Nonvariceal upper gastrointestinal bleeding in elderly people: Clinical outcomes and prognostic factors

Application of Antithrombotic Drugs in Different Age-Group Patients with Upper Gastrointestinal Bleeding

Objective

This study aimed at exploring the safety and timing of antithrombotic drugs in different age-group patients with UGIB.

Methods

An observational study retrospectively based on the single-center database with 713 patients with UGIB.

Result

Among the 713 patients, 62.13% were elderly patients (aged > 60 years) and the mortality was 2.9%. In elderly patients with UGIB, we found that previous medication history, resumption of medication, and time of resumption did not affect the in-hospital mortality. The resumption of anticoagulants increased the risk of rebleeding. The independent risk factors of mortality were CHF, cirrhosis, creatine kinase, and albumin. The independent risk factors of rebleeding were the application of anticoagulants during hospitalization, variceal bleeding, black stool, red blood cells (lab), platelets (lab), and heart rate.

Conclusions

In UGIB patients, a history of antiplatelet or antithrombotic drugs and the use of antiplatelet drugs after UGIB did not affect the patient's prognosis. In elderly UGIB patients, although antithrombotic drugs did not increase the risk of death, the increased risk of rebleeding after resumption of use deserved careful treatment. It was safe to recover anticoagulant drugs as soon as possible in young UGIB patients.

Risk factors, prediction model, and prognosis analysis of myocardial injury after acute upper gastrointestinal bleeding

Background

Cardiovascular complications in patients with acute upper gastrointestinal bleeding (AUGIB) have been associated with a high-risk of subsequent adverse consequences. This study aimed to analyze the risk factors for myocardial injury in AUGIB patients, predict the risk of myocardial injury, and explore the clinical prognosis and influencing factors in AUGIB patients with myocardial injury.

Materials and methods

A retrospective case-control study based on AUGIB patients in the First Affiliated Hospital of Xi'an Jiaotong University from 2016 to 2020 was performed. We divided the enrolled patients into a myocardial injury group and a control group according to whether they developed myocardial injury. The variables significant in the univariate analysis were subjected to binary logistic regression for risk factor analysis and were used to establish a nomogram for predicting myocardial injury. In addition, logistic regression analysis was performed to better understand the risk factors for in-hospital mortality after myocardial injury.

Result

Of the 989 AUGIB patients enrolled, 10.2% (101/989) developed myocardial injury. Logistic regression analysis showed that the strong predictors of myocardial injury were a history of hypertension (OR: 4.252, 95% CI: 1.149-15.730, P = 0.030), blood urea nitrogen (BUN) (OR: 1.159, 95% CI: 1.026-1.309, P = 0.018) and left ventricular ejection fraction (LVEF) <68% (OR: 3.667, 95% CI: 1.085-12.398, P = 0.037). The patients with a tumor history (digestive system tumors and non-digestive system tumors) had no significant difference between the myocardial injury group and the control group (P = 0.246). A prognostic nomogram model was established based on these factors with an area under the receiver operator characteristic curve of 0.823 (95% CI: 0.730-0.916). The patients with myocardial injury had a much higher in-hospital mortality rate (10.9% vs. 2.0%, P < 0.001), and an elevated D-dimer level was related to in-hospital mortality among the AUGIB patients with myocardial injury (OR: 1.273, 95% CI: 1.085-1.494, P = 0.003).

Conclusion

A history of hypertension, renal dysfunction, and cardiac function with LVEF <68% were strong predictors of myocardial injury. Coagulopathy was found to be associated with poor prognosis in AUGIB patients with myocardial injury.

Acute gastrointestinal bleeding in Egyptian elderly patients: real-life experience

Background

Elderly people are a vulnerable group of patients subjected to multiple health problems. Upper gastrointestinal bleeding (UGIB) in older adults is a frequent cause of hospital admissions. The presence of multiple comorbidities and greater medication use influence the clinical outcome.

Aim

The aim of our work was to analyze the etiology, precipitating factors, management, and outcome of the elderly Egyptian patients (> 65 years old) presenting with acute UGIB.

Methods

Three hundred thirty-two patients presenting with acute UGIB. The patients were classified into two groups according to age (elderly, above 65 years old, and young, below 65 years old). Clinical assessment, laboratory tests, and upper endoscopy were done for all patients. They were followed for 1 month.

