Epidemiology and course of gastrointestinal haemorrhage in North-east Scotland

Impact of Early Video Capsule Endoscopy on Hospitalization and Post-hospitalization Outcomes: A Propensity Score-Matching Analysis

INTRODUCTION

Video capsule endoscopy (VCE) has become the accepted evaluation of choice for patients with suspected small bowel bleeding. Our aim was to evaluate the impact of early as compared to delayed inpatient VCE on post-index hospitalization readmission rates.

METHODS

We performed a retrospective study using medical claims from the IBM® Marketscan® Commercial Database from January 1, 2004, through September 30, 2018, including adult patients that underwent an inpatient VCE. Early VCE was defined as occurring on days 0, 1, or 2 of the index hospitalizations, whereas delayed VCE was performed on days 3-7. Propensity matching was performed to create an analytic cohort, and outcomes were assessed using logistic regression.

RESULTS

Following propensity score matching, 607 patients undergoing early VCE were matched 1:1 with 607 patients undergoing delayed VCE. The median patient age was 65 (IQR: 56-78) years, and 560 (37.9%) of the included patients were female. The mean time to VCE was 1.6 (± 0.6) days for the early VCE group and 4.0 (± 1.2) days from admission for delayed VCE. In unadjusted comparisons, we found no significant difference between early VCE and delayed VCE with respect to 90-day all-cause readmission (18.6% vs. 17.0%, P = 0.5) or 90-day rebleeding risk (10.5% vs. 8.7%, P = 0.331). Patients undergoing an early VCE had a shorter hospital LOS and less total hospitalization charges.

CONCLUSION

Early as compared to delayed inpatient VCE was associated with a reduction in index hospitalization resource utilization. No differences were found with respect to reductions in readmissions or rebleeding events.

Role of Video Capsule Endoscopy as a Prelude to Deep Enteroscopy

Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.

Survey of Management in Acute upper Gastrointestinal Haemorrhage1

The answers to a questionnaire concerning attitudes of members of the British Society of Gastroenterology to the management of acute upper gastrointestinal bleeding are analysed. In the majority of cases patients were admitted to general wards under the care of physicians. Use of intensive therapy units and venous pressure monitoring varied widely. Emergency endoscopy appeared readily available and was usually the first diagnostic procedure. Double contrast radiology and emergency angiography were available in relatively few centres. Specific nonoperative treatments (angiographic and endoscopic) were scarcely employed. Most respondents agreed that elderly patients fared badly, but there was little agreement concerning other factors which influence re-bleeding or outcome. There was a wide divergence of opinion concerning the need for surgical intervention in certain hypothetical clinical situations. Despite the difficulties involved, we believe that controlled trials are necessary to improve the management of bleeding patients.

Small Bowel Endoscopy

OPINION STATEMENT

The small bowel is a challenging area for endoscopic evaluation and therapy due to its length and angulated configuration. A small lumen diameter and segmental peristalsis made it a perfect fit for examination by a novel ingestible wireless camera in a capsule. The development of capsule endoscopy changed the diagnosis and management of bleeding lesions, ulcers, and tumors deep in the small bowel, allowing earlier diagnosis with excellent patient acceptance. Device-assisted enteroscopy revolutionized small bowel therapy, particularly management of bleeding, Peutz-Jeghers polyposis, and tumor marking for minimally invasive surgery. Small bowel stricture dilation in select patients is safe and effective. Tools for a spectrum of small bowel therapies are available but remain suboptimal to tackle lesions on angulated folds deep in the small bowel. Universal terminology to describe the endoscopic appearance of vascular lesions will facilitate studies of endoscopic and medical therapy. The future holds improvements in imaging, easier advancement through the small bowel, and therapeutic capacity. This review focuses on methods of small bowel endoscopy, therapy, and outcomes.

Upper gastrointestinal bleeding: what's the score?

Upper gastrointestinal haemorrhage (UGIH) is a common medical emergency. Recent publications have emphasised the need for early risk assessment of patients with this condition to help direct management. Several risk scores have been developed for UGIH and are variably used in clinical practice. In this article, we discuss the various risk scoring systems for this condition and summarise the available evidence for their use.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM: To compare band ligation (BL) with endoscopic sclerotherapy (SCL) in patients admitted to an emergency unit for esophageal variceal rupture.

METHODS: A prospective, randomized, single-center study without crossover was conducted. After endoscopic diagnosis of esophageal variceal rupture, patients were randomized into groups for SCL or BL treatment. Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point, with a maximum volume of 20 mL. For BL patients, banding at the rupture point was attempted, followed by ligation of all variceal tissue of the distal esophagus. Primary outcomes for both groups were initial failure of bleeding control (5 d), early re-bleeding (5 d to 6 wk), and complications, including mortality. From May 2005 to May 2007, 100 patients with variceal bleeding were enrolled in the study: 50 SCL and 50 BL patients. No differences between groups were observed across gender, age, Child-Pugh status, presence of shock at admission, mean hemoglobin levels, and variceal size.

RESULTS: No differences were found between groups for bleeding control, early re-bleeding rates, complications, or mortality. After 6 wk, 36 (80%) SCL and 33 (77%) EBL patients were alive and free of bleeding. A statistically significant association between Child-Pugh status and mortality was found, with 16% mortality in Child A and B patients and 84% mortality in Child C patients (P<0.001).

CONCLUSION: Despite the limited number of patients included, our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study

BACKGROUND

Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists.

AIM

To establish the hospitalized incidence and case fatality for upper GI bleeding, and to determine how they are associated with factors including day of admission, hospital size, social deprivation and distance from hospital.

METHODS

Systematic record linkage of hospital in-patient and mortality data for 24 421 admissions for upper GI bleeding among 22 299 people in Wales from 1999 to 2007.

