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Akiki K, Mahmoud T, Alqaisieh MH, Sayegh LN, Lescalleet KE, Abu Dayyeh BK, Wong Kee Song LM, Larson MV, Bruining DH, Coelho-Prabhu N, Buttar NS, Sedlack RE, Chandrasekhara V, Leggett CL, Law RJ, Rajan E, Gleeson FC, Alexander JA, Storm AC. A novel blood-sensing capsule for rapid detection of upper GI bleeding: a prospective clinical trial. Gastrointest Endosc 2024; 99:712-720. [PMID: 38065512 DOI: 10.1016/j.gie.2023.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/07/2023] [Accepted: 11/23/2023] [Indexed: 04/24/2024]
Abstract
BACKGROUND AND AIMS Upper GI bleeding (UGIB) is a common medical emergency associated with high resource utilization, morbidity, and mortality. Timely EGD can be challenging from personnel, resource, and access perspectives. PillSense (EnteraSense Ltd, Galway, Ireland) is a novel swallowed bleeding sensor for the detection of UGIB, anticipated to aid in patient triage and guide clinical decision-making for individuals with suspected UGIB. METHODS This prospective, open-label, single-arm comparative clinical trial of a novel bleeding sensor for patients with suspected UGIB was performed at a tertiary care center. The PillSense system consists of an optical sensor and an external receiver that processes and displays data from the capsule as "Blood Detected" or "No Blood Detected." Patients underwent EGD within 4 hours of capsule administration; participants were followed up for 21 days to confirm capsule passage. RESULTS A total of 126 patients were accrued to the study (59.5% male; mean age, 62.4 ± 14.3 years). Sensitivity and specificity for detecting the presence of blood were 92.9% (P = .02) and 90.6% (P < .001), respectively. The capsule's positive and negative predictive values were 74.3% and 97.8%, and positive and negative likelihood ratios were 9.9 and .08. No adverse events or deaths occurred related to the PillSense system, and all capsules were excreted from patients on follow-up. CONCLUSIONS The PillSense system is safe and effective for detecting the presence of blood in patients evaluated for UGIB before upper GI endoscopy. It is a rapidly deployed tool, with easy-to-interpret results that will affect the diagnosis and triage of patients with suspected UGIB. (Clinical trial registration number: NCT05385224.).
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Affiliation(s)
- Karl Akiki
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Mohammad H Alqaisieh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Lea N Sayegh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Kristin E Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mark V Larson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Navtej S Buttar
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Robert E Sedlack
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA.
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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Elshaer A, Abraham NS. Management of Anticoagulant and Antiplatelet Agents in Acute Gastrointestinal Bleeding and Prevention of Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:205-216. [PMID: 38395479 DOI: 10.1016/j.giec.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Managing gastrointestinal bleeding in patients using antithrombotic agents remains challenging in clinical practice. This review article provides a comprehensive and evidence-based approach to managing acute antithrombotic-related gastrointestinal bleeding, focusing on the triage of patients, appropriate resuscitation, and timely endoscopy. The latest clinical practice guidelines are highlighted to guide decisions concerning the use of reversal agents, temporary interruption, and resumption of antithrombotic drugs. Additionally, preventive measures are discussed to lower the risk of future bleeding and minimize complications among patients prescribed antithrombotic drugs.
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Affiliation(s)
- Amany Elshaer
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Neena S Abraham
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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4
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Allo G, Gülcicegi D, Gillessen J, Kasper P, Chon SH, Goeser T, Bürger M. Timing of endoscopy in patients with elevated lactate levels and acute upper gastrointestinal bleeding; a retrospective comparative study. Scand J Gastroenterol 2024; 59:512-517. [PMID: 38149333 DOI: 10.1080/00365521.2023.2298355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND/AIMS While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy. METHODS We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB. RESULTS Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p = 0.37), rebleeding (17.2% vs. 15.7%; p = 0.82) and mortality (9.4% vs. 11.4%; p = 0.7) did not differ significantly. CONCLUSION In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.
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Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
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Yan X, Leng Z, Xu Q, Zhang Z, Xu M, Li J. The influences of timing of urgent endoscopy in patients with acute variceal bleeding: a cohort study. BMC Gastroenterol 2022; 22:506. [PMID: 36482309 PMCID: PMC9733049 DOI: 10.1186/s12876-022-02595-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There has always been a debate on the optimal timing of endoscopy in patients with acute variceal bleeding (AVB). OBJECTIVE This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB. METHODS Patients with AVB who underwent endoscopy within 24 h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. We used Cox proportional hazards model to analyze the predictors of 6-week mortality in all patients as well as in those who were at high risk of further bleeding or death. RESULTS A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6 h), and 142 patients (45.51%) underwent early endoscopy (6-24 h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12 h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06-0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902). CONCLUSIONS Endoscopy performed within 6 h of admission, rather than within 6 to 24 h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death.
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Affiliation(s)
- Xiaohan Yan
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Zhuyun Leng
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Qinwei Xu
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Zehua Zhang
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Meidong Xu
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Jingze Li
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
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Wu K, Fu Y, Guo Z, Zhou X. Analysis of the timing of endoscopic treatment for esophagogastric variceal bleeding in cirrhosis. Front Med (Lausanne) 2022; 9:1036491. [DOI: 10.3389/fmed.2022.1036491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022] Open
Abstract
BackgroundExisting guidelines recommend endoscopic treatment within 12 h or 12–24 h for patients with esophagogastric variceal bleeding (EGVB) in cirrhosis. In addition, research findings on the optimal time for endoscopy are inconsistent.AimThe aim of this study was to investigate the relationship between the timing of endoscopy and clinical outcomes in cirrhotic patients with EGVB and to analyze the risk factors for the composite outcomes after endoscopic treatment.MethodsFrom January 2019 to June 2020, 456 patients with cirrhotic EGVB who underwent endoscopy were matched by a 1:1 propensity score. Finally, 266 patients were divided into two groups, including 133 patients within 12 h (urgent endoscopy group) of admission and after 12 h (non-urgent endoscopy group). Baseline data and clinical outcomes were compared. Logistic regression model analysis was used to determine risk factors for 30 days rebleeding and mortality.ResultsIn 266 patients, the overall 30 days rebleeding rate and mortality were 10.9% (n = 29) and 3.4% (n = 9), respectively. Patients who underwent endoscopic treatment within 12 h had significantly higher 30 days rebleeding outcomes than those who underwent treatment beyond 12 h (15 vs. 6.8%, p = 0.003). However, 30 days mortality did not differ significantly between the two groups (3 vs. 3.8%, p = 0.736). Logistic regression analysis showed that age and shock on admission were independent risk factors for the composite outcome of 30 days rebleeding and mortality in patients with EGVB.ConclusionThe 30 days rebleeding rate in patients with cirrhotic EGVB treated with urgent endoscopy was significantly higher than that in patients treated with non-urgent endoscopy, but there was no significant difference in 30 days mortality.
