Management of patients with ulcer bleeding

Gastrointestinal bleeding and anticoagulant or antiplatelet drugs: systematic search for clinical practice guidelines

Gastrointestinal (GI) bleeding is a frequently encountered and very serious problem in emergency room patients who are currently being treated with anticoagulant or antiplatelet medications. There is, however, a lack of clinical practice guidelines about how to respond to these situations. The goal of this study was to find published articles that contain specific information about how to safely adjust anticoagulant and antiplatelet therapy when GI bleeding occurs.The investigators initiated a global search on the PubMed and Google websites for published information about GI bleeding in the presence of anticoagulant or antiplatelet therapy. After eliminating duplicate entries, the medical articles that remained were screened to narrow the sets of articles to those that met specific criteria. Articles that most closely matched study criteria were analyzed in detail and compared to determine how many actual guidelines exist and are useful.We could provide only minimal information about appropriate therapeutic strategies because no articles provided sufficient specific advice about how to respond to situations involving acute GI bleeding and concurrent use of anticoagulant or antiplatelet drugs. Only 4 articles provided enough detail to be of any use in an emergency situation.Clinical practice guidelines and also clinical trials for GI hemorrhaging should be expanded to state in which situations the use of anticoagulant or antiplatelet drugs should be suspended and the medications should later be resumed, and they should state the level of risk for any particular action.

Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.

Endoscopic management of acute peptic ulcer bleeding

This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis

IMPORTANCE

Current guidelines recommend an intravenous bolus dose of a proton pump inhibitor (PPI) followed by continuous PPI infusion after endoscopic therapy in patients with high-risk bleeding ulcers. Substitution of intermittent PPI therapy, if similarly effective as bolus plus continuous-infusion PPI therapy, would decrease the PPI dose, costs, and resource use.

OBJECTIVE

To compare intermittent PPI therapy with the currently recommended bolus plus continuous-infusion PPI regimen for reduction of ulcer rebleeding.

DATA SOURCES

Searches included MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases through December 2013; US and European gastroenterology meeting abstracts from 2009 to 2013; and bibliographies of systematic reviews.

STUDY SELECTION

Randomized trials of patients with endoscopically treated high-risk bleeding ulcers (active bleeding, nonbleeding visible vessels, and adherent clots) comparing intermittent doses of PPIs and the currently recommended regimen (80-mg intravenous bolus dose of a PPI followed by an infusion of 8 mg/h for 72 hours).

DATA EXTRACTION AND SYNTHESIS

Duplicate independent data extraction and risk-of-bias assessment were performed. Data were pooled using a fixed-effects model or a random effects model if statistical heterogeneity was present.

MAIN OUTCOMES AND MEASURES

The primary outcome was rebleeding within 7 days; additional predefined outcomes included rebleeding within 3 and 30 days, need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay. The primary hypothesis, defined before initiation of the literature review, was that intermittent use of PPIs was noninferior to bolus plus continuous infusion of PPIs, with the noninferiority margin predefined as an absolute risk difference of 3%.

RESULTS

The risk ratio of rebleeding within 7 days for intermittent vs bolus plus continuous infusion of PPIs was 0.72 (upper boundary of 1-sided 95% CI, 0.97) and the absolute risk difference was -2.64% (upper boundary of 1-sided 95% CI, -0.28%, which is well below the predefined noninferiority margin of 3%). Risk ratios for rebleeding within 30 days and 3 days, mortality, and urgent interventions were less than 1 and mean differences for blood transfusion and hospital length of stay were less than 0, indicating that no summary estimate showed an increased risk with intermittent therapy. The upper boundaries of 95% CIs for absolute risk differences were less than 1.50% for all predefined rebleeding outcomes.

CONCLUSIONS AND RELEVANCE

Intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. Guidelines should be revised to recommend intermittent PPI therapy.

Upper gastrointestinal active bleeding ulcers: review of literature on the results of endoscopic techniques and our experience with Hemospray

INTRODUCTION AND OBJECTIVES

Acute gastrointestinal (GI) bleeding can lead from mild to immediately life-threatening clinical conditions. Upper GI bleeding (UGIB) is associated with a mortality of 6-10%. Spurting and oozing bleeding are associated with major risk of failure. Hemospray™ (TC-325), a new hemostatic powder, may be useful in these cases. Aim of this study is to review the efficacy of traditional endoscopic treatment in Forrest 1a-1b ulcers and to investigate the usefulness of Hemospray in these patients.

