ≥5 packs of red blood cell transfusion within 24 hours. Results Among 530 included patients, the composite outcome occurred in 59 patients (19 in-hospital deaths, 13 intensive care unit admissions, and 40 transfusions of ≥5 packs of red blood cells within 24 hours). The area under the receiver operating characteristic curve of the NEWS+L score for the composite outcome was 0.76 (95% confidence interval, 0.70 to 0.82), which demonstrated a significant difference compared to PERS (0.66, 0.59–0.73, P=0.004), but not to GBS (0.70, 0.64–0.77, P=0.141) and AIMS65 (0.76, 0.70–0.83, P=0.999). The sensitivities of NEWS+L scores of 3 (n=34, 6.4%), 4 (n=92, 17.4%), and 5 (n=171, 32.3%) were 100%, 98.3%, and 96.6%, respectively, while the sensitivity of an AIMS65 score of 0 (n=159, 30.0%) was 91.5%. Conclusion The NEWS+L score showed better discriminative performance than the PERS and comparable discriminative performance to the GBS and AIMS65. The NEWS+L score may be used to identify low-risk patients among patients with UGIB.
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Affiliation(s)
- Daejin Kim
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Sion Jo
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Jae Baek Lee
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Youngho Jin
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Taeoh Jeong
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Jaechol Yoon
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Boyoung Park
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
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Moledina SM, Komba E. Risk factors for mortality among patients admitted with upper gastrointestinal bleeding at a tertiary hospital: a prospective cohort study. BMC Gastroenterol 2017; 17:165. [PMID: 29262794 PMCID: PMC5738843 DOI: 10.1186/s12876-017-0712-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency, which is potentially fatal. Proper management of UGIB requires risk-stratification of patients which can guide the type and aggressiveness of management. The aim of this was study was identify the causes of UGIB and factors that increase the risk of mortality in these patients. Methods This was a prospective cohort study conducted over a period of seven months at a tertiary hospital. Adults admitted with UGIB were included in the study. Demographic data, laboratory parameters and endoscopic findings were recorded. Patients were then followed up for 60 days to identify the occurrence of mortality. Chi-square tests and cox-regression was used to determine association between risk factors and mortality in the bivariate and multivariate analysis, respectively. Results A total of 170 patients with UGIB were included. Males accounted for the majority (71.2%). Median age of the study population was 40.0 years. Chronic liver disease was present in 30.6% of study patients. The most common cause of UGIB among the 86 patients who underwent endoscopy was oesophageal varices (57%), followed by peptic ulcer disease (18%) and gastritis (10%). Mortality occurred in 57 patients (33.5%) and was significantly higher in patients with high white blood cell count (HR 2.45, p 0.011), raised serum alanine aminotransferase (HR 4.22, p 0.016), raised serum total bilirubin (HR 5.79, p 0.008) and lack of an endoscopic procedure done (HR 4.40, p <0.001). Rebleeding was reported in 12 patients (7.1%) and readmission due to UGIB in 4 patients (2.4%) Conclusions Oesophageal varices was the most common cause of UGIB. One-third of patients admitted with upper gastrointestinal bleeding died within 60 days of admission, signifying a high burden. Rebleeding and readmission rates were low. A high WBC count, raised serum ALT, raised serum total bilirubin and a lack of endoscopy were independent predictors of mortality. These findings can be used to risk-stratify patients who may benefit from early and more aggressive management.
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Affiliation(s)
- Sibtain M Moledina
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.
| | - Ewaldo Komba
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
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Kawasaki K, Nakamura S, Kurahara K, Nagasue T, Yanai S, Harada A, Yaita H, Fuchigami T, Matsumoto T. Continuing use of antithrombotic medications for patients with bleeding gastroduodenal ulcer requiring endoscopic hemostasis: a case-control study. Scand J Gastroenterol 2017; 52:948-953. [PMID: 28532190 DOI: 10.1080/00365521.2017.1328989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to compare clinical characteristics and outcomes of bleeding gastroduodenal ulcer between patients taking antithrombotic medications and those not taking antithrombotic medications. METHODS We performed a case-control study of 346 patients with endoscopically verified bleeding gastroduodenal ulcer, which included 173 cases taking antithrombotic medications throughout peri-bleeding period and 173 age- and sex-matched controls not taking antithrombotic medications. RESULTS The cases showed less frequent Helicobacter pylori (H. pylori) infections (45.1% versus 60.7%, p = .005), more frequent duodenal location (31.8% versus 19.1%, p = .009), and more frequent rebleeding (13.9% versus 5.8%, p = .02) than the controls. Multivariate analysis revealed that duodenal location (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.37-6.65) and use of antithrombotic medications (OR 2.47, 95% CI 1.13-5.77) were independent factors for rebleeding. However, there were no differences in clinical outcomes, including final successful endoscopic hemostasis, need for surgical intervention, and mortality between cases and controls. Thromboembolic events did not occur in any cases and controls during the periendoscopic period. CONCLUSIONS Low prevalence of H. pylori infection, frequent duodenal location, and high rebleeding rate are characteristics of patients with bleeding gastroduodenal ulcer under antithrombotic medications. Continuation of antithrombotic medications can be accepted for bleeding gastroduodenal ulcer.