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Dixit VK, Sahu MK, Venkatesh V, Bhargav VY, Kumar V, Pateriya MB, Venkataraman J. Gastrointestinal Emergencies and the Role of Endoscopy. Journal of Digestive Endoscopy 2022. [DOI: 10.1055/s-0042-1755303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractMany gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.
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Affiliation(s)
- Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Manoj Kumar Sahu
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Vybhav Venkatesh
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Varanasi Yugandhar Bhargav
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Vinod Kumar
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mayank Bhushan Pateriya
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Guan J, Han Y, Fang D, Wang M, Wang G, Tian D, Li P. Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Hemorrhage: A Retrospective Analysis. Curr Med Sci 2022; 42:856-862. [DOI: 10.1007/s11596-022-2551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
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Chang A, Ouejiaraphant C, Pungpipattrakul N, Akarapatima K, Rattanasupar A, Prachayakul V. Effect of holiday admission on clinical outcome of patients with upper gastrointestinal bleeding: A real-world report from Thailand. Heliyon 2022; 8:e10344. [PMID: 36090213 PMCID: PMC9449558 DOI: 10.1016/j.heliyon.2022.e10344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/24/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022] Open
Abstract
Background Holiday admissions are associated with poorer clinical outcomes compared with non-holiday admissions. However, data remain inconsistent concerning the “holiday effect” for patients with upper gastrointestinal bleeding. This study compared the differences between clinical courses of patients with upper gastrointestinal bleeding who were admitted on holidays and non-holidays in Thailand. Methods We retrospectively reviewed the medical records of patients with upper gastrointestinal bleeding confirmed by endoscopy who were admitted on holidays and non-holidays between January 2016 and December 2017. Mortality, medical resource usage, time to endoscopy, and clinical outcomes were compared between the groups. Results In total, 132 and 190 patients with upper gastrointestinal bleeding were admitted on holidays and non-holidays, respectively. Baseline characteristics, diagnosis of variceal bleeding, and pre-and post-endoscopic scores were not different between the two groups. Patients admitted on non-holidays were more likely to undergo early endoscopy, within 24 h of hospitalization (78.9% vs. 37.9%, p < 0.001), and had a shorter median time to endoscopy (median [interquartile range]: 17 [12–23] vs. 34 [17–56] h, p < 0.001) than those admitted on holidays. No significant differences in in-hospital mortality rate, number of blood transfusions, endoscopic interventions, additional interventions (including angioembolization and surgery), and length of stay were observed. Patients admitted on holidays had increased admission costs than those admitted on non-holidays (751 [495–1203] vs. 660 [432–1028] US dollars, p= 0.033). After adjusting for confounding factors, holiday admission was a predictor of early endoscopy (adjusted odds ratio 0.159; 95% confidence interval, 0096–0.264, p < 0.001), but was not associated with in-hospital mortality or other clinical outcomes. Conclusions Patients with upper gastrointestinal bleeding who were admitted on holidays had a lower rate of early endoscopy, longer time to endoscopy, and higher admission cost than those admitted on non-holidays. Holiday admission was not associated with in-hospital mortality or other clinical outcomes.
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Affiliation(s)
- Arunchai Chang
- Division of Gastroenterology, Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand
| | | | | | - Keerati Akarapatima
- Division of Gastroenterology, Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand
| | - Attapon Rattanasupar
- Division of Gastroenterology, Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand
| | - Varayu Prachayakul
- Siriraj Gastrointestinal Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand
- Corresponding author.
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Guo CLT, Wong SH, Lau LHS, Lui RNS, Mak JWY, Tang RSY, Yip TCF, Wu WKK, Wong GLH, Chan FKL, Lau JYW, Sung JJY. Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study. Gut 2022; 71:1544-1550. [PMID: 34548338 PMCID: PMC9279843 DOI: 10.1136/gutjnl-2020-323054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/08/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE While it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess whether endoscopy timing postadmission would affect outcomes. DESIGN We conducted a retrospective, territory-wide, cohort study with healthcare data from all public hospitals in Hong Kong. Adult patients (age ≥18) that presented with AUGIB between 2013 and 2019 and received therapeutic endoscopy within 48 hours (n=6474) were recruited. Patients were classified based on endoscopic timing postadmission: urgent (t≤6), early (6<t≤24) and late (24<t≤48). Baseline characteristics were balanced with inverse probability of treatment weighting. 30-day all-cause mortality, repeated therapeutic endoscopy rate, intensive care unit (ICU) admission rate and other endpoints were compared. RESULTS Results showed that urgent timing (n=1008) had worse outcomes compared with early endoscopy (n=3865), with higher 30-day all-cause mortality (p<0.001), repeat endoscopy rates (p<0.001) and ICU admission rates (p<0.001). Late endoscopy (n=1601) was associated with worse outcomes, with higher 30-day mortality (p=0.003), in-hospital mortality (p=0.022) and 30-day transfusion rates (p=0.018). CONCLUSION Compared with urgent and late endoscopy among patients who have received therapeutic endoscopies, early endoscopy was associated with superior outcomes especially among patients with non-variceal bleeding. This supports the notion that non-variceal AUGIB patients should receive endoscopy within 24 hours, but also emphasises the importance of prior resuscitation and pharmacotherapy.
