Clinical outcomes and risk factors of rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage

Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis

BACKGROUND AND AIMS

We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States.

METHODS

UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables.

RESULTS

The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%.

CONCLUSIONS

UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.

Analysis of rebleeding in cases of an upper gastrointestinal bleed in a single center series

BACKGROUND

upper gastrointestinal bleeding (UGIB) is one of the main causes of hospital admission in gastroenterology departments and is associated with a significant morbidity and mortality. Rebleeding after initial endoscopic therapy occurs in 10-20% of cases and therefore, there is a need to define predictive factors for rebleeding.

AIM

the aim of our study was to analyze risk factors and outcomes in a population of patients who suffered a rebleed.

METHODS

five hundred and seven patients with gastrointestinal bleeding were included. Clinical and biochemical data, as well as procedures and outcome six months after admission, were all collected. Documented clinical outcome included in-hospital and six-month delayed mortality, rebleeding and six-month delayed hemorrhagic and cardiovascular events.

RESULTS

according to a logistic regression analysis, high creatinine levels were independent risk factors for rebleeding of non-variceal and variceal UGIB. In non-variceal UGIB, tachycardia was an independent risk factor, whereas albumin levels were an independent protective factor. Rebleeding was associated with in-hospital mortality (29.5% vs 5.5%; p < 0.0001). In contrast, rebleeding was not related to six-month delayed mortality or delayed cardiovascular and hemorrhagic events.

CONCLUSIONS

tachycardia and high creatinine and albumin levels were independent factors associated with rebleeding, suggestive of a potential predictive role of these parameters. The incorporation of these variables into predictive scores may provide improved results for patients with UGIB. Further validation in prospective studies is required.

Multidisciplinary Approach to Refractory Upper Gastrointestinal Bleeding: Case Series of Angiographic Embolization

Although medical and endoscopic hemostasis is now considered as the first-line therapy for nonvariceal upper gastrointestinal (UGI) bleeding, refractory bleeding still occurs in 5%-10% of the patients. In these patients, transcatheter arterial embolization (TAE) or surgery is required, but research on embolization for unmanageable UGI bleeding in Korea is scanty. We reviewed the medical records of 518 patients who underwent endoscopic hemostasis during 4 years. Among these subjects, 8 patients who required embolization due to failure of endoscopic hemostasis were enrolled. Mean patient age was 74.00 ± 8.25 years, and rebleeding occurred in 4 patients within 48 hours after TAE. Three patients with duodenal rebleeding underwent surgery, and the other patient with a gastric ulcer underwent endoscopic hemostasis. Nonvariceal UGI bleeding remains a serious clinical challenge, especially in older patients. A multidisciplinary approach including endoscopists, interventional radiologists, and surgeons may be important for the treatment of nonvariceal UGI bleeding.

Continuing use of antithrombotic medications for patients with bleeding gastroduodenal ulcer requiring endoscopic hemostasis: a case-control study

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.

Successful Endoscopic Hemostasis Is a Protective Factor for Rebleeding and Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

Rebleeding and mortality rates remain high in patients with nonvariceal upper gastrointestinal bleeding.

AIM

To identify clinical and endoscopic risk factors for rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

METHODS

This study was performed in patients with nonvariceal upper gastrointestinal bleeding who underwent upper endoscopic procedures between July 2006 and February 2013. Clinical and endoscopic characteristics were compared among patients with and without rebleeding and mortality. Logistic regression analysis was performed to determine independent risk factors for rebleeding and mortality.

RESULTS

After excluding 64 patients, data for 689 patients with nonvariceal upper gastrointestinal bleeding were analyzed. Peptic ulcer (62.6 %) was by far the most common source of bleeding. Endoscopic intervention was performed within 24 h in 99.0 % of patients, and successful endoscopic hemostasis was possible in 80.7 % of patients. The 30-day rebleeding rate was 13.1 % (n = 93). Unsuccessful endoscopic hemostasis was found to be the only independent risk factor for rebleeding (odds ratio 79.6; 95 % confidence interval 37.8-167.6; p = 0.000). The overall 30-day mortality rate was 3.2 % (n = 23). Unsuccessful endoscopic hemostasis (odds ratio 4.9; 95 % confidence interval 1.7-13.9; p = 0.003) was also associated with increased 30-day mortality in patients with nonvariceal upper gastrointestinal bleeding.

CONCLUSIONS

Successful endoscopic hemostasis is an independent protective factor for both rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.

Characteristics of nonvariceal upper gastrointestinal hemorrhage in patients with chronic kidney disease

AIM

To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage (NGIH) in patients with chronic kidney disease (CKD).

METHODS

From 2003 to 2010, a total of 72 CKD patients (male n = 52, 72.2%; female n = 20, 27.8%) who had undergone endoscopic treatments for NGIH were retrospectively identified. Clinical findings, endoscopic features, prognosis, rebleeding risk factors, and mortality-related factors were evaluated. The characteristics of the patients and rebleeding-related data were recorded for the following variables: gender, age, alcohol use and smoking history, past hemorrhage history, endoscopic findings (the cause, location, and size of the hemorrhage and the hemorrhagic state), therapeutic options for endoscopy, endoscopist experience, clinical outcomes, and mortality.