RESULTS

The hospitalized incidence of upper GI bleeding was 134 per 100 000. Case fatality was 10.0%. Incidence was stable from 1999 to 2007; case fatality fell from 11.4% in 1999-2000 to 8.6% in 2006-7. Incidence was associated significantly with social deprivation. Compared with weekday admissions, case fatality was 13% higher for weekend admissions and 41% higher for admissions on public holidays. There was little variation in case fatality according to social deprivation, hospital size or distance from hospital.

CONCLUSIONS

Incidence, but not case fatality, was associated significantly with social deprivation. The higher mortality for weekend and public holiday admissions could not be explained by measures of case mix and may indicate a possible impact of reduced staffing levels and delays to endoscopy at weekends in some hospitals.

The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal hemorrhage: an Italian population-based study

OBJECTIVE

To analyze the effects of endoscopy and care in a gastroenterology ward on 30-day mortality among Italian patients hospitalized for acute non-variceal upper gastrointestinal hemorrhage (UGIH).

METHODS

We conducted a population-based study based on administrative data contained in the Regional Hospital Information System (RHIS) for the Lazio Region (Italy). We identified all hospitalizations with a main diagnosis of UGIH during period 2000-2005. Discharge data were analyzed for procedures performed, ward where the patient was cared for, comorbidities, vital status at discharge. Vital status 30 days after admission was cross-checked with the Regional Registry of Causes of Death. Logistic regression models were performed taking into account patients' risk factors (OR and C.I. 95%).

RESULTS

A total of 13,427 hospitalizations for UGIH (mean patient age, 68 years; 60% males) were identified. The 30-day mortality was 6.9%. Significantly lower rates were observed among hospitalizations that included endoscopy (OR 0.30, 95% C.I. 0.26-0.34), specialist care (OR 0.55, 95% C.I. 0.37-0.82), or both (OR 0.12, 95% C.I. 0.07-0.22). The protective effects of endoscopy and specialist care remained strong after adjustment for potential risk factors.

CONCLUSIONS

Endoscopy, per se, reduces mortality among patients hospitalized for UGIH, and care in a gastroenterology ward may offer additional protective effects.

Clarifying the relationship between ABO/Rhesus blood group antigens and upper gastrointestinal bleeding

BACKGROUND AND AIM

The relationship between blood group antigens and peptic ulcer disease has been widely evaluated in the past. Data concerning the same association with upper gastrointestinal bleeding are very limited. We aimed to evaluate this association and we thought it was worthwhile to try to determine whether these components take some part in this complication.

METHODS

The study population consisted of 1,098 adults (364 patients and 734 volunteer blood donors as controls). Demographic features, comorbid illnesses, and use of aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) were recorded. Blood groups were examined by gel centrifugation method. We included only patients with bleeding from peptic ulcer disease and erosive gastropathy. Ulcers were classified by using Forrest's classification system in terms of rebleeding risk. Helicobacter pylori was examined by histology.

RESULTS

The gender distribution was similar in both groups. The ABO blood group phenotype distribution in patients and controls (respectively) was as follows: 46.2% versus 34.9% for group O, 32.4% versus 39.5% for group A, 15.7% versus 18.4% for group B, and 5.8% versus 7.2% for group AB. Blood group O was found to have higher frequency in the patient group than in the control group (P=0.004). Rh positivity was also higher in patients than in controls (P=0.007). H. pylori positivity was similar between blood groups among patients. The rebleeding and mortality rates between blood groups were also similar.

CONCLUSION

ABO blood group O had an important role in patients with upper gastrointestinal bleeding. The impact of blood group on rebleeding and mortality may be a focus for further studies.

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

Ninety-eight consecutive patients admitted to a small district hospital because of acute gastrointestinal haemorrhage have been studied. Patients with haematemesis and/or melaena were treated with antacids and tranexamic acid from the very beginning and were examined with early panendscopy. All patients were closely observed in an ordinary medical ward by a staff especially trained to handle acute gastrointestinal bleeding. Seven patients required acute surgery. The overall mortality was 4.1%. It is concluded that acute gastrointestinal haemorrhage can be successfully handled with modern diagnosis and treatment in a small hospital.

Non-variceal upper GI bleeding in patients already hospitalized for another condition

OBJECTIVES

To compare outpatients (OPs) presenting with non-variceal upper gastrointestinal bleeding (NVUGIB) to those who started hemorrhaging while in a hospital (inpatients, IPs) in a contemporary setting and to better identify predictors of outcome.

METHODS

Retrospective data from the Canadian Registry of Patients With Upper Gastrointestinal Bleeding Undergoing Endoscopy (RUGBE). Descriptive, inferential, and multivariate logistic regression models were carried out in 469 IPs (68.5+/-14 years, 36% women) and 1,395 OPs (65.5+/-18 years, 39% women) in 18 Canadian community and tertiary care centers.

RESULTS

Main outcomes were rebleeding, mortality, and their predictors. IPs differed from OPs in disease acuity (P=0.02) and comorbidities (3.1+/-1.7 vs. 2.3+/-1.5, P<0.001), and were admitted longer (7.2+/-7.4 vs. 5+/-5.4 days, P<0.001) and more often to intensive care unit (ICU; 40.5% vs. 16%, P<0.001). Ulcers or erosions predominated (83% vs. 85%, P=0.28), treated by endotherapy (38% vs. 36%, P=0.46). More IPs received proton pump inhibitors (PPIs; 88% vs. 83%, P=0.009). Mortality was greater for IPs (11% vs. 3.5%, P<0.001), but rebleeding (15.7% vs. 13.4%, P=0.23) and surgery (6.9% vs. 6.4%, P=0.72) were not. Among IPs, comorbidity (odds ratio, OR=1.15; 95% confidence interval, CI: 1.01-1.32) and endoscopic high-risk stigmata increased (OR=3.86, 95% CI:2.05-7.26), whereas PPI decreased (OR=0.20, 95% CI:0.10-0.42) rebleeding; high-risk stigmata (OR=3.13, 95% CI:1.23-7.99) and rebleeding (OR=4.19, 95% CI:2.06-8.55) increased mortality, whereas low disease acuity was protective (OR=0.20; 95% CI:0.46-0.90).