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Affiliation(s)
- Cosmos L T Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Louis H S Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rashid N S Lui
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Terry C F Yip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K K Wu
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - James Y W Lau
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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El-Dallal M, Walradt TJ, Stein DJ, Khrucharoen U, Feuerstein JD. Pros and Cons of Performing Early Endoscopy in Geriatric Patients Admitted with Non-variceal Upper Gastrointestinal Bleeding: Analysis of the US National Inpatient Database. Dig Dis Sci 2022; 67:826-833. [PMID: 33710436 DOI: 10.1007/s10620-021-06924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/23/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Age greater than 65 years is a well-defined risk factor for increased mortality in patients with non-variceal upper gastrointestinal bleeding (NVGIB). Endoscopy is indicated in most patients at any age but presents unique risks in the elderly cohort, and ideal timing is unclear. This study examined the association between outcomes and early (within 24 h) esophagogastroduodenoscopy (EGD) among elderly patients with NVGIB. METHODS All patients over age 65 admitted primarily for NVGIB who underwent EGD were included from the National Inpatient Sample 2016-2017. Clinical outcomes stratified by early EGD versus late EGD were compared after adjustment for comorbidities and bleeding severity using inverse probability of treatment weighting with survey-adjusted linear and logistic regression. RESULTS Out of estimated 625,530 admissions with a primary diagnosis of NVGIB, 120,835 met eligibility criteria; 24,830 underwent early EGD. Mean length of stay and total charges decreased by 1.17 days (95%CI 1.04-1.30, P < 0.001) and $5717.24 (95%CI 4034.57-7399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95%CI 1.06-1.64, P 0.01) and transfer to other hospitals 1.48 (95%CI 1.22-1.81, P < 0.001). No change was seen in the requirement for surgery or angiography. Rates of discharge to a nursing facility or home health were similar. CONCLUSION In a comprehensive cohort of geriatric patients with NVGIB, early EGD is associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer. Further research is needed to determine the optimal management of this vulnerable population.
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Affiliation(s)
- Mohammed El-Dallal
- Division of Hospital Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA. .,Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA.
| | - Trent J Walradt
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel J Stein
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Usah Khrucharoen
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA
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12
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ Med 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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13
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Lau JYW. Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy. Dig Endosc 2022; 34:260-264. [PMID: 34551156 DOI: 10.1111/den.14144] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 02/08/2023]
Abstract
For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes. The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.
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Affiliation(s)
- James Yun Wong Lau
- Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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14
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Horibe M, Iwasaki E, Matsuzaki J, Bazerbachi F, Kaneko T, Minami K, Fukuhara S, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Kanai T. Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata. Gastroenterol Rep (Oxf) 2021; 9:543-551. [PMID: 34925851 PMCID: PMC8677506 DOI: 10.1093/gastro/goab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/26/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS). Methods Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed. Results HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0–4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5–19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09–0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16–0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001). Conclusions A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, MN, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare, St Cloud Hospital, MN, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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15
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Gao DJ, Wang SP, Fu XH, Yin L, Ye X, Yang XW, Zhang YJ, Hu B. Urgent Endoscopy Improves Hemostasis in Patients With Upper Gastrointestinal Bleeding Following Biliary-pancreatic Surgery: A Retrospective Analysis. Surg Laparosc Endosc Percutan Tech 2021; 32:228-235. [PMID: 34966156 DOI: 10.1097/sle.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a lethal complication of biliary-pancreatic surgery (BPS). The role of endoscopic intervention has not been fully defined in such a critical condition. The aim of this study was to assess the efficacy and safety of endoscopic hemostasis in a retrospective cohort. MATERIALS AND METHODS Consecutive patients with acute UGIB after BPS who received interventional endoscopy between January 2007 and August 2020 were included in this study. The clinical characteristics were collected and analyzed to screen for predictive factors significantly associated with successful hemostasis. RESULTS Among 37,772 patients who underwent BPS, 26 patients (0.069%) developed acute UGIB. The sites and causes of hemorrhage were as follows: gastroenteric anastomoe (n=17), gastric stump (n=2), jejunal anastomose (n=1), duodenal bulb ulcer (n=2), pancreatojejunal anastomosis hemorrhage (n=1), cholangiojejunal anastomose (n=1), gastroenteric anastomose and gastric stump hemorrhage (n=1), and Dieulafoy lesion (n=1). Successful endoscopic hemostasis was achieved in 19 (73.1%) of the 26 UGIB patients. In the 7 patients who failed endotherapy, 1 patient received a successful radiologic intervention, 6 patients underwent reoperation and achieved hemostasis in 4, and the other 2 patients died after reoperation. Logistic regression analysis showed that presentation-to-endoscopy time (≤12 h) was the only independent predictive factor associated with successful endoscopic hemostasis. CONCLUSIONS Endoscopic hemostasis is relatively safe and effective in controlling UIGB after BPS. Prompt intervention (≤12 h) could improve the success rate of endoscopic hemostasis.
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Affiliation(s)
| | | | - Xiao-Hui Fu
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | - Lei Yin
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | | | - Xin-Wei Yang
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | - Yong-Jie Zhang
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
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16
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Kubota Y, Yamauchi H, Nakatani K, Iwai T, Ishido K, Masuda T, Maruhashi T, Tanabe S. Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding. Scand J Gastroenterol 2021; 56:1396-1405. [PMID: 34455892 DOI: 10.1080/00365521.2021.1969593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. MATERIALS AND METHODS Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. RESULTS There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. CONCLUSIONS When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.
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Affiliation(s)
- Yo Kubota
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kento Nakatani
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomonari Masuda
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Satoshi Tanabe
- Department of Research and Development Center for New Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
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17
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Bilder HG, Soccini C, Lasa JS, Zubiaurre I. Impact of time to esophagogastroduodenoscopy in patients with nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis. Rev Gastroenterol Mex (Engl Ed) 2021:S2255-534X(21)00125-0. [PMID: 34862146 DOI: 10.1016/j.rgmxen.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION There is conflicting evidence regarding the benefit of urgent esophagogastroduodenoscopy (EGD) for reducing mortality and rebleeding, in the context of nonvariceal upper gastrointestinal bleeding. AIM To describe the decrease in the risk for mortality, rebleeding, and red blood cell transfusion, with the performance of urgent EGD, in patients with nonvariceal upper gastrointestinal bleeding. MATERIALS AND METHODS We carried out a search for cohort studies or controlled clinical trials, published from December 1966 to May 2020, that compared urgent EGD versus elective EGD in the management of adults with nonvariceal upper gastrointestinal bleeding, utilizing the MEDLINE, Embase, LILACS, and Cochrane Central Register of Controlled Trials databases. Our primary outcome was the hospital mortality comparison. The incidence of rebleeding and the mean number of red blood cell units transfused were also compared. A random effects model was utilized for the meta-analysis. RESULTS Twenty-one studies that met the eligibility criteria were included, involving 489,622 patients. We found no differences in the mortality of subjects exposed to urgent EGD versus elective EGD (RR 1.12 [0.72-1.72]). There was a significant increase in the risk for rebleeding (RR 1.30 [1.05-1.60]) in the subjects exposed to urgent EGD, and fewer red blood cell units were transfused in those patients (RR 0.52 [0.05-0.99]). CONCLUSIONS Urgent EGD in subjects with nonvariceal upper gastrointestinal bleeding does not appear to have a significant impact on short-term mortality.
