Upper Gastrointestinal Bleeding

Endoscopic Therapy of Gastric Varices: Safety and Efficacy of N-Butyl-2-Cyanoacrylate Injection

Background Upper gastrointestinal bleeding (UGIB) is a common medical emergency that results in significant morbidity, mortality, and socioeconomic burden. Both types of cardio-fundal varices, gastro-esophageal varix 2 (GOV2) and isolated gastric varices type 1 (IGV1), can cause massive bleeding and often are difficult to treat compared to the other types of gastric varices. Endoscopic variceal band ligation (EVBL) is a less effective treatment modality for gastric varices than esophageal varices and is associated with high re-bleeding rates. N-butyl-2-cyanoacrylate (Histoacryl) injection is an effective and potential treatment option for fundal varices. This study aims to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate injection therapy in cardio-fundal varices. Objective To assess the efficacy and safety of n-butyl-2-cyanoacrylate injection therapy for fundal varices. Methods This retrospective observational cohort study was conducted at the Department of Gastroenterology, Allied Teaching Hospital, Gujranwala, over one year. All patients, irrespective of age and gender, presenting with UGIB and in whom fundal varices were diagnosed on gastroscopy followed by n-butyl 2-cyanoacrylate injection therapy were included in this study. The efficacy and safety of Histoacryl therapy were assessed by analyzing successful hemostasis, frequency of re-bleeding, obliteration, and regression of fundal varices on repeat endoscopy. Adverse events such as re-bleeding and mortality related to fundal variceal treatment were documented. Results A total of 60 patients were included in the study. Of these, 70% had IGV1, while the remaining 30% had GOV2. Hemostasis was achieved in 100% of patients following n-butyl-2-cyanoacrylate injection. Successful obliteration with regression of varices was observed in 91.3% of patients. Various adverse events were observed, with abdominal pain being the most common observed complication in 18.3% of participants. However, only 8.3% of participants developed re-bleeding due to ulcer formation at the injection site, and no death occurred directly due to fundal variceal treatment. Conclusion N-butyl-2-cyanoacrylate injection therapy is a lifesaving, effective, and safe intervention for controlling bleeding from cardio-fundal varices, leading to improved health status and a consequent decrease in episodes of recurrent bleeding. Its side effects are few and infrequent. However, larger-scale studies are needed to further evaluate the safety and effectiveness of n-butyl-2-cyanoacrylate injection therapy. These studies will be crucial in establishing comprehensive guidelines for the management of fundal varices.

A Nomogram Model for Prediction of Mortality Risk of Patients with Dangerous Upper Gastrointestinal Bleeding: A Two-center Retrospective Study

OBJECTIVE

This study aimed to establish a nomogram model to predict the mortality risk of patients with dangerous upper gastrointestinal bleeding (DUGIB), and identify high-risk patients who require emergent therapy.

METHODS

From January 2020 to April 2022, the clinical data of 256 DUGIB patients who received treatments in the intensive care unit (ICU) were retrospectively collected from Renmin Hospital of Wuhan University (n=179) and the Eastern Campus of Renmin Hospital of Wuhan University (n=77). The 179 patients were treated as the training cohort, and 77 patients as the validation cohort. Logistic regression analysis was used to calculate the independent risk factors, and R packages were used to construct the nomogram model. The prediction accuracy and identification ability were evaluated by the receiver operating characteristic (ROC) curve, C index and calibration curve. The nomogram model was also simultaneously externally validated. Decision curve analysis (DCA) was then used to demonstrate the clinical value of the model.

RESULTS

Logistic regression analysis showed that hematemesis, urea nitrogen level, emergency endoscopy, AIMS65, Glasgow Blatchford score and Rockall score were all independent risk factors for DUGIB. The ROC curve analysis indicated the area under curve (AUC) of the training cohort was 0.980 (95%CI: 0.962-0.997), while the AUC of the validation cohort was 0.790 (95%CI:0.685-0.895). The calibration curves were tested for Hosmer-Lemeshow goodness of fit for both training and validation cohorts (P=0.778, P=0.516).

CONCLUSION

The developed nomogram is an effective tool for risk stratification, early identification and intervention for DUGIB patients.

Association between ABO blood groups and mortality in upper gastrointestinal bleeding

OBJECTIVE

Gastrointestinal bleeding is an important part of gastrointestinal emergencies. This study aimed to examine the association between ABO blood groups and mortality in patients who were admitted to the emergency department and diagnosed with upper gastrointestinal bleeding.

METHODS

The patients with upper gastrointestinal bleeding in the emergency department of a tertiary hospital in Turkey and the data of healthy blood donors were studied. The data of these patients were analyzed, and it was determined that the primary outcome was in-hospital mortality.