CONCLUSIONS

IPs are sicker than OPs. Endoscopic hemostasis and PPI therapy favorably affect rebleeding in IPs, whereas patient characteristics principally determine the threefold greater IPs mortality.

Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting

AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death.

METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ² goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system.

RESULTS: For rebleeding, the χ² goodness-of-fit test indicated an acceptable fit for the model [χ² (8) = 12.83, P = 0.12]. For surgical procedures [χ² (8) = 5.3, P = 0.73] and death [χ² (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing a poor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability.

CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.

Comparison of inpatient and outpatient upper gastrointestinal haemorrhage

BACKGROUND AND AIMS

Inpatients developing upper gastrointestinal (GI) haemorrhage are at increased risk of death. This study was performed to elucidate differences in inpatients and outpatients.

PATIENTS/METHODS

Three hundred and sixty-two patients who needed esophagogastroduodenoscopy for upper GI bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication, and laboratory data were compared between patients who were admitted because of upper GI bleeding and patients who developed bleeding while in hospital for other reasons.

RESULTS/FINDINGS

Hospital mortality was 39.0% in inpatients vs. 11.1% in outpatients (p<0.01). Death due to bleeding was observed in 9.5% of inpatients vs. 2.5% of outpatients (p<0.01). Whereas peptic ulcer was the most common source of bleeding in both, variceal bleeding was the most common cause of death because of haemorrhage in both. Recurrent bleeding was associated with mortality in outpatients (p<0.001), but not in inpatients (p=0.11). Rates of bleeding recurrence and need for surgery was similar in both groups. Inpatients suffered more often from renal disease, pulmonary disease, diabetes mellitus, coagulopathy, or immunosuppression, and were treated more frequently with acetylsalicylic acid, glucocorticoids and heparin. The frequency of pre-existing disease was higher in inpatients.

INTERPRETATION/CONCLUSION

Higher mortality after GI bleeding in inpatients than in outpatients is due to a generally higher prevalence of co-morbidity rather than a single or a few risk factors.

Risk factors for mortality in severe upper gastrointestinal bleeding

BACKGROUND AND AIMS

Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre.

PATIENTS/METHODS

Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared.

RESULTS/FINDINGS

The mean Rockall score was 6.6+/-1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality.

INTERPRETATION/CONCLUSION

In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.

Upper gastrointestinal haemorrhage in Emergency Departments in France: causes and management

OBJECTIVES

Little is known about the epidemiology of acute upper gastrointestinal haemorrhage hospitalized in Emergency Departments. Most of the studies concerning digestive bleeding have been carried out by Gastroenterology Departments. This multicentre study included consecutive patients with acute upper gastrointestinal haemorrhage hospitalized after an initial management at Emergency Departments in France, to describe the initial medical management and to determine the causes of acute upper gastrointestinal haemorrhage. We also studied the relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and the occurrence of an acute upper gastrointestinal haemorrhage by a case-control comparison.

RESULTS

A total of 180 patients (112 men, 59+/-18 years) were included during 23 days, and 353 controls (222 men, 57+/-13 years) were selected at the same time. The delay between the first clinical signs of acute upper gastrointestinal haemorrhage and arrival at the Emergency Department was 33+/-42 h, and endoscopy was performed 14+/-16 h after admission to the Emergency Department. Sixty-six percent of patients with cirrhosis could benefit from a specific vasoactive treatment. Endoscopy was performed in 160 patients. Bleeding was caused by ulcers and gastritis in 88 patients (49%) and portal hypertension in 59 (32%). The relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and acute upper gastrointestinal haemorrhage was confirmed, odds ratio, (OR) 1.69 [95% confidence interval (CI) 1.15-2.33], but not among cirrhotic patients, odds ratio 1.12 (95% CI 0.65-1.86).

CONCLUSION

Hospitalized acute upper gastrointestinal haemorrhage in Emergency Departments in France is more often caused by cirrhosis than in other countries. Decreasing the delay between the first signs of bleeding and arrival at the Emergency Department is the main challenge in the management of acute upper gastrointestinal haemorrhage.

Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers

OBJECTIVES

The Rockall risk assessment score was devised to allow prediction of the risk of rebleeding and death in patients with upper GI hemorrhage. The score was derived by multivariate analysis in a cohort of patients with upper GI hemorrhage and subsequently validated in a second cohort. Only 4.4% of patients included in the initial study had esophageal varices, and analysis was not performed according to the etiology of the bleeding. Our aim was to assess the validity of the Rockall risk scoring system in predicting rebleeding and mortality in patients with esophageal varices or peptic ulcers.

METHODS

Admissions (n = 358) over 32 months to a single specialist GI bleeding unit were scored prospectively. The distribution of episodes of rebleeding and mortality by Rockall score were statistically analyzed using Fisher's exact test with 99% CIs calculated using a Monte Carlo method. The Child-Pugh score was determined in patients with esophageal varices.

RESULTS

The Rockall score was predictive of both rebleeding and mortality in patients with variceal hemorrhage (both ps < 0.0005), as was the Child-Pugh score (p = 0.001 and p < 0.0005, respectively). The initial Rockall score was predictive of mortality in patients with peptic ulcers (p = 0.01), although the complete score was not (p > 0.05). The complete score did, however, predict rebleeding in these patients (p = 0.001).

CONCLUSION

This is the first study to validate the Rockall score in specific subgroups of patients with esophageal varices or peptic ulcers and suggests that it is particularly applicable to variceal hemorrhage.