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18
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Park JK. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. Korean J Helicobacter Up Gastrointest Res 2021. [DOI: 10.7704/kjhugr.2021.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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19
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Merola E, Michielan A, de Pretis G. Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:1331-1340. [PMID: 33570742 DOI: 10.1007/s11739-020-02563-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the most common indication for urgent endoscopy, but the correct timing of endoscopy in these patients is still debated. Our systematic review with meta-analysis was aimed at investigating the potential clinical benefit of very early endoscopy for UGIB patients. We performed an electronic literature search of PubMed, Scopus, Web of Science and the Cochrane Library up to 23rd May 2020 and considered only randomised controlled trials (RCTs) comparing management of UGIB patients by very early vs early endoscopy. Only five RCTs were considered eligible for quantitative analysis, with a total population of 926 cases (468 in the very early endoscopy arm and 458 in the early). The meta-analysis showed no statistically significant benefit for very early endoscopy compared to early endoscopy in terms of risk of rebleeding, mortality, ICU admission, blood transfusion, surgery and length of hospital stay. However, our results showed a significantly higher need for haemostatic treatment when very early endoscopy was performed (RR 1.23, 95% CI 1.06-1.42, p < 0.01) in comparison to early endoscopy.
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Affiliation(s)
- Elettra Merola
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy.
| | - Andrea Michielan
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy
| | - Giovanni de Pretis
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy
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20
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Ejtehadi F, Sivandzadeh GR, Hormati A, Ahmadpour S, Niknam R, Pezeshki Modares M. Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review. Middle East J Dig Dis 2021; 13:177-185. [PMID: 36606214 PMCID: PMC9489462 DOI: 10.34172/mejdd.2021.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/02/2021] [Indexed: 01/07/2023] Open
Abstract
Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.
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Affiliation(s)
- Fardad Ejtehadi
- Associate Professor of Medicine, Gastroentrohepatology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholam Reza Sivandzadeh
- Assistant Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
,Corresponding Author: Gholam Reza Sivandzadeh, MD Department of Internal Medicine, Gasteroenetrohepatology Research Center, Department of Internal Medicine, School of Medicine, Shiraz University of Medical Sciences, Namazi Hospital, Zand St., Shiraz, 7193711351, Fars, Iran. Tel: + 98 711 6473236 Fax: + 98 711 6474316
| | - Ahmad Hormati
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sajjad Ahmadpour
- Assistant Professor of Radiopharmacy, Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Ramin Niknam
- Associate Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Pezeshki Modares
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
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21
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Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021; 116:899-917. [PMID: 33929377 DOI: 10.14309/ajg.0000000000001245] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.
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22
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Jawaid S. The Cost-Effectiveness of Video Capsule Endoscopy. Gastrointest Endosc Clin N Am 2021; 31:413-424. [PMID: 33743935 DOI: 10.1016/j.giec.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of video capsule endoscopy (VCE) has allowed for visualization of parts of the gastrointestinal tract generally not readily accessible by noninvasive means. Its ease of use has proved useful in diagnosing and managing various small bowel inflammatory disorders. Continued technological evolution of VCE has paved the way for use in small intestinal bleeding and in patients with acute gastrointestinal bleeding. A detailed analysis of costs associated with VCE has demonstrated its ability to promote efficient allocation of health care resources. Further work is needed regarding development of a universal infrastructure to handle the widespread use of VCE technology.
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Affiliation(s)
- Salmaan Jawaid
- Gastroenterology-Advanced Endoscopy, Baylor College of Medicine, 7200 Cambridge Street, Suite 8B, MSBCM 901, Houston, TX 77030, USA.
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23
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Bae SJ, Kim K, Yun SJ, Lee SH. Predictive performance of blood urea nitrogen to serum albumin ratio in elderly patients with gastrointestinal bleeding. Am J Emerg Med 2021; 41:152-157. [DOI: 10.1016/j.ajem.2020.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/18/2020] [Accepted: 12/10/2020] [Indexed: 01/09/2023] Open
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24
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Horibe M, Iwasaki E, Bazerbachi F, Kaneko T, Matsuzaki J, Minami K, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Chan AT, Kanai T. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020; 92:578-588.e4. [PMID: 32240682 DOI: 10.1016/j.gie.2020.03.3846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although upper GI bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3-variable score (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure] ≥1, and blood urea nitrogen/creatinine ≥30 [urea/creatinine≥140]), the Horibe gAstRointestinal BleedING scoRe (HARBINGER), with the 8-variable Glasgow-Blatchford Score (GBS) and 5-variable AIMS65 to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy. METHODS Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. On presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata. RESULTS Of 1486 enrolled patients, 637 (43%) harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver operating characteristic curve (AUC) for the HARBINGER was .76 (95% confidence interval [CI], .72-.79), which was significantly superior to both the GBS (AUC, .68; 95% CI, .64-.71; P < .001) and the AIMS65 (AUC, .54; 95% CI, .50-.58; P < .001). When the HARBINGER cutoff value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively. CONCLUSIONS The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and AIMS65.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Andrew T Chan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Marmo R, Soncini M, Marmo C, Borbjerg Laursen S, Gralnek IM, Stanley AJ. Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study. Dig Liver Dis 2020; 52:561-565. [PMID: 32111388 DOI: 10.1016/j.dld.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding. AIMS To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding. METHODS A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward. PRIMARY OUTCOME 30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding. RESULTS Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01. CONCLUSION Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Unit, L. Curto Hospital, Polla, SA, Italy.
| | - Marco Soncini
- Digestive Physiopathology Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | | | - Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ian Mark Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Family Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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Affiliation(s)
- Loren Laine
- From Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven - both in Connecticut
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Lau JYW, Yu Y, Tang RSY, Chan HCH, Yip HC, Chan SM, Luk SWY, Wong SH, Lau LHS, Lui RN, Chan TT, Mak JWY, Chan FKL, Sung JJY. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020; 382:1299-1308. [PMID: 32242355 DOI: 10.1056/nejmoa1912484] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined. METHODS To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization. RESULTS A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group. CONCLUSIONS In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).