RESULTS

The study was completed with 274 patients and 274 control group. The mean age of these patients was 65.1±18.2 years, and 64.2% of patients were males. It was found that the in-hospital mortality rate of patients with O blood group (16.2%) was statistically significantly higher than non-O blood group (7.5%) (p:0.032).

CONCLUSION

The study concluded that the mortality rate of gastrointestinal bleeding patients with O blood group was higher compared to patients with other blood groups. Physicians can use ABO blood groups to predict mortality risk in gastrointestinal bleeding.

A Retrospective Analysis of Risk Factors for Mortality during Hemodialysis at a General Hospital That Treats Comprehensive Diseases

Objective We analyzed adverse events retrospectively during a three-year follow-up of patients undergoing hemodialysis at the dialysis center of our general hospital that can treat comprehensive diseases and conducted an exploratory study focusing on the risk factors that determine the prognosis of hemodialysis patients. Methods A total of 132 hemodialysis patients at our dialysis center as of June 2017 were included in the study. Data on event incidence, including death and various clinical indicators, were collected in the electronic medical record for three years until June 2020. Results Between June 2017 and June 2020, 33 of the 132 patients died. The mortality group had a lower body mass index (BMI) and a longer duration of hemodialysis already carried out with more preexisting upper gastrointestinal (GI) bleeding, infections, ischemic heart disease (IHD), and malignancy than the survival group. Furthermore, the mortality group took more warfarin, aspirin, proton pump inhibitors and less H2 blockers than the survival group. Occurrence of upper or lower GI bleeding was similar between the mortality and survival groups. In a univariate analysis for mortality, the odds ratio was significantly higher for a low BMI (<18), long duration of hemodialysis, history of upper GI bleeding, and presence of IHD. Multivariable-adjusted odds ratios for mortality were significantly higher for cases with a history of upper GI bleeding and BMI <18. Conclusion A history of upper GI bleeding and low BMI may be poor prognostic factors of hemodialysis patients. Careful management of upper GI bleeding and a low BMI are required during the initiation of hemodialysis.

Healthcare Disparities and Upper Gastrointestinal Bleeding: Exploring the Linkages

Introduction Upper gastrointestinal bleeding (UGIB) refers to blood loss from a gastrointestinal (GI) source proximal or above the ligament of Treitz. Health equity means giving everyone an equal chance to achieve optimal health by addressing injustices, overcoming barriers, and eliminating health disparities. Healthcare providers must analyze racial and ethnic disparities in UGIB management to ensure all patients receive equal care. Identifying risk factors in specific populations leads to tailored interventions that improve outcomes. Our study aims to examine trends and identify disparities in upper gastrointestinal bleeding across races and ethnicities to promote health equity. Methods Retrospective data on upper gastrointestinal bleeding from June 2009 to June 2022 were collected and categorized into five groups based on race. The baseline characteristics of each group were matched to ensure equitable comparison. A joinpoint regression model was used to compare incidence trends, identifying potential healthcare disparities for different racial/ethnic groups over time. Patients aged 18-75 who suffered from upper gastrointestinal bleeding at Nassau University Medical Center in New York from 2010 to 2021 were selected, excluding those with incomplete baseline comorbidity information. Results This study examined 5103 cases of upper gastrointestinal bleeding, with 41.9% female. The cohort was diverse, with 29.4% African American, 15.6% Hispanic, 45.3% White, 6.8% Asian, and 2.9% of other races. Data were split into two groups; 49.9% occurred between 2009 and 2015 and 50.1% between 2016 and 2022. Findings showed increased UGIB among Hispanics and decreased bleeding among Asians during 2016-2021 compared to 2009-2015. However, no significant difference was found for African Americans, Whites, and other races. In addition, Hispanics had a rise in the annual percentage change (APC) rate, whereas Asians had a decrease. Conclusion Our study examined trends in upper gastrointestinal bleeding and potential healthcare disparities across races and ethnicities. Our findings highlight an increased incidence of UGIB in Hispanics and a decreased incidence in Asians. Additionally, we identified a significant increase in the annual percentage change rate in Hispanics and a decrease in Asians over time. Our study underscores the importance of identifying and addressing disparities in UGIB management to promote health equity. Future research can build on these findings to develop tailored interventions that improve patient outcomes.

Prevalence and risk factors of upper gastrointestinal bleeding in chronic obstructive pulmonary disease patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) can cause upper gastrointestinal bleeding. In this study we identified the risk factors for upper gastrointestinal bleeding in patients with COPD by logistic regression analysis and established a logistic regression equation to predict the probability of upper gastrointestinal bleeding in COPD patients.

AIM

To investigate the prevalence and risk factors of upper gastrointestinal bleeding in patients with COPD.

