Thirty-Year Incidence and Mortality Trends in Upper and Lower Gastrointestinal Bleeding in Finland

Hematochezia due to rectal invasion by an internal iliac artery aneurysm: A case report

BACKGROUND

This case report presents the rare occurrence of hematochezia due to an internal iliac artery aneurysm leading to an arterioenteric fistula, expanding the differential diagnosis for gastrointestinal bleeding. It emphasizes the importance of considering vascular origins in cases of atypical hematochezia, particularly in the absence of common gastrointestinal causes, and highlights the role of imaging and multidisciplinary management in diagnosing and treating such unusual presentations.

CASE SUMMARY

A 75-year-old man with a history of hypertension presented with 12 d of hematochezia, experiencing bloody stools 7-8 times per day. Initial computed tomography (CT) scans revealed an aneurysmal rupture near the right internal iliac artery with suspected hematoma development. Hemoglobin levels progressively decreased to 7 g/dL. Emergency arterial angiography and iliac artery-covered stent placement were performed, followed by balloon angioplasty. Despite initial stabilization, minor rectal bleeding and abdominal pain persisted, leading to further diagnostic colonoscopy. This identified a neoplasm and potential perforation at the proximal rectum. An exploratory laparotomy confirmed the presence of a hematoma and an aneurysm invading the rectal wall, necessitating partial rectal resection, intestinal anastomosis, and ileostomy. Postoperative recovery was successful, with no further bleeding incidents and normal follow-up CT and colonoscopy results after six months.

CONCLUSION

In cases of unusual gastrointestinal bleeding, it is necessary to consider vascular causes for effective diagnosis and intervention.

Long-Term Outcomes following Acute Upper Gastrointestinal Bleeding Remain Poor: A Single-Center Comparison over Two Distinct Time Periods within the Last 15 Years in Finland

Introduction

Acute upper gastrointestinal bleeding (AUGIB) is a common and life-threatening condition. This study aimed to compare the causes and long-term outcomes of AUGIB over two distinct periods in the last 15 years.

Methods

This population-based study included consecutive patients who underwent emergency upper endoscopy for visible bleeding in 2006 and 2016. Our primary focus was on long-term mortality up to 5 years after the endoscopy, although short-term mortality was also reported.

Results

A total of 832 patients (median age 67 [12-96] years, 37% female) were included, with peptic ulcer disease (48%), esophagitis (20%), and variceal bleeding (15%) being the most common diagnoses. The incidence of AUGIB increased with age, reaching 8.31 cases per 1,000 person-years among those aged 80 years or older. Mortality rates at 30 days, 90 days, 1 year, and 5 years were 13%, 16%, 27%, and 47%, respectively. The standardized mortality ratio was high in all age groups, with particularly elevated rates observed among younger patients compared to the standard population. Variceal bleeding, liver cirrhosis, and chronic alcohol abuse were associated with the highest mortality. Only two short-term deaths were attributed to failed hemostasis. The primary causes of death were malignancies, liver failure, and cardiac failure. No improvement in outcomes was observed between the two time periods.

Conclusion

Although the treatment of AUGIB may be relatively straightforward, the outcomes following treatment remain poor. High mortality can be attributed to the presence of coexisting conditions and patients' lifestyle.

Diagnosis and management of acute lower gastrointestinal bleeding

PURPOSE OF REVIEW

We review and summarize the most recent literature, including evidence-based guidelines, on the evaluation and management of acute lower gastrointestinal bleeding (LGIB).

RECENT FINDINGS

LGIB primarily presents in the elderly, often on the background of comorbidities, and constitutes a significant healthcare and economic burden worldwide. Therefore, acute LGIB requires rapid evaluation, informed decision-making, and evidence-based management decisions. LGIB management involves withholding and possibly reversing precipitating medications and concurrently addressing risk factors, with definitive diagnosis and therapy for the source of bleeding usually performed by endoscopic or radiological means. Recent advancements in LGIB diagnosis and management, including risk stratification tools and novel endoscopic therapeutic techniques have improved LGIB management and patient outcomes. In recent years, the various society guidelines on acute lower gastrointestinal bleeding have been revised and updated accordingly.

SUMMARY

By integrating the most recently published high-quality clinical studies and society guidelines, we provide clinicians with an up-to-date and comprehensive overview on acute LGIB diagnosis and management.