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Affiliation(s)
- James Y W Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yuanyuan Yu
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Raymond S Y Tang
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Heyson C H Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hon-Chi Yip
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shannon M Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sally W Y Luk
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sunny H Wong
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Louis H S Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rashid N Lui
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ting T Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joyce W Y Mak
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francis K L Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joseph J Y Sung
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut and VA Connecticut Healthcare System, West Haven, Connecticut.
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Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
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Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
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Chandnani S, Rathi P, Udgirkar SS, Sonthalia N, Contractor Q, Jain S. CLINICAL UTILITY OF RISK SCORES IN VARICEAL BLEEDING. Arq Gastroenterol 2019; 56:286-293. [PMID: 31633727 DOI: 10.1590/s0004-2803.201900000-54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.
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Affiliation(s)
- Sanjay Chandnani
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Pravin Rathi
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | | | - Nikhil Sonthalia
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Qais Contractor
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Samit Jain
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
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Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101618. [PMID: 31785731 DOI: 10.1016/j.bpg.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/23/2019] [Indexed: 01/31/2023]
Abstract
Endoscopy is the gold standard for evaluating and treating acute upper gastrointestinal bleeding (UGIB). The optimal timing of endoscopy is a very important consideration in the overall management of UGIB, but there is on going uncertainty regarding timing of the procedure, particularly in those with more severe bleeding. This is reflected by inconsistencies between current guidelines. Although evidence suggests endoscopy should be undertaken within 24 h for all admitted patients with UGIB, a small group of patients with severe bleeding or high-risk features may require more urgent endoscopy. The exact timing of the procedure in this high-risk group remains unclear, with recent data suggesting that performing endoscopy too early may be associated with worse outcome. In this article we examine the evidence for optimal timing of endoscopy in patients presenting with UGIB and suggest a clinical approach to this important aspect of patient management.
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Cañamares-Orbís P, Chan FKL. Endoscopic management of nonvariceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101608. [PMID: 31785733 DOI: 10.1016/j.bpg.2019.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.
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Abstract
Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
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Affiliation(s)
- Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
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Thomson M. There Is No Excuse for Mortality Due to Lack of Competency and Training of Paediatric Endoscopists in Gastrointestinal Bleeding Therapy in 2018. J Pediatr Gastroenterol Nutr 2018; 67:684-8. [PMID: 30211844 DOI: 10.1097/MPG.0000000000002148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute upper gastrointestinal bleeding in children is possibly the last medical emergency which continues to lead to the death of a child due to the lack of competency/clinical judgement of the doctor, as opposed to the disease itself, leading to mortality despite optimum medical intervention. This is unacceptable in any circumstances in 2018. It occurs due to a number of conspiring factors including lack of appreciation of the clinical presentation requiring urgent endoscopic intervention; misapprehension of the urgency of timing required of such an intervention predicated on the severity of the gastrointestinal (GI) bleed; lack of application of a paediatric-specific validated score predicting for such endoscopic intervention; lack of skill in endo-haemostatic intervention techniques by paediatric endoscopists; poor training in such techniques among paediatric endoscopists; paucity of cases with lack of exposure of the paediatric endoscopist regularly to enable skills to be maintained, once acquired; reluctance of adult endoscopists in many centres to support paediatric GI bleeding services. In essence then the paediatric GI community urgently needs to identify centres of excellence to whom these children should be transferred. Transfer is safe in all but the most critical cases once stabilised with transfusion, octreotide/terlipressin and iv proton pump inhibitors. The resources are country-dependent but this is really no excuse. We must not let this parlous state of affairs continue. Solutions are explored in this article and please let this serve as a call to action for all those involved in this continuing debacle in order to save "save-able" lives.
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Yoo JJ, Chang Y, Cho EJ, Moon JE, Kim SG, Kim YS, Lee YB, Lee JH, Yu SJ, Kim YJ, Yoon JH. Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding. World J Gastroenterol 2018; 24:5025-5033. [PMID: 30510377 PMCID: PMC6262253 DOI: 10.3748/wjg.v24.i44.5025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/15/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.
METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.
RESULTS A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).
CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.
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Affiliation(s)
- Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon 14584, South Korea
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
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Garbin N, Wang L, Chandler JH, Obstein KL, Simaan N, Valdastri P. Dual-Continuum Design Approach for Intuitive and Low-Cost Upper Gastrointestinal Endoscopy. IEEE Trans Biomed Eng 2018; 66:10.1109/TBME.2018.2881717. [PMID: 30452348 PMCID: PMC6522341 DOI: 10.1109/tbme.2018.2881717] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This paper introduces a methodology to design intuitive, low-cost, and portable devices for visual inspection of the upper gastrointestinal tract. METHODS The proposed approach mechanically couples a multi-backbone continuum structure, as the user interface, and a parallel bellows actuator, as the endoscopic tip. Analytical modeling techniques derived from continuum robotics were adopted to describe the endoscopic tip motion from user input, accounting for variations in component size and pneumatic compressibility. The modeling framework was used to improve intuitiveness of user-to-task mapping. This was assessed against a 1:1 target, while ease-of-use was validated using landmark identification tasks performed in a stomach simulator by one expert and ten non-expert users; benchmarked against conventional flexible endoscopy. Pre-clinical validation consisted of comparative trials in in-vivo porcine and human cadaver models. RESULTS Target mapping was achieved with an average error of 5° in bending angle. Simulated endoscopies were performed by an expert user successfully, within a time comparable to conventional endoscopy (<1 minute difference). Non-experts using the proposed device achieved visualization of the stomach in a shorter time (9s faster on average) than with a conventional endoscope. The estimated cost is <10 USD and <30 USD for disposable and reusable parts, respectively. Significance and Conclusions: Flexible endoscopes are complex and expensive devices, actuated via non-intuitive cable-driven mechanisms. They frequently break, requiring costly repair, and necessitate a dedicated reprocessing facility to prevent cross contamination. The proposed solution is portable, inexpensive, and easy to use, thus lending itself to disposable use by personnel without formal training in flexible endoscopy.
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Abstract
PURPOSE OF REVIEW To review new advances in managing nonvariceal upper gastrointestinal hemorrhage. RECENT FINDINGS Implementation of various scoring systems in combination with video capsule endoscopy assists in stratifying and managing nonvariceal upper gastrointestinal bleeding. New techniques such as thermocoagulation and hemoclips are useful to treat bleeding. SUMMARY The advancement of methods and procedures in managing nonvariceal upper gastrointestinal bleeding has decreased mortality of patients presenting with this type of hemorrhage. In this chapter, we will be discussing various scores to stratify nonvariceal upper gastrointestinal bleeding and techniques to stop bleeding.