PATIENTS AND METHODS

A MEDLINE search was performed and articles that evaluated hemostatic efficacy and rebleeding rate with traditional endoscopic techniques related to Forrest classification were reviewed. Patients with Forrest 1a-1b ulcers were treated with Hemospray, either as monotherapy or in association with other endoscopic techniques. Primary outcome was immediate hemostasis, secondary outcomes were recurrent bleeding and adverse events related to Hemospray use.

RESULTS

Analysis of literature showed that mean initial hemostasis success rate in Forrest 1a-1b ulcers was of 92.8%, and mean rebleeding rate was of 13.3%. We enrolled 13 patients treated with Hemospray. Initial hemostasis was achieved in 100% and we reported three cases of rebleeding. No adverse events occurred.

CONCLUSION

Forrest 1a-1b bleeding ulcer is very difficult to treat. Hemospray appears to be an effective hemostatic therapy for these ulcers. However, additional prospective studies are needed to validate these findings.

A national survey on the initial management of upper gastrointestinal bleeding

GOALS

To evaluate the initial management of upper gastrointestinal (GI) bleeding in the United States.

BACKGROUND

Various guidelines have addressed the initial management of upper GI bleeding, but the extent to which these guidelines are followed in clinical practice is unknown.

STUDY

We conducted a national survey of emergency physicians, internists, and gastroenterologists practicing in hospitals affiliated with an ACGME-accredited gastroenterology fellowship. Participants rated their agreement and adherence to 9 preendoscopic quality indicators for the initial management of upper GI bleeding. Awareness, use, and barriers to the use of early prognostic risk scores were also assessed.

RESULTS

A total of 1402 surveys were completed, with an estimated response rate of 11.3%. Gastroenterologists and trainees agreed with the quality indicators more than nongastroenterologists and attending physicians, respectively. There was no difference in the application of the quality indicators by specialty or clinical position. Among all physicians, 53% had ever heard of and 30% had ever used an upper GI bleeding risk score. More gastroenterologists than nongastroenterologists had heard of (82% vs. 44%, P<0.001) and used (51% vs. 23%, P<0.001) a risk score. There was no difference between attending physicians and trainees. Gastroenterologists and attending physicians more often cited lack of utility as a reason to not use risk scores, whereas nongastroenterologists and trainees more often cited lack of knowledge.

CONCLUSIONS

Among emergency physicians, internists, and gastroenterologists in the United States, agreement with upper GI bleeding initial management guidelines was high but adherence--especially pertaining to the use of risk scores--was low.

Nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastrointestinal bleeding and understand therapeutic modalities available in achieving hemostasis. This article summarizes guidelines in management of acute nonvariceal upper gastrointestinal bleeding and reviews recent advances in the field.

RECENT FINDINGS

Recent study showed that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days. Endoscopic therapy should be performed on actively bleeding ulcers and ulcers with visible vessel or adherent clot. An over-the-scope clip is a novel device that can be used to achieve hemostasis. It may be a useful tool for achieving hemostasis for patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy. Doppler ultrasound probe can evaluate arterial flow to the ulcer and identify ulcers that are at high risk of rebleeding.

SUMMARY

Upper gastrointestinal bleeding from peptic ulcer disease is not a new clinical problem. Yet, the approach to management continues to evolve with the accumulation of data and well designed studies on the subject.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers

BACKGROUND

Endoscopic therapy reduces the rebleeding rate and the need for surgery in patients with bleeding peptic ulcers.

OBJECTIVES

To determine whether a second procedure improves haemostatic efficacy or patient outcomes or both after epinephrine injection in adults with high-risk bleeding ulcers.

SEARCH METHODS

For our update in 2014, we searched the following versions of these databases, limited from June 2009 to May 2014: Ovid MEDLINE(R) 1946 to May Week 2 2014; Ovid MEDLINE(R) Daily Update May 22, 2014; Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations May 22, 2014 (Appendix 1); Evidence-Based Medicine (EBM) Reviews-the Cochrane Central Register of Controlled Trials (CENTRAL) April 2014 (Appendix 2); and EMBASE 1980 to Week 20 2014 (Appendix 3).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing epinephrine alone versus epinephrine plus a second method. Populations consisted of patients with high-risk bleeding peptic ulcers, that is, patients with haemorrhage from peptic ulcer disease (gastric or duodenal) with major stigmata of bleeding as defined by Forrest classification Ia (spurting haemorrhage), Ib (oozing haemorrhage), IIa (non-bleeding visible vessel) and IIb (adherent clot) (Forrest Ia-Ib-IIa-IIb).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration. Meta-analysis was undertaken using a random-effects model; risk ratios (RRs) with 95% confidence intervals (CIs) are presented for dichotomous data.