Scoring systems for risk stratification in upper and lower gastrointestinal bleeding

Several scoring systems have been developed for both upper and lower GI bleeding to predict the bleeding severity and discriminate between low-risk patients, who may be suitable for outpatient management, and those who would likely need hospital-based interventions and are at high risk for adverse outcomes. Risk scores created to identify low-risk patients (namely the Glasgow Blatchford Score and the Oakland score) showed very good discriminative performances and their implementation has proven to be effective in reducing hospital admissions and healthcare burden. Conversely, the performances of risk scores in identifying specific adverse events to define high-risk patients are less accurate, and whether their integration into routine clinical practice has a tangible impact on patient management remains unproven. This review describes the existing risk score systems for GI bleeding, emphasizes key research findings, elucidates the circumstances in which their utilization can be beneficial, examines their constraints when considering routine clinical application, and discuss future development.

CYP2C19 loss-of-function alleles are not associated with higher prevalence of gastrointestinal bleeds in those who have been prescribed antidepressants: Analysis in a British-South Asian cohort

AIMS

CYP2C19 is a hepatic enzyme involved in the metabolism of antidepressants associated with increased gastrointestinal bleed (GIB) risk. The aim of our study was to explore a possible association between loss-of-function CYP2C19 genotypes and GIB in South Asian ancestry participants prescribed antidepressants.

METHODS

Genes & Health participants with a record in Barts Health NHS Trust (N 22 753) were studied using a cross-sectional approach. CYP2C19 diplotypes were assessed and metabolizer type inferred from consortia guidance. Fisher's exact test was used to compare the prevalence of GIB in different metabolizer categories. Multivariable regression was used to test for association between antidepressant prescriptions and GIB, and between CYP2C19 metabolizer state and GIB in the subcohort prescribed antidepressants.

RESULTS

Antidepressants were frequently prescribed (47%, N = 10 612). A total of 864 participants (4%) had a GIB; 534 (62%) had been prescribed a CYP2C19 metabolized antidepressant. There was an independent association between antidepressant prescriptions and GIB events (odds ratio 1.8, confidence interval 1.5-2.0, P < 0.0001). There was no relationship between CYP2C19 inferred poor (P 0.56) or intermediate (P 0.53) metabolizer status and GIB in those prescribed an antidepressant in unadjusted analysis. A multivariable logistic regression model did not show an independent association between poor (P 0.54) or intermediate (P 0.62) CYP2C19 metabolizers and GIB in the subcohort prescribed antidepressants.

CONCLUSIONS

CYP2C19 dependent antidepressants are associated with increased GIB prevalence. GIB appeared independent from CYP2C19 metabolizer genotype in individuals who had been prescribed antidepressants. Precision dosing based on CYP2C19 genetic information alone is unlikely to reduce GIB prevalence.

Safe discharge for patients admitted for lower gastrointestinal bleeding (LGITB): derivation and validation of a novel scoring system

AIM

Bleeding from the lower gastrointestinal tract (LGITB) is a common clinical presentation. Recent guidelines have recommended for incorporation of clinical risk assessment tools in the management for LGITB. We derived and validated a novel clinical scoring system to predict safe discharge after LGITB admission, and compared it to other published scoring systems in current literature.

METHODS

A retrospective cohort of 798 patients with LGITB from August 2018 to March 2021 was included in the derivation cohort. Multivariate binary logistic regression was performed to identify significant clinical variables predictive of safe discharge. A clinical scoring system was developed based on the results, and validated on a prospective cohort of 312 consecutive patients with LGITB from April 2021 to March 2022. The performance of the novel scoring system was compared to other LGITB clinical risk assessment scores via area under the receiver operating characteristics curve (AUROC) analysis.

RESULTS

Variables predictive of safe discharge included the following; absence of previous LGITB admission, absence of ischemic heart disease, absence of blood on digital rectal examination, absence of dizziness or syncope at presentation and the systolic blood pressure and haemoglobin levels at presentation. The novel score had an AUROC of 0.907. A cut-off point of 4 provided a sensitivity of 41.9%, specificity of 97.5%, positive predictive value of 96.4% and negative predictive value of 51.5% for prediction of safe discharge. The score performs comparably to the Oakland score.

CONCLUSION

The novel LGITB clinical risk score has good predictive performance for safe discharge in patients admitted for LGITB.