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Siau K, Hodson J, Ingram R, Baxter A, Widlak MM, Sharratt C, Baker GM, Troth T, Hicken B, Tahir F, Magrabi M, Yousaf N, Grant C, Poon D, Khalil H, Lee HL, White JR, Tan H, Samani S, Hooper P, Ahmed S, Amin M, Mahgoub S, Asghar K, Leet F, Harborne MJ, Polewiczowska B, Khan S, Anjum MR, McFarlane M, Mozdiak E, O'Flynn LD, Blee IC, Molyneux RM, Kurian A, Abbas SN, Abbasi A, Karim A, Yasin A, Khattak F, White J, Ahmed R, Morgan JA, Alleyne L, Alam MA, Palaniyappan N, Rodger VJ, Sawhney P, Aslam N, Okeke T, Lawson A, Cheung D, Reid JP, Awasthi A, Anderson MR, Timothy JR, Pattni S, Ahmad S, Townson G, Shearman J, Giljaca V, Brookes MJ, Disney BR, Guha N, Thomas T, Norman A, Wurm P, Shah A, Fisher NC, Ishaq S, Major G. Time to endoscopy for acute upper gastrointestinal bleeding: Results from a prospective multicentre trainee-led audit. United European Gastroenterol J 2018; 7:199-209. [PMID: 31080604 DOI: 10.1177/2050640618811491] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/15/2018] [Indexed: 12/24/2022] Open
Abstract
Background Endoscopy within 24 h of admission (early endoscopy) is a quality standard in acute upper gastrointestinal bleeding (AUGIB). We aimed to audit time to endoscopy outcomes and identify factors affecting delayed endoscopy (>24 h of admission). Methods This prospective multicentre audit enrolled patients admitted with AUGIB who underwent inpatient endoscopy between November and December 2017. Analyses were performed to identify factors associated with delayed endoscopy, and to compare patient outcomes, including length of stay and mortality rates, between early and delayed endoscopy groups. Results Across 348 patients from 20 centres, the median time to endoscopy was 21.2 h (IQR 12.0-35.7), comprising median admission to referral and referral to endoscopy times of 8.1 h (IQR 3.7-18.1) and 6.7 h (IQR 3.0-23.1), respectively. Early endoscopy was achieved in 58.9%, although this varied by centre (range: 31.0-87.5%, p = 0.002). On multivariable analysis, lower Glasgow-Blatchford score, delayed referral, admissions between 7:00 and 19:00 hours or via the emergency department were independent predictors of delayed endoscopy. Early endoscopy was associated with reduced length of stay (median difference 1 d; p = 0.004), but not 30-d mortality (p = 0.344). Conclusions The majority of centres did not meet national standards for time to endoscopy. Strategic initiatives involving acute care services may be necessary to improve this outcome.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK.,West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospital Birmingham, Birmingham, UK
| | - Richard Ingram
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Andrew Baxter
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Monika M Widlak
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Caroline Sharratt
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Graham M Baker
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Tom Troth
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ben Hicken
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Faraz Tahir
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Malik Magrabi
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Nouman Yousaf
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Claire Grant
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Dennis Poon
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Hesham Khalil
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Hui Lin Lee
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Jonathan R White
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Huey Tan
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Syazeddy Samani
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Patricia Hooper
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Saeed Ahmed
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Muhammad Amin
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Sara Mahgoub
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Khayal Asghar
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Farique Leet
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Matthew J Harborne
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Beata Polewiczowska
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Sheeba Khan
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Muhammad R Anjum
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Michael McFarlane
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ella Mozdiak
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Lauren D O'Flynn
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ilona C Blee
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Rachel M Molyneux
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ashok Kurian
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Syed N Abbas
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Abdullah Abbasi
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Aadil Karim
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Asif Yasin
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Fawad Khattak
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Josephine White
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ruhina Ahmed
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - James A Morgan
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Lance Alleyne
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Mohamed A Alam
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Naaventhan Palaniyappan
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Victoria J Rodger
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Paramvir Sawhney
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Nasar Aslam
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Theodore Okeke
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Adam Lawson
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Danny Cheung
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Jeremy P Reid
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ashish Awasthi
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Mark R Anderson
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Joe R Timothy
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Sanjeev Pattni
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Saqib Ahmad
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Gillian Townson
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Jeremy Shearman
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Vanja Giljaca
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Matthew J Brookes
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Ben R Disney
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Neil Guha
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Titus Thomas
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Anthony Norman
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Peter Wurm
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
| | - Ashit Shah
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Neil C Fisher
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Sauid Ishaq
- West Midlands Research in Gastroenterology Group (WMRIG) collaborative, West Midlands, UK
| | - Giles Major
- Gastroenterology Audit and Research Network East Midlands (GARNet) collaborative, East Midlands, UK
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Takatori Y, Kato M, Sunata Y, Hirai Y, Kubosawa Y, Abe K, Takada Y, Hirata T, Banno S, Wada M, Kinoshita S, Mori H, Takabayashi K, Kikuchi M, Kikuchi M, Suzuki M, Uraoka T. Impaired activity of daily living is a risk factor for high medical cost in patients of non-variceal upper gastrointestinal bleeding. Surg Endosc 2019; 33:1518-22. [DOI: 10.1007/s00464-018-6433-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/05/2018] [Indexed: 12/17/2022]
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Cai JX, Saltzman JR. Initial Assessment, Risk Stratification, and Early Management of Acute Nonvariceal Upper Gastrointestinal Hemorrhage. Gastrointest Endosc Clin N Am 2018; 28:261-275. [PMID: 29933774 DOI: 10.1016/j.giec.2018.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Inhospital mortality from nonvariceal upper gastrointestinal bleeding has improved with advances in medical and endoscopy therapy. Initial management includes resuscitation, hemodynamic monitoring, proton pump inhibitor therapy, and restrictive blood transfusion. Risk stratification scores help triage bleeding severity and provide prognosis. Upper endoscopy is recommended within 24 hours of presentation; select patients at lowest risk may be effectively treated as outpatients. Emergent endoscopy within 12 hours does not improve clinical outcomes, including mortality, rebleeding, or need for surgery, despite an increased use of endoscopic treatment. There may be a benefit to emergent endoscopy in patients with evidence of active bleeding.