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Affiliation(s)
- Keisuke Kawasaki
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan.,b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Shotaro Nakamura
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
| | - Koichi Kurahara
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Tomohiro Nagasue
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Shunichi Yanai
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
| | - Akira Harada
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Hiroki Yaita
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Tadahiko Fuchigami
- b Division of Gastroenterology , Matsuyama Red Cross Hospital , Matsuyama , Japan
| | - Takayuki Matsumoto
- a Division of Gastroenterology, Department of Internal Medicine , Iwate Medical University , Morioka , Japan
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Management of upper gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis: a prospective, multicenter, observational study. Scand J Trauma Resusc Emerg Med 2017; 25:78. [PMID: 28807040 PMCID: PMC5557479 DOI: 10.1186/s13049-017-0425-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/02/2017] [Indexed: 12/16/2022] Open
Abstract
Background Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective. We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes. Method This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included. Results In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs. Conclusion Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0425-6) contains supplementary material, which is available to authorized users.
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Choi JW, Jeon SW, Kwon JG, Lee DW, Ha CY, Cho KB, Jang BI, Park JB, Park YS. Volume of hospital is important for the prognosis of high-risk patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). Surg Endosc 2016; 31:3339-3346. [PMID: 27928663 DOI: 10.1007/s00464-016-5369-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/21/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a potentially life-threatening hospital emergency requiring hemodynamic stabilization and resuscitation. This study is carried out to determine whether hospital volume can influence outcome in patients with NVUGIB. METHOD This is a retrospective study with a prospective cohort database (KCT 0000514. cris.nih.go.kr). Eight teaching hospitals were divided into two different groups: high-volume centers (HVC, ≥60 NVUGIB patients/year, four clinics) and low-volume centers (LVC, <60 NVUGIB patients/year, four clinics). Baseline characteristics of patients, risk stratification, and outcomes between hospitals of different volumes were compared. From February 2011 to December 2013, a total of 1584 NVUGIB patients enrolled in eight clinics were retrospectively reviewed. The main outcome measurements consisted of continuous bleeding after treatment, re-bleeding, necessity for surgical/other retreatments, and death within 30 days. RESULTS Similar baseline characters for patients were observed in both groups. There was a significant difference in the incidence of poor outcome between the HVC and LVC groups (9.06 vs. 13.69%, P = 0.014). The incidence rate of poor outcome in high-risk patients (Rockall score ≥8) in HVC was lower than that in high-risk patients in LVC (16.07 vs. 26.92%, P = 0.048); however, there was no significant difference in poor outcome in the lower-risk patients in either group (8.72 vs. 10.42%, P = 0.370). CONCLUSIONS Significant correlation between hospital volume and outcome in NVUGIB patients was observed. Referral to HVC for the management of high-risk NVUGIB patients should be considered in clinical practice.
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Affiliation(s)
- Jin Woo Choi
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, Korea.,Kyungpook National University Hospital/School of Medicine, 807 Hoguk-ro, Buk-gu, Daegu, 41404, Korea
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, Korea. .,Kyungpook National University Hospital/School of Medicine, 807 Hoguk-ro, Buk-gu, Daegu, 41404, Korea.
| | - Jung Gu Kwon
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chang Yoon Ha
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jung Bae Park
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Youn Sun Park
- Department of Internal Medicine, Soonchunhyang University Hospital, Gumi, Korea
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Duch P, Haahr C, Møller MH, Rosenstock SJ, Foss NB, Lundstrøm LH, Lohse N. Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study. Scand J Gastroenterol 2016; 51:1000-6. [PMID: 27152958 DOI: 10.3109/00365521.2016.1164237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care. MATERIAL AND METHODS This population-based cohort study included all emergency EGDs for PUB in adults during 2012-2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model. RESULTS Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR = 1.51 (95% CI = 1.25-1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR = 1.22 (95% CI = 0.55-2.71). The prevalence of anaesthesia care varied between the hospitals, median = 78.9% (range 6.9-98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity. CONCLUSIONS Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.
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Affiliation(s)
- Patricia Duch
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Camilla Haahr
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Morten Hylander Møller
- b Department of Intensive Care , Copenhagen University Hospital Rigshospitalet , Copenhagen , Denmark
| | - Steffen J Rosenstock
- c Department of Gastroenterology, Surgical Unit , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Nicolai B Foss
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Lars Hyldborg Lundstrøm
- d Department of Anaesthesiology and Intensive Care Medicine , Nordsjællands Hospital, Copenhagen University Hospital , Hillerød , Denmark
| | - Nicolai Lohse
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
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Thanapirom K, Ridtitid W, Rerknimitr R, Thungsuk R, Noophun P, Wongjitrat C, Luangjaru S, Vedkijkul P, Lertkupinit C, Poonsab S, Ratanachu-ek T, Hansomburana P, Pornthisarn B, Thongbai T, Mahachai V, Treeprasertsuk S. Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding. J Gastroenterol Hepatol 2016; 31:761-7. [PMID: 26514879 DOI: 10.1111/jgh.13222] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB. METHODS During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis. RESULTS A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization. CONCLUSION In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB.