Definition of factor Xa inhibitor-related, life-threatening gastrointestinal bleeding and guidance on when to use reversal therapy: A Delphi panel

Objective

To define and contextualize life-threatening gastrointestinal (GI) bleeding in the setting of factor Xa (FXa) inhibitor therapy and to derive a consensus-based, clinically oriented approach to the administration of FXa inhibitor reversal therapy.

Methods

We convened an expert panel of clinicians representing specialties in emergency medicine, gastroenterology, vascular medicine, and trauma surgery. Consensus was reached among the clinician panelists using the Delphi technique, which consisted of 2 survey questionnaires followed by virtual, real-time consensus-building exercises.

Results

Hypovolemia and hemodynamic instability were considered the most important clinical signs of FXa inhibitor-related, life-threatening GI bleeds. Clinician panelists agreed that potentially life-threatening GI bleeding should be determined on the basis of hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. Last, the panel agreed that all patients with life-threatening, FXa inhibitor-associated GI bleeding should be considered for FXa inhibitor reversal therapy; the decision to reverse FXa inhibition should be individualized, weighing the risks and benefits of reversal; and when reversal is elected, therapy should be administered within 1 h after initial emergency department evaluation, when possible.

Conclusions

Consensus-based definitions of life-threatening GI bleeding and approaches to FXa inhibitor reversal centered on hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. The results from this Delphi panel may inform clinical decision-making for the treatment of patients experiencing GI bleeding associated with FXa inhibitor use in the emergency department setting.

Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching

BACKGROUND AND AIMS

Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far.

METHODS

This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups.

RESULTS

The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001).

CONCLUSIONS

For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.

Adherence to guidelines in patients with non-variceal upper gastrointestinal bleeding (UGIB) - results from a retrospective single tertiary center registry

BACKGROUND

Guidelines for the management of upper gastrointestinal bleeding (UGIB) are regularly published, yet little is known concerning adherence to recommendations in practice.

OBJECTIVES

We aimed to assess adherence to European Society of Gastrointestinal Endoscopy (ESGE) recommendations in patients with non-variceal UGIB.

MATERIALS AND METHODS

All hospitalized patients with an esophagogastroduodenoscopy (EGD) performed due to suspected non-variceal UGIB at our department were included in a prospective registry. Data between 2018-2020 from this registry were retrospectively analyzed. Adherence to the 2015 ESGE bleeding and propofol sedation guidelines was assessed. Adherence to recommendations concerning preendoscopic (risk) evaluation, preendoscopic PPI, transfusion management, and endoscopic management of peptic ulcers was analyzed.

RESULTS

Among 1005 patients (mean age 70.4 years, 42.1% women) the most common bleeding etiologies were gastric or duodenal ulcers (16.8%), esophagitis/GERD (11.1%), and angiodysplasia (9.9%); mortality was 7.6%. Adherence to preendosopic risk evaluation was low, in 0% a Mallampati classification and in 37.5% an ASA scoring was documented. Preendoscopic PPI was started at 58.6%, and adherence to recommended transfusion management was >98%. Peptic ulcers were Forrest-graded in 72.8%. High-risk ulcers were treated appropriately in 77.9% and low-risk ulcers were not treated in 73.6%. Especially Forrest Ib ulcers were undertreated, with an adherence of 59.6%. Only 22/179 (12.3%) patients with peptic ulcers and early endoscopy were consistently managed according to ESGE recommendations.

CONCLUSIONS

Adherence to ESGE guidelines in patients with non-variceal UGIB is moderate to low, even at a tertiary university hospital. Strategies must be devised for guidelines to reach patients in everyday practice.

Trends of Upper Gastrointestinal Bleeding Mortality in the United States Before and During the COVID-19 Era: Estimates From the Centers for Disease Control WONDER Database

Background

There have been reports of increased upper gastrointestinal bleeding (UGIB) in patients with coronavirus disease 2019 (COVID-19). Still, only a few studies have examined the mortality rate associated with UGIB in the United States before and during COVID-19. Hereby, we explored the trends of UGIB mortality in the United States before and during COVID-19. The study's objective was to investigate whether the COVID-19 pandemic significantly impacted UGIB mortality rates in the USA.

Methods

The decedents with UGIB were included. Age-standardized mortality rates were estimated with the indirect method using the 2000 US Census as the standard population. We utilized the deidentified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Linear regression analysis was performed to determine 2021 projected mortality rates based on trends between 2012 and 2019 to quantify the association of the pandemic with UGIB-related deaths.