METHODS

A total of 400 COPD patients treated at our hospital from October 2016 to October 2021 were selected, of which 240 were used for modeling. The prevalence of upper gastrointestinal bleeding in the modeling group was counted, the clinical data of patients with and without upper gastrointestinal bleeding were compared, and the factors influencing the occurrence of upper gastrointestinal bleeding were identified by logistic regression analysis. The rest 160 cases were included in a validation group to verify the performance of the logistic regression model developed.

RESULTS

Among the 240 COPD patients in the modeling group, the prevalence of upper gastrointestinal bleeding was 19.58% (47/240). The proportions of patients with coronary heart disease, severe infection, pulmonary encephalopathy, low ALB, and Helicobacter pylori infection were significantly higher in patients with upper gastrointestinal bleeding than in those without (P < 0.05). Age ≥ 60 years, COPD grade III, disease duration ≥ 4.3 years, gastritis, peptic ulcer, coronary heart disease, severe infection, pulmonary encephalopathy, and Helicobacter pylori infection were identified to be independent risk factors for upper gastrointestinal bleeding in COPD patients, while ALB elevation was a protective factor (P < 0.05). The area under the curve (AUC) of the logistic regression prediction model for predicting upper gastrointestinal bleeding in COPD patients was 0.867 (95% confidence interval [CI]: 0.818-0.907), with a sensitivity of 85.11% and specificity of 75.13%. When the logistic regression prediction model was applied to the validation group (160 COPD patients), the Hosmer-Lemeshow χ² value was 3.142 (P = 0.514) and the AUC was 0.900 (95%CI: 0.855-0.935), suggesting good discriminant validity and calibration of the model.

CONCLUSION

The prevalence of upper gastrointestinal bleeding in COPD patients is relatively high, and its occurrence is related to many factors such as patient age, COPD severity and course, gastritis, peptic ulcer, coronary heart disease, severe infection, pulmonary encephalopathy, Helicobacter pylori infection, and elevated ALB. The logistic regression prediction model developed has good discriminant validity and calibration for predicting the risk of upper gastrointestinal bleeding in COPD patients.

Prevalence and risk factors of upper gastrointestinal bleeding in chronic obstructive pulmonary disease patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) can cause upper gastrointestinal bleeding. In this study we identified the risk factors for upper gastrointestinal bleeding in patients with COPD by logistic regression analysis and established a logistic regression equation to predict the probability of upper gastrointestinal bleeding in COPD patients.

AIM

To investigate the prevalence and risk factors of upper gastrointestinal bleeding in patients with COPD.

METHODS

A total of 400 COPD patients treated at our hospital from October 2016 to October 2021 were selected, of which 240 were used for modeling. The prevalence of upper gastrointestinal bleeding in the modeling group was counted, the clinical data of patients with and without upper gastrointestinal bleeding were compared, and the factors influencing the occurrence of upper gastrointestinal bleeding were identified by logistic regression analysis. The rest 160 cases were included in a validation group to verify the performance of the logistic regression model developed.

RESULTS

Among the 240 COPD patients in the modeling group, the prevalence of upper gastrointestinal bleeding was 19.58% (47/240). The proportions of patients with coronary heart disease, severe infection, pulmonary encephalopathy, low ALB, and Helicobacter pylori infection were significantly higher in patients with upper gastrointestinal bleeding than in those without (P < 0.05). Age ≥ 60 years, COPD grade III, disease duration ≥ 4.3 years, gastritis, peptic ulcer, coronary heart disease, severe infection, pulmonary encephalopathy, and Helicobacter pylori infection were identified to be independent risk factors for upper gastrointestinal bleeding in COPD patients, while ALB elevation was a protective factor (P < 0.05). The area under the curve (AUC) of the logistic regression prediction model for predicting upper gastrointestinal bleeding in COPD patients was 0.867 (95% confidence interval [CI]: 0.818-0.907), with a sensitivity of 85.11% and specificity of 75.13%. When the logistic regression prediction model was applied to the validation group (160 COPD patients), the Hosmer-Lemeshow χ² value was 3.142 (P = 0.514) and the AUC was 0.900 (95%CI: 0.855-0.935), suggesting good discriminant validity and calibration of the model.

CONCLUSION

The prevalence of upper gastrointestinal bleeding in COPD patients is relatively high, and its occurrence is related to many factors such as patient age, COPD severity and course, gastritis, peptic ulcer, coronary heart disease, severe infection, pulmonary encephalopathy, Helicobacter pylori infection, and elevated ALB. The logistic regression prediction model developed has good discriminant validity and calibration for predicting the risk of upper gastrointestinal bleeding in COPD patients.

