Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

The role of urgent endoscopy in high-risk nonvariceal upper gastrointestinal bleeding (NVUGIB) is unclear. The aim of this study was to determine whether esophagogastroduodenoscopy (EGD) performed sooner than the currently recommended 24 h in high-risk patients presenting with NVUGIB is associated with lower all-cause in-hospital mortality.

METHODS

All adult patients undergoing EGD for the indications of coffee-grounds vomitus, hematemesis or melena at a university hospital over an 18-month period were enrolled. Patients with variceal and lower gastrointestinal bleeding were excluded. Data were prospectively collected.

RESULTS

A total of 934 patients were included. The area under the receiver operating characteristic curve (AUROC) for the Glasgow-Blatchford score (GBS) was 0.813 for predicting all-cause in-hospital mortality, with a cut-off score of ≥ 12 resulting in 90 % specificity. In low-risk patients with GBS < 12, presentation-to-endoscopy time in those who died and in those who survived was similar. In high-risk patients with GBS of ≥ 12, presentation-to-endoscopy time was significantly longer in those who died than in those who survived. Multivariate analysis of the high-risk cohort showed presentation-to-endoscopy time to be the only factor associated with all-cause in-hospital mortality. For high-risk patients, the AUROC for presentation-to-endoscopy time in predicting all-cause in-hospital mortality was 0.803, with a sensitivity of 100 % at the cut-off time of 13 h. All-cause in-hospital mortality in high-risk patients was significantly higher in those with presentation-to-endoscopy time of > 13 h compared with those undergoing endoscopy in < 13 h from presentation (44 % vs. 0 %; P < 0.001).

CONCLUSIONS

Endoscopy within 13 h of presentation was associated with lower mortality in high-risk but not low-risk NVUGIB.

Splenic tuberculosis presenting as pyrexia of unknown origin

We report a case of a previously healthy 38-year old lady who presented with prolonged fever and hepatosplenomegaly. Intensive investigations were performed for pyrexia of unknown origin which revealed negative. CT scan of the abdomen showed multiple hypodense lesions which did not respond to broad-spectrum antibiotics. Percutaneous biopsy of the splenic lesion revealed granuloma formation and Langhan's giant cells suggestive of TB. She responded well with anti- TB medication but required extended treatment duration of 24 months due to persistence of the splenic lesion on repeated CT scans. This case illustrates a very rare clinical entity of isolated splenic TB with a therapeutic dilemma following incomplete resolution, despite prolonged treatment.

Ultrasonography is not reliable in diagnosing liver cirrhosis in clinical practice

BACKGROUND

The diagnosis of liver cirrhosis is important in the evaluation and management of patients. Liver biopsy is the gold standard but it is invasive. Ultrasonography is a non-invasive and useful modality in assessing the liver for certain conditions but its sensitivity and specificity in diagnosing cirrhosis is unknown locally.

AIM

To assess the accuracy of ultrasonography in diagnosing compensated liver cirrhosis in daily clinical practice outside the context of clinical trials.

METHODS

All the liver biopsies were identified from the Pathology Logbook retrospectively from January 1998 to March 2001. Only patients who had both liver biopsy and ultrasonography with no clinical evidence of cirrhosis were included. Patients with incomplete data, hepatoma or liver secondaries were excluded. Ultrasonographic diagnosis of cirrhosis was based on nodularity or irregularity of the liver surface, small liver size, coarse echotexture and increase attenuation by using the 3.5 to 5 MHz transducers.

RESULTS

A total of 151 liver biopsies were performed during this period. Eighty-eight patients who had both ultrasound and liver biopsy were analysed. Seventeen patients had ultrasonographic diagnosis of cirrhosis but only six cases were proven by a liver biopsy. On the other hand, 10/16 cases of biopsy-proven cirrhosis were "missed" by ultrasound. Thus, the sensitivity of ultrasonography in diagnosing cirrhosis was 37.5% and the specificity was 84.7%. The positive and negative predictive values were 35.3% and 85.9% respectively.

CONCLUSION

Low frequency ultrasonography is not a sensitive test for the diagnosis of liver cirrhosis in daily clinical practice.

Risk factors for stroke and predictors of one-month mortality

BACKGROUND

Stroke is the third most common cause of death in Malaysia.The prevalence of risk factors and predictors of mortality of stroke in Malaysia are poorly understood.

AIM

To identify the prevalence of major risk factors for stroke and to determine predictors of one-month mortality.

METHOD

Prospective study of all stroke patients admitted to Penang Hospital between December 1998 and November 1999. All patients were subjected to brain CT. Predictors of one-month mortality: systolic and diastolic hypertension, hyperglycaemia, type of stroke, age > or = 70, poor Glasgow coma score (GCS) on admission and deterioration of score were assessed.

RESULTS

A total of 246 (139 male and 107 female) patients were included. Median age was 65 years. Hypertension was the commonest risk factor (71.5%) followed by diabetes mellitus (40.2%) and hyperlipidaemia (37%). 74.8% of the cases were ischaemic in origin and 25.2% haemorrhagic. Mortality at one month was 20.3%. Using multivariate analysis and logistic regression, deterioration of GCS (OR = 46.04), poor GCS on admission (OR = 12.35) and haemorrhagic stroke (OR = 3.45) were independent predictors of one-month mortality.

CONCLUSION

Hypertension and diabetes mellitus are the commonest risk factors of stroke among patients admitted to a tertiary hospital in Malaysia. Significant predictors of one-month mortality include the admission GCS, deterioration of GCS and haemorrhagic stroke.