Surgery in the acute management of bleeding peptic ulcer

The management of bleeding peptic ulcers is an increasing challenge in an ageing population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers, and ulcers that fail endoscopic therapy are often 'difficult' ulcers, highly demanding for most gastric surgeons. Mortality in patients requiring eventual salvage surgery is high. Planned urgent surgery is preferable to emergency surgery in elderly patients. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for early surgery. Such a logical approach has, however, not been supported by evidence in the literature. At surgery, an aggressive approach is recommended. Post-operative bleeding is more common after lesser surgery, and this complication is often fatal. When re-bleeding occurs, a selective approach is suggested as emergency surgery carries with it a substantial mortality. Large chronic ulcers with exigent bleeding are less likely to respond to endoscopic re-treatment. Expedient surgery is advised for these patients.

Characterization of gastrointestinal bleeding in severely ill hospitalized patients

OBJECTIVE

To characterize the source of bleeding and the prognosis in critically ill patients with upper gastrointestinal hemorrhage that developed while in the hospital.

SETTING

Intensive care units of a large academic tertiary-care center.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients undergoing endoscopy in intensive care units for gastrointestinal bleeding that developed while in the hospital.

MEASUREMENTS AND MAIN RESULTS

Medical records were available for 142 patients. Of these, 66 met the criteria for in-hospital bleeding. Peptic ulcer disease, present in 56% of patients, was the most common bleeding source identified. Of patients with peptic ulcer disease, nine of 37 (24%) had stigmata of recent hemorrhage. Ten patients (15%) received endoscopic hemostasis interventions (eight receiving therapy for bleeding ulcers, two receiving therapy for esophageal varices). The in-hospital mortality rate was 42%. The cause of death was sepsis and/or multiple system organ failure in 21 patients (75%); the gastrointestinal bleeding may have contributed to the onset of sepsis in one of these patients. No patients died directly of gastrointestinal bleeding.

CONCLUSIONS

Critically ill patients who bleed while in the hospital have similar sources of bleeding and rates of endoscopically directed therapy as patients admitted to hospital with bleeding. The mortality rate is very high in patients with bleeding that develops in the hospital, and this is usually a result of systemic disease. These data may help clinicians and patients to estimate the potential benefit of urgent endoscopy in critically ill patients.

Validation of the Rockall risk scoring system in upper gastrointestinal bleeding

BACKGROUND

Several scoring systems have been developed to predict the risk of rebleeding or death in patients with upper gastrointestinal bleeding (UGIB). These risk scoring systems have not been validated in a new patient population outside the clinical context of the original study.

AIMS

To assess internal and external validity of a simple risk scoring system recently developed by Rockall and coworkers.

METHODS

Calibration and discrimination were assessed as measures of validity of the scoring system. Internal validity was assessed using an independent, but similar patient sample studied by Rockall and coworkers, after developing the scoring system (Rockall's validation sample). External validity was assessed using patients admitted to several hospitals in Amsterdam (Vreeburg's validation sample). Calibration was evaluated by a chi2 goodness of fit test, and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve.

RESULTS

Calibration indicated a poor fit in both validation samples for the prediction of rebleeding (p<0.0001, Vreeburg; p=0.007, Rockall), but a better fit for the prediction of mortality in both validation samples (p=0.2, Vreeburg; p=0.3, Rockall). The areas under the ROC curves were rather low in both validation samples for the prediction of rebleeding (0.61, Vreeburg; 0.70, Rockall), but higher for the prediction of mortality (0.73, Vreeburg; 0.81, Rockall).

CONCLUSIONS

The risk scoring system developed by Rockall and coworkers is a clinically useful scoring system for stratifying patients with acute UGIB into high and low risk categories for mortality. For the prediction of rebleeding, however, the performance of this scoring system was unsatisfactory.

Comparative safety evaluation of non-narcotic analgesics

Both spontaneous reports and single outcome studies may distort the overall safety evaluation of drugs. We identified epidemiologic studies, published from January 1970 to December 1995, that investigated the association of serious adverse effects with aspirin, diclofenac, acetaminophen, and dipyrone to determine and compare the excess mortality associated with short-term drug use. The estimated excess mortality due to community-acquired agranulocytosis, aplastic anemia, anaphylaxis, and serious upper gastrointestinal complications was 185 per 100 million for aspirin, 592 per 100 million for diclofenac, 20 per 100 million for acetaminophen, and 25 per 100 million for dipyrone. The estimates were largely influenced by the excess mortality associated with upper gastrointestinal complications. A relative risk estimate of 300 or more for the association of dipyrone with agranulocytosis would have been necessary for the excess mortality of dipyrone to be comparable to that of aspirin or diclofenac. Based on published epidemiologic evidence used to determine the excess mortality associated with short-term use of these four non-narcotic analgesics, the current regulatory ranking of the drugs appears inappropriate.

Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Steering Committee of the National Audit of Acute Upper Gastrointestinal Haemorrhage

AIMS

To assess changes in practice and outcome in acute upper gastrointestinal haemorrhage following the feedback of data, the reemphasis of national guidelines, and specific recommendations following an initial survey.

DESIGN

A prospective, multicentre, audit cycle. Forty five hospitals from three health regions participated in two phases of the audit cycle.

PATIENTS

Phase I: 2332 patients with acute upper gastrointestinal haemorrhage; phase II: 1625 patients with upper gastrointestinal haemorrhage.

METHODS

Patients were evaluated with respect to management (with reference to the recommendations in the national guidelines), mortality, and length of hospital stay.