RESULTS

The average size of the hemorrhagic site was 13.7 ± 10.2 mm, and the most common hemorrhagic site in the stomach was the antrum (n = 21, 43.8%). The most frequent method of hemostasis was combination therapy (n = 32, 44.4%). The incidence of rebleeding was 37.5% (n = 27), and 16.7% (n = 12) of patients expired due to hemorrhage. In a multivariate analysis of the risk factors for rebleeding, alcoholism (OR = 11.19, P = 0.02), the experience of endoscopists (OR = 0.56, P = 0.03), and combination endoscopic therapy (OR = 0.06, P = 0.01) compared with monotherapy were significantly related to rebleeding after endoscopic therapy. In a risk analysis of mortality after endoscopic therapy, only rebleeding was related to mortality (OR = 7.1, P = 0.02).

CONCLUSION

Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD, especially when a patient is an alcoholic.

Chronic kidney disease, hemodynamic instability, and endoscopic high-risk appearance are associated with 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding

The results of studies that evaluated predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are inconsistent. The aim of this study was to investigate predictive factors for 30-day rebleeding in these patients. A consecutive 312 patients presenting symptoms and signs of gastrointestinal bleeding were enrolled in this prospective, observational study. Clinical and demographic characteristics and endoscopic findings were evaluated for potential factors associated with 30-day rebleeding using logistic regression analysis. Overall, 176 patients were included (male, 80.1%; mean age, 59.7±16.0 yr). Rebleeding within 7 and 30 days occurred in 21 (11.9%) and 27 (15.3%) patients, respectively. We found that chronic kidney disease (CKD) (OR, 10.29; 95% CI, 2.84-37.33; P<0.001), tachycardia (pulse>100 beats/min) during the admission (OR, 3.79; 95% CI, 1.25-11.49; P=0.019), and Forrest classes I, IIa, and IIb (OR, 6.14; 95% CI, 1.36-27.66; P=0.018) were significant independent predictive factors for 30-day rebleeding. However, neither Rockall nor Blatchford scores showed statistically significant relationships with 30-day rebleeding in a multivariate analysis. CKD, hemodynamic instability during hospitalization, and an endoscopic high-risk appearance are significantly independent predictors of 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding. These factors may be useful for clinical management of such patients.

Non-variceal upper gastrointestinal bleeding: clinical, therapeutic and evolution aspects. Comparison between a tertiary medical center and a municipal hospital

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies in gastroenterology practice. In recent years, the introduction of urgent upper gastrointestinal endoscopy (UGIE) and of the treatment with proton pump inhibitors (PPIs) in high doses has resulted in an improvement of the treatment outcome in patients with UGIB, but without a significant improvement in mortality rates. In our study we compared the epidemiological, clinical, therapeutic, and prognostic aspects in patients with non-variceal UGIB admitted over a period of one year in a tertiary center where urgent UGIE is a routine procedure and in a municipal hospital where UGIE with endoscopic hemostasis is not available. Patients admitted to the tertiary medical center had more clinical and endoscopic severity factors compared to those from the municipal hospital: they were older, with more frequent intake of NSAIDs, several comorbidities, some of them severe, and more severe posthemorrhagic anemia. The endoscopic examination revealed that active bleeding and stigmata of recent hemorrhage were more frequent in these patients. Urgent UGIE and, where necessary because of lesions, endoscopic hemostasis were performed in most of these patients. Patients admitted to the municipal hospital were treated more frequently with high-dose intravenous PPIs. Patients undergoing urgent UGIE and endoscopic therapy had a shorter duration of hospitalization. However, there were no differences regarding the need for surgery or mortality rates. The results of our study are consistent with the literature.

Weekend and nighttime effect on the prognosis of peptic ulcer bleeding

AIM: To evaluate whether weekend or nighttime admission affects prognosis of peptic ulcer bleeding despite early endoscopy.

METHODS: Retrospective data collection from four referral centers, all of which had a formal out-of-hours emergency endoscopy service, even at weekends. A total of 388 patients with bleeding peptic ulcers who were admitted via the emergency room between January 2007 and December 2009 were enrolled. Analyzed parameters included time from patients’ arrival until endoscopy, mortality, rebleeding, need for surgery and length of hospital stay.

RESULTS: The weekday and weekend admission groups comprised 326 and 62 patients, respectively. There were no significant differences in baseline characteristics between the two groups, except for younger age in the weekend group. Most patients (97%) had undergone early endoscopy, which resulted in a low mortality rate regardless of point of presentation (1.8% overall vs 1.6% on the weekend). The only outcome that was worse in the weekend group was a higher rate of rebleeding (12% vs 21%, P = 0.030). However, multivariate analysis revealed nighttime admission and a high Rockall score (≥ 6) as significant independent risk factors for rebleeding, rather than weekend admission.

CONCLUSION: Early endoscopy for peptic ulcer bleeding can prevent the weekend effect, and nighttime admission was identified as a novel risk factor for rebleeding, namely the nighttime effect.