Strategic Management of Bleeding Small Bowel Gastrointestinal Angiodysplasias (GIADs): A 12 Year Retrospective Review in a Veteran Population and Cost Comparison

BACKGROUND

Gastrointestinal angiodysplasias (GIADs), also known as gastrointestinal angioectasias, are dilated, abnormally thin-walled blood vessels that occur in the mucosa and submucosa throughout the gastrointestinal tract. As a common cause of small bowel bleeding, GIADs have a significant impact on patient's morbidity and healthcare costs. Presently, somatostatin has been used widely to treat GIADs, but it is unclear if other therapies are as beneficial and cost-effective as somatostatin in managing GIADs. (2) Methods: A retrospective chart review was performed, which included subjects treated with Lanreotide, a somatostatin analog, and other therapies at the VA Loma Linda Healthcare System (VALLHCC) from January 2006 to December 2018. Patients who had symptomatic GIADs were detected by video capsule endoscopy (VCE), a device-assisted enteroscopy (DAE) or, in our case, push enteroscopy (PE) with an Endocuff. (3) Results: Three hundred twelve patients were diagnosed with GIADs. In this group of patients, 72 underwent ablation (endoscopic BICAP) with the addition of Lanreotide (SST), 63 underwent ablation therapy, eight were treated with SST only, 128 received iron replacement only, 25 received iron plus SST therapy, and 61 were observed with no therapy. Each group was followed via their hemoglobin (Hgb) level immediately thereafter, and Hgb levels were then obtained every 3 months for a 12-month period. After ablation therapy, 63 patients maintained stable Hgb levels over the course of the study, suggesting a significant therapeutic effect by controlling active bleeding. The 27 patients receiving ablation +SST therapy did not show improvements when compared to ablation only and the 128 patients who received iron therapy alone. (4) Conclusions: Importantly, 12 years of managing these patients has given us a cost- and time-sensitive strategy to maintain the patients' Hgb levels and avoid hospital admissions for acute bleeding. Iron treatment alone is effective compared to SST treatment in recovering from GIADs. Eliminating SST treatment from therapeutic intervention would save $89,100-445,550 per patient, depending on the number of doses for private care patients and $14,286-28,772 for VA patients, respectively. A suggested therapy would be to perform DAE on actively bleeding patients, ablate the lesions using a coagulation method, and place the patient on iron. If that fails, gastroenterologists should repeat VCE and perform either PE with Endocuff or balloon enteroscopy (all DAEs).

Intravenous Drip of Somatostatin Followed by Restricted Fluid Resuscitation to Treat Upper Gastrointestinal Bleeding in Patients with Liver Cirrhosis

Objective

Liver cirrhosis is a common, often progressive, and usually fatal disorder. Upper gastrointestinal bleeding is a leading cause of death in patients with liver cirrhosis. The purpose of this study was to evaluate the effectiveness of somatostatin combined with restricted fluid resuscitation in the treatment of upper gastrointestinal bleeding in the patients with liver cirrhosis.

Methods

From January 2018 to December 2020, 84 patients with liver cirrhosis complicated by upper gastrointestinal bleeding admitted to the Department of Gastroenterology of Ningbo Yinzhou No. 2 Hospital were selected as study participants. They were randomly assigned into the study group (n = 42) and control group (n = 42). All patients were given intravenous drip of somatostatin. The study group was supplemented with restricted fluid resuscitation therapy. The hemoglobin (Hb), platelet, fibrinogen, hematocrit, transfusion volume of red blood cells, hemostatic time, hemostatic rates in 0 h–24 h, 24 h–48 h, and >48 h, rebleeding rates, resuscitation rate, and incidence rates of complications were compared between the two groups 48 h after treatment.

Results

It was found that the Hb, platelet, fibrinogen, and hematocrit were notably increased in the study group compared to the control group 48 h after treatment (P < 0.01). The proportion of patients with excellent response was notably higher in the study group than in the control group (P < 0.05). The overall response rate of the study group was 90.48%, which was significantly higher than 71.43% in the control group (P < 0.05). The study group had lower transfusion volume of red blood cells, shorter hemostatic time, and lower rebleeding rates than the control group (P < 0.01). The hemostatic rate of 0 h–24 h in the study group was remarkably higher than that in the control group (P < 0.05). The hemostatic rate of >48 h in the study group was lower than that in the control group (P < 0.05). The overall incidence rate of complications in the study group was 9.52%, which was significantly lower than 30.95% in the control group (P < 0.05).

Conclusion

These data suggest that intravenous drip of somatostatin followed by restricted fluid resuscitation leads to a better clinical efficacy in treating upper gastrointestinal bleeding in patients with liver cirrhosis considering higher resuscitation rate and hemostatic rate and reduced incidence of complications, which is conducive to the recovery of patients and worthy of further clinical promotion.