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Affiliation(s)
- Kessarin Thanapirom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Rattikorn Thungsuk
- Division of Gastroenterology, Sawanpracharak Hospital, Nakhon Sawan, Thailand
| | - Phadet Noophun
- Division of Gastroenterology, Surin Hospital, Surin, Thailand
| | - Chatchawan Wongjitrat
- Division of Gastroenterology, HRH Princess Maha Chakri Sirindhorn Medical Center-MSMC Hospital, Bangkok, Thailand
| | - Somchai Luangjaru
- Division of Gastroenterology, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Padet Vedkijkul
- Division of Gastroenterology, Maharaj Nakhon Si Thammarat Hospital, Nakhon Si Thammarat, Thailand
| | | | | | | | | | - Bubpha Pornthisarn
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Thammasat University Hospital, Pathum Thani, Thailand
| | - Thirada Thongbai
- Division of Gastroenterology, Bangkok Metropolitan Administration General Hospital, Bangkok, Thailand
| | - Varocha Mahachai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Teles Sampaio E, Maia L, Salgueiro P, Marcos-Pinto R, Dinis-Ribeiro M, Pedroto I. Antiplatelet agents and/or anticoagulants are not associated with worse outcome following nonvariceal upper gastrointestinal bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:703-708. [DOI: 10.17235/reed.2016.4424/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wehbeh A, Tamim HM, Abu Daya H, Abou Mrad R, Badreddine RJ, Eloubeidi MA, Rockey DC, Barada K. Aspirin Has a Protective Effect Against Adverse Outcomes in Patients with Nonvariceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2015; 60:2077-87. [PMID: 25732717 DOI: 10.1007/s10620-015-3604-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 02/18/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the effect of aspirin and anticoagulants on clinical outcomes and cause of in-hospital death in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). METHODS Patients were identified from a tertiary center database that included all patients with UGIB. Clinical outcomes including (1) in-hospital mortality, (2) severe bleeding, (3) rebleeding, (4) in-hospital complications, and (5) length of hospital stay were examined in patients taking (a) aspirin only, (b) anticoagulants only, and (c) no antithrombotics. RESULTS Of 717 patients with NVUGIB, 56 % (402) were taking at least one antithrombotic agent. Seventy-eight (11 %) patients died in hospital, and 310 (43 %) had severe bleeding (BP < 90 mmHg, HR > 120 b/min, Hb < 7 g/dL on presentation, or transfusion of >3 units). On multivariate analysis, being on aspirin was protective against in-hospital mortality [OR 0.26 (0.13-0.53)], rebleeding [OR 0.31 (0.17-0.59)], and predictive of a shorter hospital stay (coefficient = -4.2 days; 95 % CI -8.7, 0.3). Similarly, being on nonaspirin antiplatelets was protective against in-hospital mortality (P = 0.03). However, being on anticoagulants was predictive of in-hospital complications [OR 2.0 (1.20-3.35)] and severe bleeding [OR 1.69 (1.02-2.82)]. Compared to those not taking any antithrombotics, patients who bled on aspirin were less likely to die in hospital of uncontrolled gastrointestinal bleeding (3.6 vs 0 %, P ≤ 0.01) and systemic cancer (4.9 vs 0 %, P ≤ 0.002), but equally likely to die of cardiovascular/thromboembolic disease, sepsis, and multiorgan failure. CONCLUSION Patients who present with NVUGIB on aspirin had reduced in-hospital mortality and fewer adverse outcomes, while those on anticoagulants had increased in-hospital complications.
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Affiliation(s)
- Antonios Wehbeh
- Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Riad El Solh, Beirut, 1107 2020, Lebanon,
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de Carvalho Pedroto IMT, Azevedo Maia LA, Durão Salgueiro PS, Teles de Sampaio EMCM, Küttner de Magalhães RS, Barbosa Magalhães MJDS, Marcos-Pinto RJ, Pereira Dias CCR, Dinis-Ribeiro M. Out-of-hours endoscopy for non-variceal upper gastrointestinal bleeding. Scand J Gastroenterol 2015; 50:495-502. [PMID: 25631327 DOI: 10.3109/00365521.2014.964759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most countries lack a well-coordinated approach to out-of-hours endoscopy. Economic constraints and lack of resources have been identified as important barriers. OBJECTIVE To assess the performance evaluation of an out-of-hours emergency endoscopy model of care. DESIGN During a 3 year period (January 2010 to December 2012), data from consecutive outpatients (n = 332) with non-variceal acute upper gastrointestinal bleeding admitted or transferred to a single referral hospital were prospectively collected. RESULTS 34% (n = 113) were direct admissions whereas 66% (n = 219) were transferred from other hospitals. Median time to upper endoscopy esophagogastroduodenoscopy (EGD) was 6 h and 7.7 h for direct admissions and transferred, respectively. EGD was performed within 24 h in 90% of the patients. Rebleeding, in-hospital mortality, 30 day mortality and need for surgery were respectively 9.8%, 5.8%, 7.4%, and 6.6% and were not significantly different between the two groups. Age, malignancy, and moderate to high clinical Rockall risk score were independent predictors of in-hospital mortality in both groups. Age remained as an important predictor of main outcomes in transferred patients, while comorbidities differed according to admission status and predictable outcomes. CONCLUSION This gastroenterology emergency model improved access and equity to out-of-hours endoscopy in an effective, safe, and timely way, recognized by the rates and the homogeneity observed in the outcomes, between transferred patients and direct admissions.
