Epidemiology of acute upper gastrointestinal bleeding

Consensus and controversies in platelet transfusion

Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.

Changing trends in acute upper-GI bleeding: a population-based study

BACKGROUND

Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear.

OBJECTIVE

To analyze the time trends of UGIB in 2 different management eras.

DESIGN

Prospective observational study.

SETTING

General university-affiliated hospital.

PATIENTS AND INTERVENTIONS

A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period.

RESULTS

The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%).

LIMITATIONS

A single-center study and a potential lack of generalizability.

CONCLUSIONS

From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.

Refractory peptic ulcer disease

Refractory PUD is a diagnostic and therapeutic challenge. Optimal management of severe or refractory PUD requires a multidisciplinary team approach, using primary care providers, gastroenterologists, and general surgeons. Medical management has become the cornerstone of therapy. Identification and eradication of H pylori infection combined with acid reduction regimens can heal ulceration and also prevent recurrence. Severe, intractable or recurrent PUD and associated complications mandates a careful and methodical evaluation and management strategy to determine the potential etiologies and necessary treatment (medical or surgical) required.

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

AIM: To identify clinical parameters, and develop an Upper Gastrointesinal Bleeding (UGIB) Etiology Score for predicting the types of UGIB and validate the score.

METHODS: Patients with UGIB who underwent endoscopy within 72 h were enrolled. Clinical and basic laboratory parameters were prospectively collected. Predictive factors for the types of UGIB were identified by univariate and multivariate analyses and were used to generate the UGIB Etiology Score. The best cutoff of the score was defined from the receiver operating curve and prospectively validated in another set of patients with UGIB.

RESULTS: Among 261 patients with UGIB, 47 (18%) had variceal and 214 (82%) had non-variceal bleeding. Univariate analysis identified 27 distinct parameters significantly associated with the types of UGIB. Logistic regression analysis identified only 3 independent factors for predicting variceal bleeding; previous diagnosis of cirrhosis or signs of chronic liver disease (OR 22.4, 95% CI 8.3-60.4, P < 0.001), red vomitus (OR 4.6, 95% CI 1.8-11.9, P = 0.02), and red nasogastric (NG) aspirate (OR 3.3, 95% CI 1.3-8.3, P = 0.011). The UGIB Etiology Score was calculated from (3.1 × previous diagnosis of cirrhosis or signs of chronic liver disease) + (1.5 × red vomitus) + (1.2 × red NG aspirate), when 1 and 0 are used for the presence and absence of each factor, respectively. Using a cutoff ≥ 3.1, the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. The score was prospectively validated in another set of 195 UGIB cases (46 variceal and 149 non-variceal bleeding). The PPV and NPV of a score ≥ 3.1 for variceal bleeding were 79% and 97%, respectively.

CONCLUSION: The UGIB Etiology Score, composed of 3 parameters, using a cutoff ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy.

Dietary and socio-economic factors in relation to Helicobacter pylori re-infection

AIM: To examine if dietary and socio-economic factors contribute to Helicobacter pylori (H pylori) re-infection.

METHODS: The population of patients consisted of subjects in whom H pylori infection had been successfully treated in the past. Patients were divided into two groups: I-examined group (111 persons with H pylori re-infection) and II-control group (175 persons who had not been re-infected). The respondents were interviewed retrospectively on their dietary habits and socio-economic factors.

RESULTS: A statistically significant lower frequency of fermented dairy products (P < 0.0001), vegetables (P = 0.02), and fruit (P = 0.008) consumption was noted among patients with H pylori re-infection as compared to those who had not been re-infected.

CONCLUSION: High dietary intake of probiotic bacteria, mainly Lactobacillus, and antioxidants, mainly vitamin C (contained in fruit and vegetables), might decrease the risk of H pylori re-infection.

Identification of Helicobacter pylori infected patients, using administrative data

BACKGROUND

Helicobacter pylori is a prevalent organism implicated in peptic ulcer disease.

AIM

To validate administrative data for diagnosis of H. pylori-infected patients.

METHODS

Administrative data identified patients with ICD-9 code for H. pylori (041.86) or prescription of eradication therapy; diagnosis was confirmed by chart abstraction. Multivariable regression assessed predictors of infection considering drug therapy, ICD-9 code 041.86, procedure code, in-patient or out-patient diagnostic code, age, gender and race to generate an algorithm for validation.

RESULTS

The test cohort of 531 patients (361 potential cases; 170 random controls) was primarily male (94%), Caucasian (59%) and elderly [67 years (s.d. 10)]. The positive predictive value (PPV) of ICD-9 code 041.86 was 100% and 97.4% if from an in-patient or out-patient encounter, respectively. Eradication drug therapy had a PPV of 73.7% (triple therapy) and 97.7% (quadruple therapy). The strongest predictors were out-patient ICD-9 code 041.86 (OR 8.1; 95% CI: 7.0-9.1); eradication drug therapy (OR 7.4; 95% CI: 6.6-8.3); oesophagogastroduodenoscopy (OR 3.5; 95% CI: 3.3-3.6); and age > or =70 (OR 1.2; 95% CI: 1.1-1.4). An algorithm including these data elements yielded a c-statistic of 0.93 and PPV of 97.9%.

CONCLUSIONS

Administrative data can diagnose H. pylori-infected patients. The diagnostic algorithm includes presence of eradication drug therapy overlapping with an out-patient ICD-9 code 041.86 among elderly adults.

Antifibrinolytic amino acids for acquired coagulation disorders in patients with liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities, which include accelerated fibrinolysis. Several primary treatments are used for upper gastrointestinal bleeding in patients with liver diseases. Supplementary interventions are often used as well. One of them could be antifibrinolytic amino acids administration.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2006), MEDLINE (1950 to March 2006), EMBASE (1980 to March 2006), Science Citation Index EXPANDED (1945 to March 2006), LILACS (1982 to March 2006), ClinicalTrials.gov (at www.clinicaltrials.gov) (accessed August 2006), ISI Web of Science (April 2006), and the International Standard Randomised Controlled Trial Number Register (at http://controlled-trials.com/isrctn/search.asp) (accessed August 2006). We also checked the reference lists of all the trials identified by the above methods.

SELECTION CRITERIA

We searched for randomised clinical trials irrespective of blinding, language, or publication status.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials with antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

AUTHORS' CONCLUSIONS

We were unable to identify randomised clinical trials on the safety and efficacy of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with liver disease (acute or chronic) plus acquired coagulation disorders. The effects of antifibrinolytic amino acids has to be tested in randomised clinical trials.