RESULTS

Following the distribution of data from the first phase of the National Audit and the formulation of specific recommendations for improving practice, the proportion of hospitals with local guidelines or protocols for the management of upper gastrointestinal haemorrhage rose from 71% (32/45) to 91% (41/45); 12 of the 32 hospitals with guidelines during the first phase revised their guidelines following the initial survey. There was a small but significant increase in the proportion of all patients who underwent endoscopy (from 81% to 86%), the proportion who underwent endoscopy within 24 hours of admission (from 50% to 56%), and the use of central venous pressure monitoring in patients with organ failure requiring blood transfusion or those with profound shock (from 30% to 43%). There was, however, no change in the use of high dependency beds or joint medical/surgical management in high risk cases. There was no significant change in crude or risk standardised mortality (13.4% in the first phase and 14.4% in the second phase).

CONCLUSIONS

Although many of the participating hospitals have made efforts to improve practice by producing or updating guidelines or protocols, there has been only a small demonstrable change in some areas of practice during the National Audit. The failure to detect any improvement in mortality may reflect this lack of change of practice, but may also reflect the fact that a large proportion of the deaths in this unselected study are not preventable; only a very large study could hope to demonstrate a significant change out of the context of a clinical trial.

The long-term management of patients with bleeding duodenal ulcers

BACKGROUND

Gastrointestinal haemorrhage is a common complication of duodenal ulcers. Patients who bleed are at substantial risk of recurrent bleeding.

AIM

To determine whether appropriate therapeutic steps were taken to reduce the risk of recurrent haemorrhage in patients with a bleeding duodenal ulcer.

METHODS

The management of patients surviving a duodenal ulcer bleed in the University Hospital. Nottingham, was assessed by case-note review before (1993) and after (1995-1996) institution of clinical guidelines. The following measures aimed at reducing the risk of recurrent haemorrhage were considered appropriate: stopping non-steroidal anti-inflammatory drugs (NSAIDs) when these were implicated in bleeding; successful eradication of Helicobacter pylori if present; and long-term maintenance acid-suppression therapy.

RESULTS

In 1993, appropriate steps were taken to reduce the risk of recurrent haemorrhage in only 48% of cases. Following the institution of guidelines, management improved significantly in 1995-1996 (appropriate in 83% of cases, P < 0.001), was associated with increased referral to gastroenterologists (P < 0.001), improved patient compliance with follow-up (P < 0.05), and more rigorous attempts to identify (P < 0.001) and ensure clearance (P < 0.001) of H. pylori.

CONCLUSION

In this study, inadequate long-term management of patients with a bleeding duodenal ulcer was common. This was to a failure to adopt strategies aimed at reducing the risk of ulcer relapse and rebleeding. The quality of care improved significantly following the institution of guidelines and encouragement to refer to gastroenterologists.

Upper gastrointestinal bleeding in an open-access dedicated unit

The open-access high dependency bleeding unit in Aberdeen admits all patients with suspected gastrointestinal bleeding from a stable adult population of 468,000. The aim is to reduce mortality, morbidity and hospital stay, and create a prospective whole community database. An agreed management protocol is based on prompt resuscitation and early diagnosis. From October 1991 to September 1993 there were 1,602 consecutive admissions with suspected upper or lower gastrointestinal haemorrhage. Bleeding was confirmed in 1,098 of 1,324 patients with presumed upper gastrointestinal haemorrhage, (117 bleeding episodes per 100,000 per year). The overall 30-day mortality was 3.9%, with all deaths attributable to significant concurrent illness. Mortality from peptic ulcer bleeding was 5.3%, with an operation rate of 17% and surgical mortality of 8%. Rapid diagnosis allowed 48% of 523 patients with trivial bleeds to be discharged after a median stay of 24 hours. Centralised expertise and equipment is the essence of the unit's success. The interests of patient care are better served, nursing skills are better developed and teaching opportunities better structured. The major improvement in clinical care, welcomed by hospital colleagues, management and general practitioners, makes the unit an indispensable part of acute medical provision.

Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage

Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multi-centre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation. We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14.3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places. Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.

Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage

OBJECTIVE

To describe the current epidemiology of acute upper gastrointestinal haemorrhage.

DESIGN

Population based, unselected, multicentre, prospective survey.

SETTING

74 hospitals receiving emergency admissions in four health regions in the United Kingdom.

SUBJECTS

4185 cases of acute upper gastrointestinal haemorrhage in which patients were aged over 16 years identified over four months.

OUTCOME MEASURES

Incidence and mortality.

RESULTS

The overall incidence of acute upper gastrointestinal haemorrhage in the United Kingdom is 103/100,000 adults per year. The incidence rises from 23 in those aged under 30 to 485 in those aged over 75. At all ages incidence in men was more than double that in women except in elderly patients. 14% of the haemorrhages occurred in inpatients already in hospital for some other reason. In 27% of cases (37% female, 19% male) patients were aged over 80. Overall mortality was 14% (11% in emergency admissions and 33% in haemorrhage in inpatients). In the emergency admissions, 65% of deaths in those aged under 80 were associated with malignancy or organ failure at presentation. Mortality for patients under 60 in the absence of malignancy or organ failure at presentation was 0.8%.

CONCLUSIONS

The incidence of acute upper gastrointestinal haemorrhage is twice that previously reported in England and similar to that reported in Scotland. The incidence increases appreciably with age. Although the proportion of elderly patients continues to rise and mortality increases steeply with age, age standardised mortality is lower than in earlier studies. Deaths occurred almost exclusively in very old patients or those with severe comorbidity.

Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage

Endoscopic haemostasis by injection of adrenaline was attempted in 135 consecutive patients with active upper gastrointestinal bleeding. Initial haemostasis was obtained in 127 patients following injection of 5-15 ml 1:10,000 adrenaline; eight patients in whom haemostasis was not achieved underwent immediate laparotomy. There was further haemorrhage in 25 patients, which was successfully treated by further injection of adrenaline in ten. Fifteen patients had major rebleeding requiring emergency surgery. Stepwise logistic regression analysis identified three factors that, taken together, were highly predictive of the need for surgery: pulse rate on admission, the position of the ulcer and whether the patient was obese. A scoring system was derived from the logistic analysis equation that was found to predict correctly the need for emergency surgery in 84 per cent of patients. In patients with a high probability of rebleeding surgery should be considered after initial endoscopic haemostasis and stabilization. In the majority of patients endoscopic treatment alone is sufficient for permanent haemostasis.