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Bijpuria P, Thor S, Parsa L, Schlachterman A, Ahmad A. Do medicine residents triage patients with gastrointestinal bleeding appropriately? Hosp Pract (1995) 2015; 43:31-35. [PMID: 25659954 DOI: 10.1080/21548331.2015.1008379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Gastrointestinal specialists depend on internal medicine (IM) teams to accurately identify acute gastrointestinal bleeding (GIB). We evaluated whether IM residents' assessment of GIB correlated with the impressions of GI specialists during consultations at an inner-city university teaching hospital. METHODS A questionnaire was distributed to house staff requesting GIB consultations and to the GI fellows performing the consults between August 2011 and April 2012. Residents and fellows were asked to assess GIB, specifically melena, using a stool color card and digital rectal examination (DRE) findings. Fellow DRE findings served as controls for stool color identification. RESULTS Eighty-seven GI consults were eligible for the study. Residents and fellows completed 81 and 86 questionnaires, respectively. A total of 76 questionnaires were included for analysis. A DRE was performed by medical staff before calling a consult in 65% of cases compared with fellows (97% of cases, P = 0.0001). Residents more frequently labeled stool as melena (42%) in patients as compared with fellows (12%, P = 0.0001). Residents inaccurately identified melenic stools in 22 patients (11 based on stool color and 11 based on DRE findings). Residents were more likely to label a consult as emergent than fellows (13.5% vs 4%, P < 0.05). CONCLUSION Residents are less likely to perform DRE during an evaluation for GIB and to accurately identify melena based on stool color or DRE findings. There appears to be a need to educate residents on the appropriate terminology for stool color and the importance of DRE to accurately triage patients with acute GIBs.
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de Groot N, van Oijen M, Kessels K, Hemmink M, Weusten B, Timmer R, Hazen W, van Lelyveld N, Vermeijden, Curvers W, Baak L, Verburg R, Bosman J, de Wijkerslooth L, de Rooij J, Venneman N, Pennings M, van Hee K, Scheffer R, van Eijk R, Meiland R, Siersema P, Bredenoord A. Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding. United European Gastroenterol J 2014; 2:197-205. [PMID: 25360303 DOI: 10.1177/2050640614531574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/08/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding. METHODS WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes. RESULTS We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively). CONCLUSIONS Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.
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Affiliation(s)
- Nl de Groot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Mgh van Oijen
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; University of California Los Angeles/Veterans Affairs Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA ; Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - K Kessels
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M Hemmink
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Wl Hazen
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - N van Lelyveld
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Vermeijden
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Wl Curvers
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Lc Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - R Verburg
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands
| | - Jh Bosman
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Lrh de Wijkerslooth
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - J de Rooij
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Ng Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - M Pennings
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - K van Hee
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rch Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rl van Eijk
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - R Meiland
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - Pd Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Aj Bredenoord
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
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Lanas A, Carrera-Lasfuentes P, García-Rodríguez LA, García S, Arroyo-Villarino MT, Ponce J, Bujanda L, Calleja JL, Polo-Tomas M, Calvet X, Feu F, Perez-Aisa A. Outcomes of peptic ulcer bleeding following treatment with proton pump inhibitors in routine clinical practice: 935 patients with high- or low-risk stigmata. Scand J Gastroenterol 2014; 49:1181-90. [PMID: 25144754 DOI: 10.3109/00365521.2014.950694] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess rates of further bleeding, surgery and mortality in patients hospitalized owing to peptic ulcer bleeding. MATERIALS AND METHODS Consecutive patients hospitalized for peptic ulcer bleeding and treated with a proton pump inhibitor (PPI) (esomeprazole or pantoprazole) were identified retrospectively in 12 centers in Spain. Patients were included if they had high-risk stigmata (Forrest class Ia-IIb, underwent therapeutic endoscopy and received intravenous PPI ≥120 mg/day for ≥24 h) or low-risk stigmata (Forrest class IIc-III, underwent no therapeutic endoscopy and received intravenous or oral PPI [any dose]). RESULTS Of 935 identified patients, 58.3% had high-risk stigmata and 41.7% had low-risk stigmata. After endoscopy, 88.3% of high-risk patients and 22.1% of low-risk patients received intravenous PPI therapy at doses of at least 160 mg/day. Further bleeding within 72 h occurred in 9.4% and 2.1% of high- and low-risk patients, respectively (p < 0.001). Surgery to stop bleeding was required within 30 days in 3.5% and 0.8% of high- and low-risk patients, respectively (p = 0.007). Mortality at 30 days was similar in both groups (3.3% in high-risk and 2.3% in low-risk patients). CONCLUSION Among patients hospitalized owing to peptic ulcer bleeding and treated with PPIs, patients with high-risk stigmata have a higher risk of further bleeding and surgery, but not of death, than those with low-risk stigmata.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, Universidad de Zaragoza, IIS Aragón , Zaragoza , Spain
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Gargallo CJ, Sostres C, Lanas A. Prevention and Treatment of NSAID Gastropathy. ACTA ACUST UNITED AC 2014; 12:398-413. [DOI: 10.1007/s11938-014-0029-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Fonseca J, Meira T, Nunes A, Santos CA. Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:128-32. [PMID: 25003265 DOI: 10.1590/s0004-28032014000200011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/20/2014] [Indexed: 11/22/2022]
Abstract
CONTEXT Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. OBJECTIVES The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. METHODS From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake. RESULTS From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. CONCLUSIONS Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.