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Affiliation(s)
- Jennifer X Cai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Cho SH, Lee YS, Kim YJ, Sohn CH, Ahn S, Seo DW, Kim WY, Lee JH, Lim KS. Outcomes and Role of Urgent Endoscopy in High-Risk Patients With Acute Nonvariceal Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2018. [PMID: 28634135 DOI: 10.1016/j.cgh.2017.06.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated clinical outcomes in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), and determined if urgent endoscopy is effective. METHODS Consecutive patients with a Glasgow-Blatchford score greater than 7 who underwent endoscopy for acute nonvariceal UGIB at the emergency department from January 1, 2005, to December 31, 2014, were included. Urgent (<6 h) and elective (6-48 h) endoscopies were defined according to the time to endoscopy after the initial presentation. The primary outcomes were mortality and rebleeding within 28 days of admission. RESULTS Among 961 patients, 571 patients underwent urgent endoscopy. The 28-day mortality rate was 2.5%, and the rebleeding rate was 10.4%. There were significant differences in mortality rate (1.6% vs 3.8%), the number of transfused packed red blood cells (2.6 ± 2.5 vs 2.3 ± 2.1 packs), need for intervention (69.5% vs 53.5%), and embolization (2.8% vs 0.5%), but no differences in rebleeding, intensive care unit admission, vasopressor use, and length of stay between the urgent and elective endoscopy groups. Mortality was associated with malignancy (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.33-9.62), cirrhosis (OR, 4.67; 95% CI, 1.85-11.76), urgent endoscopy (OR, 0.36; 95% CI, 0.14-0.95), failed primary endoscopic treatment (OR, 15.03; 95% CI, 4.63-48.82), and rebleeding (OR, 2.77; 95% CI, 1.03-7.45). Rebleeding was associated with Forrest I ulcers (OR, 7.67; 95% CI, 2.71-21.69), Forrest II ulcers (OR, 2.34; 95% CI, 1.51-3.60), and coagulopathy (OR, 2.34; 95% CI, 1.51-3.60). CONCLUSIONS Urgent endoscopy was an independent predictor of lower mortality rate but was not associated with rebleeding in high-risk patients with acute nonvariceal UGIB.
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Affiliation(s)
- Soo-Han Cho
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Gupta A, Agarwal R, Ananthakrishnan AN. "Weekend Effect" in Patients With Upper Gastrointestinal Hemorrhage: A Systematic Review and Meta-analysis. Am J Gastroenterol 2018; 113:13-21. [PMID: 29134968 DOI: 10.1038/ajg.2017.430] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 10/09/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES "Weekend effect" refers to worse outcomes among patients presenting to the hospital on weekends or holidays. We performed a systematic review and meta-analysis of observational studies assessing the impact of the "weekend effect" in patients with upper gastrointestinal hemorrhage (UGIH). METHODS We searched key bibliographic databases using keywords and MeSH terms related to gastrointestinal hemorrhage and "weekend effect". Our primary analysis evaluated mortality in patients with UGIH who were hospitalized on the weekend or after-hours compared with a weekday. Secondary outcomes included need for definitive therapy and length of hospital stay. Relevant data were extracted and meta-analyses were performed using random effects model. Subgroup sensitivity analyses were also performed to assess the effects of key variables. RESULTS A total of 21 of 224 identified studies met inclusion criteria. Overall, there was no association between weekend admission and mortality among patients with UGIH (Odds Ratio (OR): 1.06; 95% confidence interval (CI): 0.99-1.14). However, meta-analysis using only the nine studies that did not report having a weekend rounder showed a significant increase in mortality (OR: 1.12; 95% CI: 1.07-1.17). There was no effect of weekend admission on any of our secondary outcomes. CONCLUSIONS Current evidence suggests that weekend admission is associated with significant increase in mortality in patients with non-variceal UGIH but no difference in mortality was noted in patients with variceal UGIH. Our findings are relevant to policymakers, practitioners and providers who should ensure the creation of consistent quality and access to care throughout the week.
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Leiman DA, Mills AM, Shofer FS, Weber AT, Leiman ER, Riff BP, Lewis JD, Mehta SJ. Glasgow Blatchford Score of limited benefit for low-risk urban patients: a mixed methods study. Endosc Int Open 2017; 5:E950-E958. [PMID: 28971143 PMCID: PMC5621904 DOI: 10.1055/s-0043-117880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/26/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Most patients with upper gastrointestinal bleeding (UGIB) are hospitalized. Risk-stratifying UGIB with scoring tools may decrease avoidable admissions, thereby reducing the cost of care. We sought to describe how frequently low-risk UGIB patients present to urban emergency departments (ED) and the proportion who are admitted to examine how incorporating risk scores into decision support might diminish healthcare utilization in this population. PATIENTS AND METHODS This is a retrospective cohort study of ED patients presenting from 2009 - 2013 to three urban hospitals that do not use electronic UGIB decision support. We used ED disposition diagnosis codes (ICD-9) to identify patients followed by manual chart review for verification and additional data collection. Patients with a Glasgow Blatchford Score (GBS) of 0 were classified as low risk. We also surveyed ED physicians at these hospitals to assess their beliefs about UGIB decision support. RESULTS Over the study period, 66 patients (13.2 per year) presented to the ED with low-risk UGIB. Of these, 10 patients (15.2 %) were admitted and none required endoscopic hemostasis. Most survey respondents (55.6 %, n = 20) were aware of UGIB risk scores but a minority (19.4 %, n = 7) used one. CONCLUSIONS Low-risk UGIB patients infrequently present to the ED and only a minority are admitted. Despite advocacy to incorporate decision support into routine clinical care, ED physicians independently identified low risk patients. There is insufficient evidence to suggest the magnitude of this problem is large enough to warrant implementation of decision support for low risk UGIB.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University of School of Medicine, 2301 Erwin Road, Durham, NC, USA,Corresponding author David A. Leiman, MD, MSHP 200 Trent Drive, Box 3913Durham, NC 27710+1-919-681-8147
| | - Angela M. Mills
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
| | - Frances S. Shofer
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
| | - Andrew T. Weber
- Department of Internal Medicine, Geffen School of Medicine at the University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, California, United States
| | - Erin R. Leiman
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Brian P. Riff
- Advanced Endoscopy Center, St. Jude Medical Center, Fullerton, California, United States
| | - James D. Lewis
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Shivan J. Mehta