Results

Elderly females showed higher incidence of acute UGIB (45.8% versus 28.9%) with significant P-value (0.001). The incidence of esophageal varices was high in young patients than in the elderly (46.4% vs 35.5%) with P-value (0.045), while the elderly patients showed a higher incidence of esophageal ulcers and gastric mass than the young patients (7.8% vs 2.4%), (6% vs 0%) with P-value (0.025 and 0.013) respectively. Also, there was a higher incidence of peptic ulcer in elderly than young patients but does not reach a significant value with P-value (0.067), while there was no difference between both groups as regards presence of (fundal varix, erosive gastritis, moniliasis, portal hypertensive gastropathy, antral gastritis, bulb duodenitis, post band ulcer, dieulafoy, gastric polyp, and angiodysplasia). Rockall score, duration of hospital stay, and mortality incidence (33.1% vs 15.7%) were high in the elderly than young patients with P-value (< 0.001).

Conclusion

The elderly are vulnerable groups who are at high risk of adverse outcome and mortality following acute upper gastrointestinal bleeding.

Risk stratifying patients with non-varicosic upper gastrointestinal hemorrhage using the Glasgow-Blatchford score: A case series of 91 patients

Introduction

Non-variceal upper gastrointestinal hemorrhage (NVUGIH) often leads to systematic hospitalization and emergency endoscopy. However, in most cases, it does not constitute an immediate life threat. This study aimed to evaluate the Glasgow-Blatchford Score (GBS) in predicting the need for transfusions, and/or endoscopic or surgical treatments.

Materials and methods

We conducted a retrospective monocentric study including 91 patients admitted in the general surgery department of the Hospital La Rabta Tunis for a NVUGIH.

Univariate analysis was performed with the Student t-test for continuous variables and with the Chi-square test for categorical variables. For a cut-off point of 9, we calculated the sensibility and the sensitivity of the GBS to predict the need for transfusions and/or hemostatic procedure.

Results

During the study period, 91 patients were admitted for NVUGIH. Sixty-one patients (67%) were transfused. Seven patients (7.7%) underwent emergency surgery and two patients had endoscopic hemostasis.

The predictive factors for the use of transfusion and/or hemostasic treatments were: Age >50 years, ASA score, HR ≥ 90 bpm, pallor, Hb ≤ 9,5 g/dl, Urea ≥9,7 mmol/L.

For a cut-off of 9 points of the GBS, sensitivity was 85.71% and specificity 92.86%. The positive predictive value was 96%. The negative predictive value was 74%.

Conclusion

The main interest of the GBS lies in dispatching the patients between intensive care units for therapeutic intervention (if GBS> = 9) and ordinary hospitalization for surveillance (if GBS <9). It then makes it possible to rationalize the management of patients with digestive hemorrhage to identify those requiring hospital treatments (transfusion, endoscopic treatment, or surgery).

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Non variceal upper gastrointestinal bleeding often leads to systematic emergency endoscopy.

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In most cases, bleeding does not constitute an immediate life threat.

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The Glasgow-Blatschford score can be reliable to predict the need for therapeutic intervention.

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For a score inferior to nine, patients can be admitted into an ordinary unit.

Upper gastrointestinal bleeding in patients 80 years old and over. A comparison with younger patients and risk factors analysis for in-hospital and delayed mortality

INTRODUCTION

Outcomes in old patients with upper gastrointestinal bleeding (UGIB) have been scarcely studied. Our aim was to compare very old individuals (>80 years old) with younger patients with UGIB, and to identify risk factors for the main outcomes.

METHODS

A single-centre prospectively collected database was analysed. Descriptive, inferential and multivariate logistic regression models were performed. Main clinical outcomes were in-hospital and delayed 6-month mortality.