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Affiliation(s)
- Jorge Fonseca
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Tânia Meira
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Ana Nunes
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
| | - Carla Adriana Santos
- Hospital Garcia de Orta, Serviço de Gastrenterologia, Grupo de Estudo de Nutrição Entérica - GENE, Pragal, Almada, Portugal
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Abu Daya H, Eloubeidi M, Tamim H, Halawi H, Malli AH, Rockey DC, Barada K. Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding. J Dig Dis 2014; 15:283-92. [PMID: 24593260 DOI: 10.1111/1751-2980.12140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB). METHODS The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded. RESULTS Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6). CONCLUSIONS Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.
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Affiliation(s)
- Hussein Abu Daya
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
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Regional differences in outcomes of nonvariceal upper gastrointestinal bleeding in Saskatchewan. Can J Gastroenterol Hepatol 2014; 28:135-9. [PMID: 24619634 PMCID: PMC4071880 DOI: 10.1155/2014/291289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with significant mortality. OBJECTIVE To examine several factors that may impact the mortality and 30-day rebleed rates of patients presenting with NVUGIB. METHODS A retrospective study of the charts of patients admitted to hospital in either the Saskatoon Health Region (SHR) or Regina Qu'Appelle Health Region (RQHR) (Saskatchewan) in 2008 and 2009 was performed. Mortality and 30-day rebleed end points were stratified according to age, sex, day of admission, patient status, health region, specialty of the endoscopist and time to endoscopy. Logistic regression modelling was performed, controlling for the Charlson comorbidity index, age and sex as covariates. RESULTS The overall mortality rate observed was 12.2% (n=44), while the overall 30-day rebleed rate was 20.3% (n=80). Inpatient status at the time of the rebleeding event was associated with a significantly increased risk of both mortality and rebleed, while having endoscopy performed in the RQHR versus SHR was associated with a significantly decreased risk of rebleed. A larger proportion of endoscopies were performed both within 24 h and by a gastroenterologist in the RQHR. CONCLUSION Saskatchewan has relatively high rates of mortality and 30-day rebleeding among patients with NVUGIB compared with published rates. The improved outcomes observed in the RQHR, when compared with the SHR, may be related to the employ of a formal call-back endoscopy team for the treatment of NVUGIB.
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Jung SH, Oh JH, Lee HY, Jeong JW, Go SE, You CR, Jeon EJ, Choi SW. Is the AIMS65 score useful in predicting outcomes in peptic ulcer bleeding? World J Gastroenterol 2014; 20:1846-1851. [PMID: 24587662 PMCID: PMC3930983 DOI: 10.3748/wjg.v20.i7.1846] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/03/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the applicability of AIMS65 scores in predicting outcomes of peptic ulcer bleeding.
METHODS: This was a retrospective study in a single center between January 2006 and December 2011. We enrolled 522 patients with upper gastrointestinal haemorrhage who visited the emergency room. High-risk patients were regarded as those who had re-bleeding within 30 d from the first endoscopy as well as those who died within 30 d of visiting the Emergency room. A total of 149 patients with peptic ulcer bleeding were analysed, and the AIMS65 score was used to retrospectively predict the high-risk patients.