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Refaai MA, Kothari TH, Straub S, Falcon J, Sarode R, Goldstein JN, Brainsky A, Omert L, Lee ML, Milling TJ. Four-Factor Prothrombin Complex Concentrate Reduces Time to Procedure in Vitamin K Antagonist-Treated Patients Experiencing Gastrointestinal Bleeding: A Post Hoc Analysis of Two Randomized Controlled Trials. Emerg Med Int 2017; 2017:8024356. [PMID: 29057123 DOI: 10.1155/2017/8024356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/06/2017] [Indexed: 01/21/2023] Open
Abstract
Introduction To investigate the impact of a 4-factor prothrombin complex concentrate (4F-PCC [Beriplex®/Kcentra®]) versus plasma on “time to procedure” in patients with acute/severe gastrointestinal bleeding requiring rapid vitamin K antagonist (VKA) reversal prior to invasive procedure. Methods A post hoc analysis of two phase III trials of 4F-PCC versus plasma in patients with acute/severe gastrointestinal bleeding. The treatment arms were compared for study treatment volume, infusion times, and time from start of study treatment to procedure. Results Analysis included 42 patients (plasma, n = 20; 4F-PCC, n = 22). Median (interquartile range) infusion time was significantly shorter for the 4F-PCC group than for the plasma group (16 [13, 26] min versus 210 [149, 393] min; P < 0.0001). Median infusion volumes were significantly smaller (103 [80, 130] mL versus 870 [748, 1001] mL; P < 0.0001) and median time from study treatment initiation to first procedure was significantly shorter in the 4F-PCC group than in the plasma group (17.5 [12.8, 22.8] versus 23.9 [18.5, 62.0] h; P = 0.037). Conclusions In this analysis of patients with acute/severe gastrointestinal bleeding requiring urgent VKA reversal prior to an invasive procedure, 4F-PCC (compared with plasma) was associated with smaller infusion volumes, shorter infusion times, and reduced time to procedure.
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Garg SK, Anugwom C, Campbell J, Wadhwa V, Gupta N, Lopez R, Shergill S, Sanaka MR. Early esophagogastroduodenoscopy is associated with better Outcomes in upper gastrointestinal bleeding: a nationwide study. Endosc Int Open 2017; 5:E376-E386. [PMID: 28512647 PMCID: PMC5432117 DOI: 10.1055/s-0042-121665] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and study aims We analyzed NIS (National Inpatient Sample) database from 2007 - 2013 to determine if early esophagogastroduodenoscopy (EGD) (24 hours) for upper gastrointestinal bleeding improved the outcomes in terms of mortality, length of stay and costs. Patients and methods Patients were classified as having upper gastrointestinal hemorrhage by querying all diagnostic codes for the ICD-9-CM codes corresponding to upper gastrointestinal bleeding. For these patients, performance of EGD during admission was determined by querying all procedural codes for the ICD-9-CM codes corresponding to EGD; early EGD was defined as having EGD performed within 24 hours of admission and late EGD was defined as having EGD performed after 24 hours of admission. Results A total of 1,789,532 subjects with UGIH were identified. Subjects who had an early EGD were less likely to have hypovolemia, acute renal failure and acute respiratory failure. On multivariable analysis, we found that subjects without EGD were 3 times more likely to die during the admission than those with early EGD. In addition, those with late EGD had 50 % higher odds of dying than those with an early EGD. Also, after adjusting for all factors in the model, hospital stay was on average 3 and 3.7 days longer for subjects with no or late EGD, respectively, then for subjects with early EGD. Conclusion Early EGD (within 24 hours) is associated with lower in-hospital mortality, morbidity, shorter length of stay and lower total hospital costs.
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Affiliation(s)
- Sushil K. Garg
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - Chimaobi Anugwom
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - James Campbell
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - Vaibhav Wadhwa
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic,
Cleveland, Ohio, United States
| | - Nancy Gupta
- Department of Gastroenterology, University of Iowa, Iowa City, Iowa, United
States
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United
States
| | - Sukhman Shergill
- All India Institute of Medical Sciences, Medicine, New Delhi,
India
| | - Madhusudhan R. Sanaka
- Digestive Disease Institute, Department of Gastroenterology & Hepatology,
The Cleveland Clinic, Cleveland, Ohio, United States,Corresponding author Madhu Sanaka, MD, FACG, FASGE Director of Endoscopy ResearchDepartment of GastroenterologyDesk Q39500 Euclid AvenueCleveland, OH 44195+1-216-444-6283
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Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc 2017; 85:936-944.e3. [PMID: 27623102 DOI: 10.1016/j.gie.2016.08.049] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The optimal timing of endoscopy in patients with peptic ulcer bleeding (PUB) remains unclear. The aim of this study was to examine the association between timing of endoscopy and mortality in PUB. METHODS In a nationwide cohort study based on a database of consecutive patients admitted to the hospital with PUB in Denmark, patients were stratified according to the presence of hemodynamic instability at presentation and American Society of Anesthesiologists (ASA) score. Using descriptive statistics and logistic regression analyses, we identified optimal time frames for endoscopy and analyzed the association between timing of endoscopy and in-hospital mortality after adjusting for confounding factors. RESULTS In total, 12,601 patients were included. We did not find any universal association between timing of endoscopy and mortality in hemodynamically stable patients with an ASA score of 1 to 2. In hemodynamically stable patients with an ASA score of 3 to 5, endoscopy 12 to 36 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .48; 95% CI, .34-.67) compared with endoscopy outside this time frame. In patients with hemodynamic instability, endoscopy 6 to 24 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .73; 95% CI, .54-.98) compared with endoscopy outside this time frame. CONCLUSIONS Timing of endoscopy is associated with mortality in patients with PUB and an ASA score of 3 to 5 or hemodynamic instability. Our findings suggest that in these patients, a period of time to optimize resuscitation and manage comorbidities before endoscopy may improve outcome.
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Affiliation(s)
- John C T Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - James Y W Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
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Klein A, Gralnek IM. Video capsule endoscopy for triage of patients with acute upper GI hemorrhage: Is seeing believing? Gastrointest Endosc 2016; 84:914-916. [PMID: 27855797 DOI: 10.1016/j.gie.2016.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Rappaport Family Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel; Rappaport Family Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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