RESULTS

698 patients were included, 143 very old and 555 aged <80. Old patients differed from younger ones in comorbidities (85.9% vs. 62%, P < .0001), oral anticoagulants (32.3% vs. 12.7%; P < .0001), and antiplatelets intake (32.3% vs. 21.2%; P < .007). No differences were found in the need for endoscopic interventions, blood unit transfusions, hospital stay, in-hospital rebleeding and mortality. Among very old patients, creatinine levels were higher in those who died compared with the ones who survived (1.92 ± 1.46 vs. 1.25 ± 0.59 mg/dL; P = .002), they had lower haemoglobin levels (8.1 ± 1.4 vs. 9.1 ± 2.4 g/dL; P = .04) and longer hospital stays (17.75 ± 15.5 vs. 8.1 ± 8.4 days; P < .0001). Logistic regression showed creatinine levels (OR: 2.42; 95% CI: 1.24-4.74; P = .01), cirrhosis (OR: 2.88, 95% CI: 1.88-17.34; P = .04) and being an impatient (OR: 3.90; 95% CI: 1.11-20; P = .035) were independent risk factors for mortality in older patients. They had an increased delayed 6-month mortality compared with younger patients (17.5% vs. 8%, P = .001).

CONCLUSIONS

Creatinine levels, cirrhosis or the onset of UGIB while being an inpatient were independent risk factors for mortality in very old patients. Delayed mortality was higher among them, mostly caused by cardiovascular events and neoplasms, but not in-hospital mortality.

Risk Factors for Acute Coronary Syndrome in Upper Gastrointestinal Bleeding Patients

Background

Upper gastrointestinal bleeding (UGIB) is a common critical disease with a certain fatality rate. Acute coronary syndrome (ACS), another critical ill condition, is a regular occurrence in the UGIB. We identified risk factors for ACS in UGIB.

Methods

676 patients diagnosed with UGIB were enrolled retrospectively. We assessed the occurrence of ACS in UGIB patients and identified the risk factors for ACS by logistic regression analysis and random forest analysis.

Results

After propensity score matching (PSM), the ACS group (n = 69) and non-ACS group (n = 276) were analyzed. Logistic regression analysis showed that syncope (P = 0.001), coronary heart disease history (P = 0.001), Glasgow Blatchford score (P ≤ 0.001), Rockall risk score (P = 0.004), red blood cell distribution width (RDW) (P ≤ 0.001), total bilirubin (TBil) (P = 0.046), fibrinogen (P ≤ 0.001), and hemoglobin (P = 0.001) had important roles in ACS patients. With Mean Decrease Gini (MDG) sequencing, fibrinogen, RDW, and hemoglobin were ranked the top three risk factors associated with ACS. In ROC analysis, fibrinogen (AUC = 0.841, 95% CI: 0.779-0.903) and RDW (AUC = 0.826, 95% CI: 0.769-0.883) obtained good discrimination performance. According to sensitivity > 80%, the pAUC of fibrinogen and RDW were 0.077 and 0.101, respectively, and there was no significant difference (P = 0.326). However, according to specificity > 80%, the pAUC of fibrinogen was higher than that of RDW (0.126 vs. 0.088, P = 0.018).

Conclusion

Fibrinogen and RDW were important risk factors for ACS in UGIB. Additionally, combination with coronary heart disease, syncope, hemoglobin, and TBil played important roles in the occurrence of ACS. Meanwhile, it was also noted that Rockall score and Glasgow Blatchford score should be performed to predict the risk.

Comparison of various risk scores for the prognosis of hemorrhagic upper gastrointestinal mucosal disorder

Background

Various risk scores have been proposed that are useful for the management of upper gastrointestinal bleeding (UGIB), which is an important disease in emergency medicine. Few studies have examined the usefulness of Charlson Comorbidity index (CCI) in this disease, which evaluates the patient’s general condition by scoring the patient’s underlying disease. There have been no studies investigating the efficacy of CCI compared to other risk scores in the management of UGIB requiring endoscopic hemostasis.

Methods

In addition to the Glasgow-Blatchford score, AIMS65 score, and Rockall score, we investigated the efficacy of the outcome prediction obtained by the original CCI and the updated CCI, scored only with respect to the underlying disease. We also examined the cutoff value when using the risk score. This retrospective study included 265 patients with hemorrhagic upper gastrointestinal mucosal lesions who underwent emergency endoscopic hemostasis during a 6-year period between 2011 and 2016 in our hospital.

Results

The updated CCI and AIMS65 score correlated with prognosis in multivariate analysis (p = 0.002 and p = 0.003, respectively). In clinical practice, the prognosis might be worse if both updated CCI and AIMS65 score were 3 point or more.