RESULTS: A total of 149 patients with peptic ulcer bleeding were analysed. The poor outcome group comprised 28 patients [male: 23 (82.1%) vs female: 5 (10.7%)] while the good outcome group included 121 patients [male: 93 (76.9%) vs female: 28 (23.1%)]. The mean age in each group was not significantly different. The mean serum albumin levels in the poor outcome group were slightly lower than those in the good outcome group (P = 0.072). For the prediction of poor outcome, the AIMS65 score had a sensitivity of 35.5% (95%CI: 27.0-44.8) and a specificity of 82.1% (95%CI: 63.1-93.9) at a score of 0. The AIMS65 score was insufficient for predicting outcomes in peptic ulcer bleeding (area under curve = 0.571; 95%CI: 0.49-0.65).
CONCLUSION: The AIMS65 score may therefore not be suitable for predicting clinical outcomes in peptic ulcer bleeding. Low albumin levels may be a risk factor associated with high mortality in peptic ulcer bleeding.
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Bai Y, Du YQ, Wang D, Zou DW, Jin ZD, Zhan XB, Zhao XY, Sha WH, Wang JB, Yu WF, Jiang Y, Ye LP, Zhang ST, Zhou LY, Chen MH, Yu XF, Zheng JW, Wang RQ, Huang XJ, Chen DF, Wang HH, Tian DA, Lu NH, Hou XH, Ji F, Wang JY, Yuan YZ, Fan DM, Wu KC, Jiang B, Li ZS. Peptic ulcer bleeding in China: a multicenter endoscopic survey of 1006 patients. J Dig Dis 2014; 15:5-11. [PMID: 24118892 DOI: 10.1111/1751-2980.12104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to describe the clinical picture, management and outcomes of Chinese patients with peptic ulcer bleeding (PUB), especially in those with high risks. METHODS A multicenter endoscopic survey was conducted. All consecutive patients with endoscopy confirmed PUB from October 2010 to June 2011 were enrolled. Data including patients' gender, age, symptoms and endoscopic findings, Forrest classification, and endoscopic and medical treatment were documented. High-risk ulcer was defined as Forrest grades Ia to IIb upon endoscopy. Rates of rebleeding, surgery and mortality were recorded. RESULTS In all, 1006 patients were included. Of these 437 (43.4%) were categorized with high-risk PUB, among whom 110 (25.2%) received endoscopic treatment, and the success rate was 99.1%. Rebleeding rates 1-3 days, 4-5 days and 6-30 days after treatment in high-risk patients who did and did not receive endoscopic treatment were 10.9% versus 10.4%, 3.6% versus 3.7% and 0.9% versus 1.5%, respectively. The surgery rates of high-risk patients with or without endoscopic treatment were 1.8% (2/110) versus 1.8% (6/327). During the 9-month study period, two patients with high-risk PUB died, therefore, the overall mortality rate of high-risk PUB was 0.5% (2/437). CONCLUSION The study suggests that the proportions of high-risk PUB in China is 43.4%, while rebleeding and surgery rate after endoscopic treatment as well as the mortality rate of high-risk PUB in China are 15.6%, 1.8% and 0.5%, respectively.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Yang JY, Lee TC, Montez-Rath ME, Chertow GM, Winkelmayer WC. Risk factors of short-term mortality after acute nonvariceal upper gastrointestinal bleeding in patients on dialysis: a population-based study. BMC Nephrol 2013; 14:97. [PMID: 23621917 PMCID: PMC3639820 DOI: 10.1186/1471-2369-14-97] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 04/24/2013] [Indexed: 11/16/2022] Open
Abstract
Background Impaired kidney function is an established predictor of mortality after acute nonvariceal upper gastrointestinal bleeding (ANVUGIB); however, which factors are associated with mortality after ANVUGIB among patients undergoing dialysis is unknown. We examined the associations among demographic characteristics, dialysis-specific features, and comorbid conditions with short-term mortality after ANVUGIB among patients on dialysis. Methods Design: Retrospective cohort study. Setting: United States Renal Data System (USRDS), a nation-wide registry of patients with end-stage renal disease. Participants: All ANVUGIB episodes identified by validated algorithms in Medicare-covered patients between 2003 and 2007. Measurements: Demographic characteristics and comorbid conditions from 1 year of billing claims prior to each bleeding event. We used logistic regression extended with generalized estimating equations methods to model the associations among risk factors and 30-day mortality following ANVUGIB events. Results From 2003 to 2007, we identified 40,016 eligible patients with 50,497 episodes of ANVUGIB. Overall 30-day mortality was 10.7% (95% CI: 10.4-11.0). Older age, white race, longer dialysis vintage, peritoneal dialysis (vs. hemodialysis), and hospitalized (vs. outpatient) episodes were independently associated with a higher risk of 30-day mortality. Most but not all comorbid conditions were associated with death after ANVUGIB. The joint ability of all factors captured to discriminate mortality was modest (c=0.68). Conclusions We identified a profile of risk factors for 30-day mortality after ANVUGIB among patients on dialysis that was distinct from what had been reported in non-dialysis populations. Specifically, peritoneal dialysis and more years since initiation of dialysis were independently associated with short-term death after ANVUGIB.