Results

The mortality rate increased from 3.3 per 100,000 to 4.3 per 100,000 among the population between 2012 and 2021. There was a significant increase in the overall mortality rate between each year and the following year from 2012 to 2019, ranging from 0.1 to 0.2 per 100,000, while the rise in the overall mortality rate between each year and 2021 ranges from 0.4 to 0.9 per 100,000.

Conclusions

Our results showed that the mortality rate increased among the population between 2012and 2021, suggesting a possible influence of COVID-19 infection on the incidence and mortality of UGIB.

Evaluation of a New Animal Tissue-Free Bleeding Model for Training of Endoscopic Hemostasis

BACKGROUND

For endoscopists, knowledge of the available hemotherapeutic devices and materials as well as competence in using them is a life-saving expertise in the treatment of patients with acute gastrointestinal bleeding. These competences can be acquired in training on live animals, animal organs, or simulators. We present an animal tissue-free training model of the upper gastrointestinal tract for bleeding therapy.

METHODS

An artificial, animal tissue-free mucosa and submucosa with the opportunity of injection and clipping therapy were created first. Patches with this artificial mucosa and submucosa were placed into silicone and latex organs with human-like anatomy. Esophageal bleeding situations were imitated as variceal bleeding and bleeding of a reflux esophagitis in latex organs. Finally, a modular training model with human anatomy and replaceable bleeding sources was created. Evaluation of the novel model for gastroscopic training was performed in a multicentric setting with endoscopic beginners and experts.

RESULTS

Evaluation was carried out by 38 physicians with different levels of education in endoscopy. Evaluation of the model was made with grades from one (excellent) to six (bad): suitability for endoscopic training was 1.4, relevance of the endoscopic training was 1.6, and grading for haptic and optic impression of the model was 1.7.

CONCLUSIONS

The creation of a gastroscopic model for the training of hemostatic techniques without animal tissues was possible and multiple endoscopic bleeding skills could be trained in it. Evaluation showed good results for this new training option, which could be used in every endoscopic unit or other places without hygienic doubts.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Influence of non-alcoholic fatty liver disease on non-variceal upper gastrointestinal bleeding: A nationwide analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease globally with an estimated prevalence of 25%, with the clinical and economic burden expected to continue to increase. In the United States, non-variceal upper gastrointestinal bleeding (NVUGIB) has an estimated incidence of 61-78 cases per 100000 people with a mortality rate of 2%-15% based on co-morbidity burden.

AIM

To identify the outcomes of NVUGIB in NAFLD hospitalizations in the United States.

METHODS

We utilized the National Inpatient Sample from 2016-2019 to identify all NVUGIB hospitalizations in the United States. This population was divided based on the presence and absence of NAFLD. Hospitalization characteristics, outcomes and complications were compared.

RESULTS

The total number of hospitalizations for NVUGIB was 799785, of which 6% were found to have NAFLD. NAFLD and GIB was, on average, more common in younger patients, females, and Hispanics than GIB without NAFLD. Interestingly, GIB was less common amongst blacks with NAFLD. Multivariate logistic regression analysis was conducted, controlling for the multiple covariates. The primary outcome of interest, mortality, was found to be significantly higher in patients with NAFLD and GIB [adjusted odds ratio (aOR) = 1.018 (1.013-1.022)]. Secondary outcomes of interest, shock [aOR = 1.015 (1.008-1.022)], acute respiratory failure [aOR = 1.01 (1.005-1.015)] and acute liver failure [aOR = 1.016 (1.013-1.019)] were all more likely to occur in this cohort. Patients with NAFLD were also more likely to incur higher total hospital charges (THC) [$2148 ($1677-$2618)]; however, were less likely to have a longer length of stay [0.27 d (0.17-0.38)]. Interestingly, in our study, the patients with NAFLD were less likely to suffer from acute myocardial infarction [aOR = 0.992 (0.989-0.995)]. Patients with NAFLD were not more likely to suffer acute kidney injury, sepsis, blood transfusion, intubation, or dialysis.

CONCLUSION

NVUGIB in NAFLD hospitalizations had higher inpatient mortality, THC, and complications such as shock, acute respiratory failure, and acute liver failure compared to those without NAFLD.