Conclusion

In addition to the AIMS65 score, the updated CCI can be a useful tool for managing upper gastrointestinal mucosal disorder bleeding that requires endoscopic hemostasis.

Changing patterns of upper gastrointestinal bleeding over 23 years in Turkey

BACKGROUND/AIMS

This study aimed to compare the causes of nonvariceal upper gastrointestinal bleeding (NVUGB), demographics, risk factors, and outcomes of patients during two periods between 1993 and 2016 in a tertiary health-care center in Turkey.

MATERIALS AND METHODS

We compared the causes of NVUGB and clinical outcomes in 421 patients hospitalized between January 1993 and December 1995 with those of 231 patients with NVUGB hospitalized between January 2015 and September 2016. We also compared epidemiological characteristics, risk factors, and the rates of endoscopic hemostatic procedures.

RESULTS

We observed significant increases in patients' mean age, in the percentage of patients with comorbid conditions, and in the percentage of patients who received direct-acting oral anticoagulants before bleeding. We also observed a statistically nonsignificant increase in the diagnoses of gastric ulcer, along with a significant concordant decrease in diagnoses of duodenal ulcer as a cause of bleeding. The use of emergency surgical hemostasis decreased among cases of peptic ulcer bleeding. The overall rate of mortality from bleeding did not significantly change between the two periods.

CONCLUSION

Over the 23 years studied, the causes of NVUGB changed, probably because the population was increasingly elderly population and because of the use of anticoagulants and better therapeutic approaches to chronic duodenal ulcers. The use of emergency surgical hemostasis reduced, but mortality rate did not significantly change between the two specific periods.

Comparison of the Glasgow-Blatchford and Rockall Scores for prediction of nonvariceal upper gastrointestinal bleeding outcomes in Chinese patients

The Glasgow-Blatchford scores (GBS) and Rockall scores (RS) are commonly used for stratifying patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Although predictive value of these scoring methods has been extensively validated, their clinical effectiveness remains unclear. The following study evaluated the GBS and RS scoring system with reference to bleeding, needs for further surgery, endoscopic intervention and death, in order to verify their effectiveness and accuracy in clinical application.Patients who presented with NVUGIH, or who were consequently diagnosed with the disease (by endoscopy examination) between January 1, 2008, and December 31, 2012 were enrolled in the study. GBS and RS scores were compared to predict bleeding, the needs for further surgery, endoscopic intervention, death by ROC curves and AUC value.Among 2977 patients, the pre-endoscopic RS and complete RS score (CRS) were superior to the GBS score (AUC: 0.842 vs 0.804 vs 0.622, respectively) for predicting the mortality risk in patients. The pre-endoscopic RS score predicting re-bleeding was significantly higher than the CRS and the GBS score (AUC: 0.658 vs 0.548 vs 0.528, respectively). In addition, the 3 scoring systems revealed to be poor predictors of surgical operation effectiveness (AUC: 0.589 vs 0.547 vs 0.504, respectively).Our data demonstrated that the GBS and RS scoring systems could be used to predict outcomes in patients with nonvariceal upper gastrointestinal bleeding.

Clinical experience with ferric carboxymaltose in the management of anemia in acute gastrointestinal bleeding

OBJECTIVE

The aim of this study was to assess the efficacy and safety of intravenous ferric carboxymaltose (FCM) following hospitalization for acute gastrointestinal bleeding (AGIB) in the context of a restrictive transfusion strategy.

PATIENTS AND METHODS

A retrospective single-center study analyzed patients with AGIB (excluding AGIB secondary to portal hypertension) administered a single FCM dose with or without blood transfusion.

RESULTS

Eighty-six episodes in 84 patients were analyzed. Seventy-nine patients had upper AGIB. Nineteen episodes were associated with hemodynamic instability. FCM was administered during hospitalization as a single dose of 1000 mg iron in 84/86 episodes and as a single dose of 500 mg iron in two episodes, with blood transfusion in 60/86 (69.8%) episodes. The mean hemoglobin (Hb) was 9.0 g/dl at admission, 7.6 g/dl at the lowest in-hospital value, 9.4 g/dl at discharge, and 12.7 g/dl at follow-up (mean: 55 days postdischarge) (P<0.001 for follow-up vs. all other timepoints). The lowest mean in-hospital Hb value was 7.2 and 8.8 g/dl, respectively, in patients with transfusion+FCM versus FCM alone; the mean Hb was 12.4 versus 13.7 g/dl at follow-up. In patients administered FCM alone, the mean Hb at follow-up in the subpopulations aged older than or equal to 75 years (n=33), Charlson comorbidity index of at least 3 (n=48), and Hb of up to 10 g/dl at admission (n=47) were 12.6, 13.1, and 13.3 g/dl, respectively. No adverse effects were detected.