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Affiliation(s)
- Ju-Yeh Yang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, 1070 Arastradero Rd,, Suite 313, Palo Alto, CA 94304, USA
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Ursachen, patientenspezifische Risikofaktoren und prognostische Indikatoren bei akuter gastrointestinaler Blutung und intensivmedizinischer Therapieindikation. Med Klin Intensivmed Notfmed 2013; 108:214-22. [DOI: 10.1007/s00063-013-0226-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/16/2013] [Accepted: 01/26/2013] [Indexed: 12/14/2022]
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Lanas A, Polo-Tomas M, García-Rodríguez LA, García S, Arroyo-Villarino MT, Ponce J, Bujanda L, Calleja JL, Calvet X, Feu F, Perez-Aisa A, Sung JJY. Effect of proton pump inhibitors on the outcomes of peptic ulcer bleeding: comparison of event rates in routine clinical practice and a clinical trial. Scand J Gastroenterol 2013; 48:285-94. [PMID: 23298283 DOI: 10.3109/00365521.2012.758764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess clinical outcomes in patients treated with proton pump inhibitors (PPIs) after endoscopic hemostasis in routine clinical care, and to compare these outcomes to those seen in a randomized controlled trial (RCT) of i.v. esomeprazole. MATERIALS AND METHODS Patients with peptic ulcer bleeding and endoscopic stigmata of recent hemorrhage, who were treated with i.v. esomeprazole or pantoprazole ≥120 mg/day following therapeutic endoscopy, were identified from 12 hospitals in Spain (n = 539). Outcomes assessed included further bleeding, all-cause mortality and surgery. The results were compared to those of the RCT. RESULTS Overall, 9.1% (95% confidence interval [CI]: 6.7-11.5) of patients experienced further bleeding within 72 h following initial endoscopy, 14.3% (95% CI: 11.3-17.2) of patients had further bleeding within 30 days and 3.3% (95% CI: 1.8-4.9) of patients died within 30 days. In the RCT, the rate of rebleeding within 72 h was significantly lower in the esomeprazole arm (5.9%) than in the placebo arm (10.3%; p = 0.026). The further bleeding rate in patients treated with esomeprazole in routine clinical practice (7.8%; 95% CI: 4.6-11.1) was between these two values. Similar results were seen with the other outcomes studied. CONCLUSIONS The proportion of patients treated with i.v. esomeprazole in routine clinical practice who experienced further bleeding following endoscopic treatment for peptic ulcer bleeding was between the rates observed in the esomeprazole group and the placebo group in the RCT.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, Universidad de Zaragoza, IIS Aragón, Zaragoza, Spain.
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Abstract
Background Upper gastrointestinal (GI) bleeding is one of the most common, high risk emergency disorders in the western world. Almost nothing has been reported on longer term prognosis following upper GI bleeding. The aim of this study was to establish mortality up to three years following hospital admission with upper GI bleeding and its relationship with aetiology, co-morbidities and socio-demographic factors. Methods Systematic record linkage of hospital inpatient and mortality data for 14 212 people in Wales, UK, hospitalised with upper GI bleeding between 1999 and 2004 with three year follow-up to 2007. The main outcome measures were mortality rates, standardised mortality ratios (SMRs) and relative survival. Results Mortality at three years was 36.7% overall, based on 5215 fatalities. It was highest for upper GI malignancy (95% died within three years) and varices (52%). Compared with the general population, mortality was increased 27-fold during the first month after admission. It fell to 4.3 by month four, but remained significantly elevated during every month throughout the three years following admission. The most important independent prognostic predictors of mortality at three years were older age (mortality increased 53 fold for people aged 85 years and over compared with those under 40 years); oesophageal and gastric/duodenal malignancy (48 and 32 respectively) and gastric varices aetiologies (2.8) when compared with other bleeds; non-upper GI malignancy, liver disease and renal failure co-morbidities (15, 7.9 and 3.9); social deprivation (29% increase for quintile V vs I); incident bleeds as an inpatient (31% vs admitted with bleeding) and male patients (25% vs female). Conclusion Our study shows a high late as well as early mortality for upper GI bleeding, with very poor longer term prognosis following bleeding due to malignancies and varices. Aetiologies with the worst prognosis were often associated with high levels of social deprivation.