Effect of the COVID-19 pandemic on the epidemiological trends and outcomes of gastrointestinal bleeding: a nationwide study

The COVID-19 pandemic altered healthcare delivery in the United States. This study examined the effect of the COVID-19 pandemic on the epidemiological trends and outcomes of gastrointestinal bleeding. We compared the admission rate, in-hospital mortality rate, and mean length of hospital stay between 2019 and 2020 to estimate the pandemic effect. The study highlighted disparities in outcomes of gastrointestinal bleeding hospitalizations stratified by sex and race. We noted a 9.5% reduction in the total number of hospitalizations in 2020. We also observed a 13% increase in overall mortality during the pandemic (P < 0.001). There was a 15.8% increase in mortality among men (P = 0.007), compared to a 4.7% increase among women (P = 0.059). There was a significant increase in mortality among Whites in 2020 compared to Black and Hispanic populations. On multivariable logistic regression, admission during the COVID-19 pandemic was associated with increased length of stay when adjusted for age, sex, and race. Despite the direct COVID-19-related morbidity and mortality, the so-called indirect effect of the pandemic cannot be overlooked. For the remainder of the pandemic and future health emergencies, it is critical to balance mitigation of the spread of the contagion with clear public health messages to not neglect other life-threatening emergencies.

Clinical Characteristics and Outcomes of Hospital-Acquired Lower Gastrointestinal Bleeding: A Single Centre Retrospective Cohort Study

Background Lower gastrointestinal bleeding (LGIB) is common in inpatient and outpatient settings; however, there are limited studies on the clinical characteristics and patient outcomes of those with hospital-acquired LGIB. Methods We performed a retrospective cohort study of patients with hospital-acquired LGIB who underwent colonoscopy during hospitalization between January 2017 and December 2021. We described the clinical characteristics, etiology, and clinical outcomes of patients stratified as those undergoing colonoscopy within 24 hours from haematochezia onset (early colonoscopy group) or after 24 hours from onset (late colonoscopy group). We used multivariable logistic regression to identify factors associated with endoscopic intervention in the early and late colonoscopy groups. Results Of the 272 patients included, the median age was 79 years (interquartile range: 72-85 years), 153 (56%) were bedridden, and 172 (63%) had hypoalbuminemia. The most frequent etiology was rectal ulcer (101 cases, 37%), whereas 7 (2.6%) had diverticular bleeding. The endoscopic intervention was performed on 16.7% and 7.9% of early and late colonoscopy patients. There were more patients with both non-severe and severe rebleeding in the early colonoscopy group (16% and 12%, respectively) than in the late colonoscopy group (11% and 6.5%, respectively). Colonoscopy-on-worktime was the only factor independently associated with a higher occurrence of endoscopic intervention. Conclusions In our sample, very old patients with hospital-acquired LGIB required endoscopy mainly due to rectal ulcers. Further studies will be necessary to investigate the differences between community-acquired LGIB and hospital-acquired LGIB and the optimal timing of colonoscopy for these patients.

Mortality Trends of Gastrointestinal, Liver, and Pancreaticobiliary Diseases: A Hospital-Based Prospective Study in the Southeast of Iran

Background: Gastrointestinal (GI), liver, and pancreaticobiliary diseases, in addition to the high health care utilization, account for a significant proportion of disability and death in Iran. We aimed to assess the incidence of in-hospital mortality for the total GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman, Iran. Methods: In a cross-sectional study from May 2017 to April 2018, we collected the data of in-hospital death records due to GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman city. GI and liver diseases were classified into three main categories: 1. Non-malignant GI diseases, 2. Non-malignant liver and pancreaticobiliary diseases, and 3. GI, liver, and pancreaticobiliary malignancies. All data were analyzed using SPSS software, version 22 (IBM). Results: Of 3427 in-hospital mortality, 269 (7.84%) deaths were due to GI, liver, and pancreaticobiliary diseases, of which 82 (30.48%) were related to non-malignant GI disorders, 92 (34.20%) to the non-malignant liver and pancreaticobiliary diseases, and 95 (35.31%) were associated with GI, liver and pancreaticobiliary malignancies. Most patients were male (62.08%), and the most common age was between 60-80 years (40.5%). GI bleeding occurred in 158 (58.73%) patients, and variceal bleeding was the most common cause (28.48%). Additionally, cirrhosis was reported in 41 out of 92 (44.56%), and hepatitis B virus (HBV) was the most common cause of cirrhosis among 17 out of 41 (41.46%). Conclusion: Our results show that gastric, colorectal, and pancreatic cancers and cirrhosis due to HBV were the most common causes of mortality associated with GI, liver, and pancreaticobiliary diseases in the hospitals of Kerman.