MAIN RESULTS

Nineteen studies of 2033 initially randomly assigned participants were included, of which 11 used a second injected agent, five used a mechanical method (haemoclips) and three employed thermal methods.The risk of further bleeding after initial haemostasis was lower in the combination therapy groups than in the epinephrine alone group, regardless of which second procedure was applied (RR 0.53, 95% CI 0.35 to 0.81). Adding any second procedure significantly reduced the overall bleeding rate (persistent and recurrent bleeding) (RR 0.57, 95% CI 0.43 to 0.76) and the need for emergency surgery (RR 0.68, 95% CI 0.50 to 0.93). Mortality rates were not significantly different when either method was applied.Rebleeding in the 10 studies that scheduled a reendoscopy showed no difference between epinephrine and combined therapy; without second-look endoscopy, a statistically significant difference was observed between epinephrine and epinephrine and any second endoscopic method, with fewer participants rebleeding in the combined therapy group (nine studies) (RR 0.32, 95% CI 0.21 to 0.48).For ulcers of the Forrest Ia or Ib type (oozing or spurting), the addition of a second therapy significantly reduced the rebleeding rate (RR 0.66, 95% CI 0.49 to 0.88); this difference was not seen for type IIa (visible vessel) or type IIb (adherent clot) ulcers. Few procedure-related adverse effects were reported, and this finding was not statistically significantly different between groups. Few adverse events occurred, and no statistically significant difference was noted between groups.The addition of a second injected method reduced recurrent and persistent rebleeding rates and surgery rates in the combination therapy group, but these findings were not statistically significantly different. Significantly fewer participants died in the combined therapy group (RR 0.50, 95% CI 0.25 to 1.00).Epinephrine and a second mechanical method decreased recurrent and persistent bleeding (RR 0.31, 95% CI 0.18 to 0.54) and the need for emergency surgery (RR 0.20, 95% CI 0.06 to 0.62) but did not affect mortality rates.Epinephrine plus thermal methods decreased the rebleeding rate (RR 0.49, 95% CI 0.30 to 0.78) and the surgery rate (RR 0.20, 95% CI 0.06 to 0.62) but did not affect the mortality rate.Our risk of bias estimates show that risk of bias was low, as, although the type of study did not allow a double-blind trial, rebleeding, surgery and mortality were not dependent on subjective observation. Although some studies had limitations in their design or implementation, most were clear about important quality criteria, including randomisation and allocation concealment, sequence generation and blinding.

AUTHORS' CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding and the need for surgery in patients with high-risk bleeding peptic ulcer. The main adverse events include risk of perforation and gastric wall necrosis, the rates of which were low in our included studies and favoured neither epinephrine therapy nor combination therapy. The main conclusion is that combined therapy seems to work better than epinephrine alone. However, we cannot conclude that a particular form of treatment is equal or superior to another.

Randomised clinical trial: prevention of recurrence of peptic ulcers by rabeprazole in patients taking low-dose aspirin

BACKGROUND

Few studies have evaluated the effects of rabeprazole on low-dose aspirin (LDA)-induced gastroduodenal injuries.

AIM

To conduct a randomised, double-blind, triple-dummy, active-controlled, multicentre trial, named the PLANETARIUM study, to assess the efficacy, dose-response relationship and safety of rabeprazole for peptic ulcer recurrence in Japanese patients on long-term LDA therapy.

METHODS

Eligible patients had a history of endoscopically confirmed peptic ulcers and were receiving long-term LDA (81 or 100 mg/day) therapy for cardiovascular or cerebrovascular protection. Subjects were randomly segregated into three groups receiving rabeprazole 10 mg once daily (standard dose in Japan), rabeprazole 5 mg once daily, or teprenone (geranylgeranylacetone; mucosal protective agent commercially available in Japan) 50 mg three times per day as an active control. The primary endpoint was recurrence of peptic ulcers over 24 weeks.

RESULTS

Among 472 randomised subjects, 452 subjects (n = 151, 150, 151, respectively) constituted the full analysis set. The cumulative recurrence rates of peptic ulcers over 24 weeks in the 10- and 5-mg rabeprazole groups were 1.4% and 2.8%, respectively, both of which were significantly lower than that in the teprenone group (21.7%). The cumulative occurrence rate of bleeding ulcers over 24 weeks in the teprenone group was 4.6%, while bleeding ulcers were not observed in the 10- or 5-mg rabeprazole groups. Rabeprazole was well tolerated at both doses.