Review article: Helicobacter pylori eradication--understandable caution but no excuse for inertia

The long-term management of patients with peptic ulcer disease is unsatisfactory, as judged by the persistently high levels of haemorrhage, perforation and death from this condition in Western countries. Although ulcer recurrence and complications can be prevented, many patients with peptic ulcer disease fail to receive the benefits of modern therapeutic regimens. In recent years, eradication of Helicobactor pylori has been promoted as a 'cure' for peptic ulcer disease and, while such claims are premature, there can be little doubt that this treatment--when successful--dramatically improves the medium-term prognosis of ulcer patients. However, in general, clinicians have given this promising therapeutic advance a lukewarm welcome. The aim of this detailed review of the literature is to remove the uncertainty and confusion surrounding many aspects of eradication therapy. Estimates are provided of the eradication rates after either triple therapy or the combination of omeprazole plus amoxycillin, and the sources of variation in published studies are discussed. Problems associated with eradication therapy, including side effects, compliance and re-infection, are addressed in order to ascertain the extent and clinical significance of each factor. In addition, studies reporting the outcome of patients with peptic ulcer disease after eradication are assessed with reference to both ulcer recurrence and complications. The result of the review is to dissipate much of the scepticism concerning eradication therapy. However, whilst acknowledging the efficacy of eradication therapy, its limitations have also to be recognized. By itself, it does not provide the complete answer to peptic ulcer disease. For some ulcer patients, eradication therapy is the preferred option; for others, prophylactic therapy with H2-receptor antagonists is more suitable. Guidelines are proposed for the selection of patients for each alternative therapy. The crucial point is that patients with peptic ulcer--excluding the small proportion with a mild form of the disease--require positive, long-term management consisting of either continuous prophylaxis with H2-receptor antagonists or the eradication of Helicobacter pylori.

Prognostic factors in upper gastrointestinal bleeding

In this study we examined factors of possible prognostic value about outcome in a consecutive series of 2217 patients with hematemesis and melena. Death occurred in 189 (8.5%) patients, and 243 (11%) patients experienced rebleeding. Death was significantly associated with rebleeding, age over 60 years, and the finding of blood in the stomach at endoscopy. Rebleeding was significantly associated with melena, identification of a gastric or duodenal ulcer, endoscopic stigmata of hemorrhage such as blood, clot, and active bleeding, and the finding of shock at admission. However, female gender, previous history of ulceration, or indigestion of ulcerogenic drugs, especially nonsteroidal antiinflammatory drugs, were poor predictors of either death or rebleeding. We conclude that the identification of patients at a high risk could contribute to improved management of patients with gastrointestinal bleeding, including early therapeutic intervention.

Bleeding peptic ulcer occurring in hospitalized patients: analysis of predictive and risk factors and comparison with out-of-hospital onset of hemorrhage

We reviewed 84 consecutive cases of peptic ulcer hemorrhage, which occurred, in an area of 270,000 people, from 1986 to 1988, in patients already hospitalized for other diseases (in-bleeders). These subjects were compared with a prospective series of 386 patients who initially bled as out-patients and were then admitted (out-bleeders). Of 84 hemorrhages in hospitalized patients, 41 followed major surgery, while 43 were associated with other severe conditions. Bleeding site was duodenal in two thirds. Mean age was 67 +/- 15 years versus 59 +/- 15 among out-bleeders. Fifty percent of in-bleeders had recently received nonsteroidal antiinflammatory drugs (NSAIDs), and one third were on anticoagulants and 10% on corticosteroids; in 39 (46%) bleeding was shown to be persistent or recurrent, 5 (5.9%) underwent endoscopic and 18 (21%) surgical therapy; 29 died (34%). The corresponding figures among out-bleeders were: further bleeding 80 (20.7%), endoscopic therapy 12 (3.1%), surgery 25 (6.5%), deaths 17 (4.4%). As regards in-bleeders, only active bleeding and endoscopic stigmata emerged as statistically significant risk factors for further bleeding. The latter was shown to be significantly related to mortality. The most relevant finding was, however, that NSAIDs and anticoagulants, in association with stress and aging, are very frequently involved in peptic ulcer bleeding of hospitalized patients. The fatal outcome of one third, despite all available treatments, highlights the importance of prevention against drug- and stress-related mucosal damage in in-patients suffering from severe diseases.

The role of angiography in the investigation of acute or chronic gastrointestinal haemorrhage

We have reviewed the clinical details and radiology of all patients with non-variceal gastrointestinal haemorrhage referred for angiography during an 8 year period. Forty-six patients with a history of overt bleeding had 49 technically satisfactory angiograms of which 29 were true positives but 16 were false negatives (sensitivity 64%, accuracy 63%). The accuracy of angiography in this group was much higher (92%) in those patients referred within 24 h of admission. Nine patients who had a history of iron-deficiency anaemia due to sub-acute blood loss had 9 angiograms. Five studies in this group were correct (two true negatives and three true positives) but there were four false positive studies. Angiography is an effective means of diagnosis in patients with acute gastrointestinal haemorrhage who have a negative endoscopy but best results will only be achieved when the study is performed with minimal delay following negative endoscopy. Angiography should also be considered in patients with continuing subacute blood loss when other investigations are negative.