Risk factors for major gastrointestinal bleeding in the general population in Finland

BACKGROUND

Data on non-drug related risk-factors for gastrointestinal bleeding (GIB) in the general population are limited, especially for life-style factors, clinical measurements and laboratory parameters.

AIM

To identify and investigate non-drug risk factors for major GIB in the general population of Finland.

METHODS

We performed a retrospective cohort study using data from the FINRISK health examination surveys, which have been conducted every 5 years across Finland from 1987 to 2007. Participants were adults aged 25 years to 74 years, excluding those with a previous hospitalization for GIB. Follow-up from enrollment was performed through linkage to national electronic health registers and ended at an event of GIB that led to hospitalization/death, death due to any other cause, or after 10 years. Covariates included demographics, socioeconomic and lifestyle factors, clinical measurements, laboratory parameters and comorbidities. Variable selection was undertaken using Least Absolute Shrinkage and Selection Operator (LASSO) and factors associated with GIB were identified using Cox regression.

RESULTS

Among 33,508 participants, 403 (1.2%) experienced GIB [256 men (63.5%); mean age, 56.0 years (standard deviation (SD) ± 12.1)] and 33105 who did not experience GIB [15768 men (47.6%); mean age, 46.8 (SD ± 13) years], within 10 years of follow-up. Factors associated with a significantly increased risk of GIB were baseline age [per 10-year increase; hazard ratio (HR) 1.62, 95% confidence interval (CI): 1.42-1.86], unemployment (HR: 1.70, 95%CI: 1.11-2.59), body mass index (BMI) (HR: 1.15, 95%CI: 1.01-1.32), gamma-glutamyl transferase (GGT) (HR: 1.05, 95%CI: 1.02-1.09), precursors of GIB (HR: 1.90, 95%CI: 1.37-2.63), cancer (HR: 1.47, 95%CI: 1.10-1.97), psychiatric disorders (HR: 1.32, 95%CI: 1.01-1.71), heart failure (HR: 1.46, 95%CI: 1.04-2.05), and liver disorders (HR: 3.20, 95%CI: 2.06-4.97). Factors associated with a significantly decreased risk of GIB were systolic blood pressure (SBP) (HR: 0.78, 95%CI: 0.64-0.96), 6-10 cups of coffee a day (HR: 0.67, 95%CI: 0.46-0.99), or > 10 cups (HR: 0.43, 95%CI: 0.23-0.81).

CONCLUSION

Our study confirms established risk-factors for GIB and identifies potential risk-factors not previously reported such as unemployment, BMI, GGT, SBP and coffee consumption.

Long-term functional outcomes and mortality after hospitalization for extracranial hemorrhage

BACKGROUND

The effects of extracranial hemorrhage (ECH), or bleeding outside the brain, are often considered transient. Yet, there are few data on the long-term and functional consequences of ECH.

OBJECTIVE

Define the association of ECH hospitalization with functional independence and survival in a nationally representative cohort of older adults.

DESIGN

Longitudinal cohort study.

SETTINGS AND PARTICIPANTS

Data from the Health and Retirement Study from 1995 to 2016, a nationally representative, biennial survey of older adults. Adults aged 66 and above with Medicare linkage and at least 12 months of continuous Medicare Part A and B enrollment.

INTERVENTION

Hospitalization for ECH.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios and predicted likelihood of independence in all activities of daily living (ADLs), independence in all instrumental activities of daily living (IADLs) and extended nursing home stay. Adjusted hazard ratio and predicted likelihood for survival.

RESULTS

In a cohort of 6719 subjects (mean age 77, 59% women) with average follow-up time of 8.3 years (55,767 person-years), 736 (11%) were hospitalized for ECH. ECH was associated with a 15% increase in ADL disability, 15% increase in IADL disability, 8% increase in nursing home stays, and 4% increase in mortality. After ECH, subjects became disabled and died at the same annual rate as pre-ECH but never recovered to pre-ECH levels of function. In conclusion, hospitalization for ECH was associated with significant and durable declines in independence and survival. Clinical and research efforts should incorporate the long-term harms of ECH into decision-making and strategies to mitigate these effects.