CONCLUSION

Treatment with FCM for AGIB is associated with a good erythropoietic response and anemia correction after hospitalization, even in severe episodes or when transfusion is needed. FCM is safe and well tolerated, and may support a restrictive transfusion policy.

Risk factors of upper gastrointestinal hemorrhage with acute coronary syndrome

BACKGROUND

Research showed that the mortality of upper gastrointestinal hemorrhage (UGH) complicated with acute coronary syndrome (ACS) was higher than single UGH in elderly patients. This study aimed to determine the risk factors that associated with an increased risk of ACS occurrence after UGH.

METHODS

A population-based nested case-control study was conducted analyzing the hospital information system database of Shengjing Hospital of China Medical University from September 1, 2009 to December 31, 2014. We included 3217 elderly patients who experienced a UGH, among which 152 cases were identified and matched 604 selected controls. Multivariate conditional logistic regression models were used to characterize risk factors associated with ACS occurrence and death after UGH.

RESULTS

Diabetes (odds ratio (OR) = 1.84, 95% confidence interval (CI) 1.13-2.71, P = 0.039), smoking (OR = 1.87, 95% CI 1.19-2.73, P = 0.028), vasopressin or terlipressin use (OR = 1.51, 95% CI 1.02-2.14, P = 0.043), liver cirrhosis (OR = 2.43, 95% CI 1.45-4.38, P = 0.013), hemoglobin level (OR = 2.36, 95% CI 1.65-3.79, P = 0.014) and history of ACS (OR = 1.98, 95% CI 1.13-3.49, P = 0.017) increased risk of ACS incidence in elderly patients with UGH. Moreover, diabetes (OR = 2.14, 95% CI 1.15-4.21, P = 0.041), smoking (OR = 2.93, 95% CI 1.17-5.31, P = 0.043) and hemoglobin levels (OR = 1.95, 95% CI 1.24-3.16, P = 0.038) were independent variables for the mortality underwent UGH with ACS in elderly patients.

CONCLUSIONS

History of diabetes, vasopressin or terlipressin use, smoking, liver cirrhosis, hemoglobin level and history of ACS are risk factors to develop ACS in elderly patients with UGH. Importantly, diabetes, smoking and lower hemoglobin level are key variables for mortality.

Prognostic Significance of Elevated Cardiac Troponin in Acute Gastrointestinal Bleeding

BACKGROUND

Acute gastrointestinal bleeding (AGIB) is responsible for over 140,000 hospitalizations annually. Cardiovascular-related deaths account for 30% of the patients surviving the initial episode of AGIB. The purpose of this study was to identify the impact of elevated troponin on short-term mortality and length of stay (LOS) of these patients.

METHODS

From July 2013 to July 2016, 290 patients admitted with a diagnosis of AGIB and who had cardiac troponin I measured within 24 h of presentation were retrospectively reviewed. Clinical variables including 30-day mortality, 30-day readmission and LOS were then compared between the groups of troponin elevation and no troponin elevation.

RESULTS

The overall 30-day mortality among patients with AGIB was 6.5% (19/290). Cardiac troponin was elevated in 10% of patients (29/290). Among patients with normal troponin, 5% (13/261) died within 30 days. In patients with troponin elevation, 21% died in the same period (6/29, P = 0.001). The LOS was also higher in patients with troponin elevation (6 vs. 5 days, P = 0.02). There was no difference in 30-day readmission among the two groups. Past history of coronary artery disease, congestive heart failure, hypertension, aspirin use and elevated creatinine was more common in patients with troponin elevation. On multivariate analysis, troponin elevation on presentation is associated with increased mortality (odds: 5.50, CI: 1.73 - 17.47, P = 0.004).

CONCLUSION

In patients admitted to the inpatient service with AGIB, elevated troponin I on presentation is associated with high short-term mortality and longer hospital stay.