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Variability in the management of nonvariceal upper gastrointestinal bleeding in Europe: an observational study. Adv Ther 2012; 29:1026-36. [PMID: 23225523 DOI: 10.1007/s12325-012-0069-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Despite recent advances in endoscopic and pharmacological management, nonvariceal upper gastrointestinal bleeding (NVUGIB) is still associated with considerable mortality and morbidity that vary between countries. The European Survey of Nonvariceal Upper Gastrointestinal Bleeding (ENERGiB) reported clinical outcomes across Europe (Belgium, Greece, Italy, Norway, Portugal, Spain, and Turkey) and evaluated management strategies in a "real-world" European setting. This article presents the differences in clinical management strategies among countries participating in ENERGiB. METHODS Adult patients consecutively presenting with overt NVUGIB at 123 participating hospitals over a 2-month period were included. Data relevant to the initial NVUGIB episode and for up to 30 days afterwards were collected retrospectively from patient medical records. RESULTS The number of evaluable patients was 2,660; patient demographics and clinical characteristics were similar across countries. There was wide between-country variability in the area and speciality of the NVUGIB management team and unit transfer rates after the initial hospital assessment. The mean time from admission to endoscopy was <1 day only in Italy and Spain. Wide variation in the use of preendoscopy (35.0-88.7%) and relatively consistent (86.5-96.0%) postendoscopic pharmacological therapy rates were observed. There was substantial by-country variability in the rate of therapeutic procedures performed during endoscopy (24.9-47.6%). NVUGIB-related healthcare resource consumption was high and variable (days hospitalized, mean 5.4-8.7 days; number of endoscopies during hospitalization, mean 1.1-1.7). CONCLUSIONS ENERGiB demonstrates that there are substantial differences in the management of patients with acute NVUGIB episodes across Europe, and that in many cases the guideline recommendations for the management of NVUGIB are not being followed.
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Nonvariceal upper gastrointestinal bleeding in Portugal: A multicentric retrospective study in twelve Portuguese hospitals. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:377-85. [DOI: 10.1016/j.gastrohep.2012.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 02/19/2012] [Accepted: 02/23/2012] [Indexed: 01/25/2023]
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Zeitoun JD, Rosa-Hézode I, Chryssostalis A, Nalet B, Bour B, Arpurt JP, Denis J, Nahon S, Pariente A, Hagège H. Epidemiology and adherence to guidelines on the management of bleeding peptic ulcer: a prospective multicenter observational study in 1140 patients. Clin Res Hepatol Gastroenterol 2012; 36:227-34. [PMID: 22306054 DOI: 10.1016/j.clinre.2011.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 11/18/2011] [Accepted: 11/25/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Mortality of upper gastrointestinal bleeding seems declining. Whether practice guidelines for the management of peptic ulcer bleeding are followed is unknown. We aimed to update epidemiology of peptic ulcer bleeding and to assess the adherence to guidelines in the French community. METHODS Between March, 2005 and February, 2006, a prospective multicenter study was conducted including all patients with communautary upper gastrointestinal bleeding. Data from patients with peptic ulcer bleeding were extracted and analyzed. RESULTS Out of 3203 analyzable patients included, 1140 (35.6%) had a peptic ulcer bleeding and 965 of them a duodenal and/or gastric ulcer. Seven hundred and thirty-five were male (64.5%) and mean age was 66.4 years (±18.8). Overall, 699 patients (61.3%) were taking medication inducing upper gastrointestinal bleeding. Two-hundred and sixty-eight (23.5%) patients had endoscopic therapy, 190 (70.9%) of whom had epinephrine injection alone. Among the 349 patients with high risk stigmata on endoscopy (Forrest IA, IB, IIA), 209 (59.9%) underwent endoscopic therapy. One thousand one hundred and seven patients (97.1%) were given proton-pump inhibitors. One hundred and thirty-four patients (11.8%) experienced haemorrhagic recurrence. Forty-eight patients (4.2%) underwent surgery and 61 (5.4%) died. CONCLUSIONS Consistently with previous studies, mortality of upper gastrointestinal bleeding seems declining. Further progress lies above all in prevention but also probably in better adherence to therapeutic guidelines and management of comorbidities.
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Affiliation(s)
- Jean-David Zeitoun
- Department of gastroenterology, Henri-Mondor-hospital, 51, avenue du Maréchal-de-Lattre, 94010 Créteil, France.
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Pérez Aisa A, Nuevo J, López Morante AA, González Galilea A, Martin de Argila C, Aviñoa Arreal D, Feu F, Borda Celaya F, Gisbert JP, Pérez Roldan F, Gonzalvo Sorribes JM, Palazón Azorín JM, Ponce Romero M, Castro Fernández M, Catalina Rodriguez MV, Gallego Montañés S, Calvet X, Rodrigo Saez L, Montoro Huguet M, González Méndez Y, Sierra Hernández A, Sánchez Hernández E, Dominguez Muñoz E, Pérez Cuadrado E, Muñoz M, Lanas A. [Current management of nonvariceal upper gastrointestinal bleeding in Spain]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:468-75. [PMID: 22542917 DOI: 10.1016/j.gastrohep.2012.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 02/10/2012] [Accepted: 02/15/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. METHODS The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. RESULTS Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%. CONCLUSIONS This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.
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Affiliation(s)
- Angeles Pérez Aisa
- Unidad de Digestivo, Agencia Pública Empresarial Sanitaria Costa del Sol, Marbella, Málaga, España.
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Lanas Á. Avances en patología gastrointestinal asociada a antiinflamatorios no esteroideos y ácido acetilsalicílico. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34 Suppl 2:36-42. [DOI: 10.1016/s0210-5705(11)70019-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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