Incidence and pattern of peptic ulcer bleeding in a defined geographical area. DUSUK Study Group

Despite the introduction of effective medical treatment for peptic ulcer disease, no decrease in the incidence of bleeding has been observed. Unfortunately, most incidence studies rely on a questionable case ascertainment and poor data. We therefore conducted a prospective study, to achieve an unbiased estimate of incidence and pattern of peptic ulcer bleeding in Düsseldorf (Germany). In a 1-year period all patients with endoscopically verified peptic ulcer bleeding who were admitted to the departments of internal medicine or surgery in nine hospitals or seen by nine general practitioners offering endoscopic service were included in the study. Incidence rates were calculated in accordance with sociodemographic variables and expressed per 100,000 person-years of observation. The overall incidence of peptic ulcer bleeding was 51.4, with almost even rates for gastric (26.5) and duodenal (24.9) ulcer. Age was associated with an increased likelihood of bleeding in gastric ulcer patients of 19 per decade from about 40 years onwards (duodenal ulcer, 15). The incidence was about twice as high in men as in women (relative risk = 1.9). The pattern of peptic ulcer bleeding was similar in gastric and duodenal ulcers with regard to ulcer size, multiple lesions, and bleeding activity at endoscopy. However, patients with gastric ulcer bleeding had significantly more often accompanying or underlying diseases. No significant differences were observed between gastric and duodenal ulcer bleeding with regard to nonsteroidal antiinflammatory drug intake and ulcer history. The incidence rates in our study are in the upper range of the literature and comparable to rates from the USA and UK both before and after the introduction of H2 blockers. We hypothesize that the persistently high incidence rate is a superposition of two trends: higher incidences due to a more elderly and diseased population and more NSAID intake, and lower incidences due to effective medical treatment.

Criteria for Selective Admission of Patients with Haematemesis

A retrospective survey of 157 consecutive admissions for haematemesis was carried out in order to determine whether patients at low risk of adverse events could be identified at the time of admission from simple clinical features. In addition to known prognostic factors such as hypotension, tachycardia and anaemia, we studied the character of the vomit classified into altered or frank blood. Death, surgical intervention and transfusion of more than 2 units of blood were defined as ‘adverse events’. No adverse event occurred in 37 patients who vomited only altered blood and who did not have melaena, or in 42 patients with a concentration of haemoglobin of 12g/dl or more who vomited altered blood only. Classification by other prognostic criteria was not as sensitive. These results suggested that patients with haematemesis who have negligible risk of serious sequelae can be identified at an early stage in the course of their disease from simple features of clinical history and examination. Excessive use of resources should be avoided in such patients, and selective admission may be justified.

Upper gastrointestinal hemorrhage in Jordan: An analysis of causes, characteristics and outcome

Two hundred twenty-four patients presenting consecutively with massive upper gastrointestinal hemorrhage were endoscoped within 24 hours to determine the site of bleeding. Outcome was evaluated in relation with presenting variables. Duodenal ulcer was found to be the most common source of bleeding. Endoscopy demonstrated 33% of all patients had more than one potential bleeding site. Patients with duodenal ulcer were significantly younger than patients with gastric ulcer (41 +/- 17 years versus 58 +/- 19 years, respectively). There was a tendency for upper gastrointestinal hemorrhage to present more often in the winter months. Eighty-one percent of duodenal ulcer patients and 57% of gastric ulcer patients had dyspepsia prior to the presentation of bleeding. There was a strong correlation between presence of concomintant disease and the age of the patient. Forty-three percent of patients had ingested aspirin or other nonsteroidal anti-inflammatory agents in the week prior to the bleed compared with 18% in a control group. All nine patients with bleeding diathesis (including that induced by anticoagulant maintenance therapy) had an underlying source of bleeding. Sixty-nine percent of the patients had spontaneous resolution of their bleeding within 24 hours while 25% underwent emergency surgery. The overall mortality rate was 10%. Age, underlying chronic liver disease, and transfusion requirements were found to be independent predictors of mortality assessed by multivariate regression analysis.

A randomized comparative study of laser photocoagulation, heater probe, and bipolar electrocoagulation in the treatment of actively bleeding ulcers

A randomized study was performed to compare the efficacy of Nd:YAG laser, heater probe, and bipolar electrocoagulation in the treatment of active bleeding from peptic ulcers. Nine hundred and forty-eight consecutive patients with upper gastrointestinal bleeding underwent endoscopy and 91 patients with active bleeding from peptic ulcer were randomized to receive laser (N = 30), heater probe (N = 31), and bipolar electrocoagulation (N = 30). The angulation of the probe to the ulcer base was assessed at endoscopy. The three treatment groups were comparable in their clinical and endoscopic characteristics. There was no significant difference among patients treated with laser, heater probe, and bipolar electrocoagulation in the rate of re-bleeding (10%, 19.4%, and 10%), duration of hospital stay (4, 4, and 5 days), and proportion requiring emergency surgery (7%, 13%, and 7%), but the cost per patient was higher with laser than heater probe and bipolar electrocoagulation. The angulation of the probe to the ulcer base did not affect the re-bleeding rate. No complication was reported. We conclude that the three modalities were equally effective and safe in endoscopic hemostasis but because bipolar electrocoagulation and heater probe were cheaper, they were recommended for use.

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.

Audit of mortality in upper gastrointestinal bleeding

The outcome in 1017 patients with haematemesis and malaena referred to two major hospitals in Nottingham within a 2-year period has been prospectively evaluated. Ninety one (9%) patients died during the time period under consideration and all but four were found to have been over 60 years of age. There were 13 (14%) deaths following rebleeding, of whom 5 (5%) could have been potentially avoided by alterations in management. Some improvement of mortality might result from intensive-care facilities with better management of transfusions and earlier detection of rebleeding allowing earlier endoscopy or surgery. The majority of patients (81%), however, died from concomitant disease which was exacerbated by gastrointestinal haemorrhage or bleeding developed in patients with an already existing end-stage disease. These results show that a reduction of mortality in patients with gastrointestinal bleeding is hampered by the high number of poor-risk patients. The rise in the proportion of elderly patients with this disorder seems to continue.

Preoperative and intraoperative localisation of gastrointestinal bleeding of obscure origin

In the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 99mTc pertechnetate scan, 99mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.

Tranexamic acid as an aid to reducing blood transfusion requirements in gastric and duodenal bleeding

A prospective randomised double blind study examined the effect of the antifibrinolytic drug tranexamic acid compared with placebo in 154 patients bleeding from verified benign lesions in the stomach or duodenum or both. Three out of 72 patients receiving tranexamic acid underwent emergency surgery compared with 15 out of 82 given placebo (p = 0.010). Nineteen patients receiving placebo rebled during their admission as compared with 10 in the active treatment group (p = 0.097). Blood transfusion requirements were significantly reduced by tranexamic acid (p = 0.018). Side effects occurred in six patients, of which an uncomplicated deep venous thrombosis was the most severe. Tranexamic acid reduces the blood transfusion requirement and need for emergency surgery in patients bleeding from a benign gastric or duodenal lesion.

Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage

Data collected prospectively from 326 admissions for acute upper gastrointestinal haemorrhage were examined to identify factors predicting further haemorrhage or mortality. Seven predictive factors were identified by univariate analysis for both further haemorrhage and/or mortality, but only age over 60 years, an admission haemoglobin less than 8 g/dl and the presence of endoscopic stigmata of recent haemorrhage were shown by stepwise logistic regression to have independent significance for further haemorrhage. An age over 60 years, the presence of clinical shock on admission and an episode of further haemorrhage following admission emerged as independently significant in the prediction of mortality.

[Hemorrhaging peptic ulcer--Therapy? When? Which?]

The influence of frequency of surgical interventions and the time of operation on the overall mortality is still a matter of considerable controversy. A close correlation between the risk and incidence of recurrent bleeding and the primary bleeding status during emergency endoscopy let us to design a new concept of a more aggressive surgical strategy. The dominating criteria for choice of treatment based on instant endoscopical classification of bleeding type and activity. The overall mortality was 5.4%. 59 patients (53%) underwent surgery with only two hospital deaths (3.4%). Among the group with conservative treatment there were four additional deaths (7.5%), all patients being above 70 years of age. The results suggest that mortality rates in patients with bleeding gastroduodenal ulcers can be reduced by a more aggressive surgical approach.

Clinical application of inhibitors of fibrinolysis

The basic proteinase inhibitor from bovine organs, aprotinin, was first identified in 1930 and its effect on enzyme and other biological systems has since been extensively studied. Aprotinin can only be administered intravenously and has a half-life of about 2 hours. Its administration at the start of cardiopulmonary bypass surgery appears to reduce blood loss and to protect against global myocardial ischaemia. Similarly, a smaller infarct size seems to result from early administration of aprotinin within the first hour after myocardial infarction, though further studies are needed to confirm this effect. A combination of aprotinin with tranexamic acid may be effective in preventing or delaying rebleeding after rupture of an intracerebral aneurysm; the addition of aprotinin seems to decrease the incidence of delayed cerebral vasospasm and ischaemic complications which are sometimes noted when tranexamic acid alone is used. Aprotinin is also effective as adjuvant treatment in traumatic haemorrhagic shock. The recommended loading dose is 15,000 to 20,000 KIU/kg bodyweight administered as a short intravenous infusion, followed by 50,000 KIU/hour by continuous infusion. Side effects of aprotinin are very rare. Epsilon-Aminocaproic acid (EACA), p-aminomethylbenzoic acid (PAMBA) and tranexamic acid are synthetic antifibrinolytic amino acids. Saturation of the lysine binding sites of plasminogen with these inhibitors displaces plasminogen from the fibrin surface. On a molar basis tranexamic acid is at least 7 times more potent that epsilon-aminocaproic acid and twice as potent as p-aminomethylbenzoic acid. All 3 compounds are readily absorbed from the gastrointestinal tract and excreted in active form in the urine. The plasma half-life of tranexamic acid is about 80 minutes. The main indications for tranexamic acid are the prevention of excessive bleeding after tonsillectomy, prostatic surgery, and cervical conisation, and primary and IUD-induced menorrhagia. It is possible that gastric and intestinal bleeding can also be reduced as well as recurrent epistaxis. Tranexamic acid could also be useful after ocular trauma. The value of fibrinolysis inhibitors in the prevention of bleeding after tooth extraction in patients with haemophilia is well documented, as is the treatment of hereditary angioneurotic oedema. The usual dose of tranexamic acid is 0.5 to 1g (10 to 15 mg/kg bodyweight) given intravenously 2 to 3 times daily, or 1 to 1.5 g orally 3 to 4 times daily. This dose needs to be reduced in patients with renal insufficiency. The main side effects of tranexamic acid are nausea or diarrhoea.

Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management

Seventeen patients with chronic obscure gastrointestinal bleeding presenting over a 5-year period are described. While representing only 6 per cent of the total number of admissions due to gastrointestinal haemorrhage they required a disproportionate amount of medical attention, including 67 admissions, 73 radiological and 56 endoscopic procedures and transfusion of a total of 198 units of blood. The diagnoses included 5 cases of recurrent acute upper gastrointestinal erosions, 7 small bowel abnormalities and 4 colonic lesions, with 1 patient undiagnosed. Eight arteriovenous malformations (AVM) were demonstrated angiographically and one Meckel's diverticulum identified by a 99Tcm pertechnetate scan. There were 5 cases in which laparotomy yielded the final diagnosis and in one of these peroperative endoscopy of the small bowel was required. On the basis of our experience and a review of other series, a logical plan of investigation is described for such difficult cases.