CONCLUSION

Rabeprazole prevents the recurrence of peptic ulcers with no evidence of a major dose-response effect in subjects on low-dose aspirin therapy.

Completion rate of small bowel capsule endoscopy is higher after erythromycin compared to domperidone

Background

In up to 30 percent of small bowel capsule endoscopy procedures, the capsule does not reach the cecum within recording time. A prolonged gastric transit time has been recognized as a risk factor for incomplete capsule endoscopy. The aim of this study was to analyze if a single dose of orally administered erythromycin prior to capsule endoscopy results in a higher completion rate compared to orally administered domperidone.

Methods

Single centre, non-concurrent prospective cohort study, 649 capsule endoscopy procedures were included. Cecal completion rates, gastric and small bowel transit times and diagnostic yield were analyzed.

Results

239 patients received erythromycin, 410 patients received domperidone. The cecal completion rate was 86% after erythromycin versus 80% after domperidone (p = 0.03). After excluding known risk factors for incomplete capsule endoscopy such as hospitalization and previous abdominal surgery, erythromycin still resulted in an increased completion rate (p = 0.04). Median gastric transit time was lower after erythromycin compared to domperidone (13 min versus 22 min, p < 0.001). Median small bowel transit times were similar in both groups (236 min versus 248 min, p = 0.21).

Conclusions

In this study, the largest to date on this subject, the cecal completion rate was higher with erythromycin than with domperidone, but there was no difference in the diagnostic yield.

Evidence-based review of gastrointestinal bleeding in the chronic kidney disease patient

Patients with end-stage renal disease are more likely to suffer from gastrointestinal (GI) problems, including bleeding from upper and lower sources. Peptic ulcer disease is the most common cause of upper GI bleeding, and although there is some debate in the literature regarding whether the frequency of ulcer disease is higher in patients with kidney disease, it is well established that outcomes are worse in patients with compromised renal function. Angioectasias can be found throughout the GI tract and are another common cause of bleeding; management can be divided into localized endoscopic therapy and systemic hormonal treatment, or surgery for refractory cases. The most frequent causes of lower GI bleeding in this population, in addition to angioectasias, are diverticulosis, hemorrhoids, and ischemic colitis.

Endoscopic haemostasis: an overview of procedures and clinical scenarios

Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.

Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study

BACKGROUND

Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified.

OBJECTIVE

To assess clinical outcomes of NVUGIB and identify predictors of mortality from NVUGIB in patients with in-hospital bleeding compared with outpatients.

DESIGN

Secondary analysis of prospectively collected data from 2 nationwide multicenter databases. Descriptive, inferential, and multivariate logistic regression models were carried out in 338 inpatients (68.6 ± 16.4 years of age, 68% male patients) and 1979 outpatients (67.8 ± 17 years of age, 66% male patients). A predictive model was constructed using the risk factors identified at multivariate analysis, weighted according to the contribution of each factor.

SETTINGS

A total of 23 Italian community and tertiary care centers.

PATIENTS

Consecutive patients admitted for acute NVUGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Recurrent bleeding, surgery, and 30-day mortality.

RESULTS

The mortality rate in patients with in-hospital bleeding was significantly higher than that in outpatients (8.9% vs 3.8%; odds ratio [OR] 2.44; 95% confidence interval [CI], 1.57-3.79; P < .0001). Hemodynamic instability on presentation (OR 7.31; 95% CI, 2.71-19.65) and the presence of severe comorbidity (OR 6.72; 95% CI, 1.87-24.0) were the strongest predictors of death for in-hospital bleeders. Other independent predictors of mortality were a history of peptic ulcer disease and failed endoscopic treatment. Rebleeding was a strong predictor of death only for outpatients (OR 5.22; 95% CI, 2.45-11.10). Risk factors had a different prognostic impact on the 2 populations, resulting in a significantly different prognostic accuracy of the model (area under the receiver-operating characteristic curve = 0.83; 95% CI, 0.77-0-93 vs 0.74; 95% CI, 0.68-0.80; P < .02).

LIMITATIONS

Study design not experimental, no data on ward specialty, potential referral bias.

CONCLUSIONS

In-hospital bleeders have a significantly higher risk of death because they are sicker and more often hemodynamically unstable than outpatients. Predictors of death have a different impact in the 2 populations.

Low adherence to Helicobacter pylori testing in hospitalized patients with bleeding peptic ulcer disease

BACKGROUND

Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing.

MATERIALS AND METHODS

Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined.

RESULTS

Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed (OR = 5.1, 95% CI 2.3-11.5; p < .0001).

CONCLUSIONS

Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes.

Gastrointestinal ulcers, role of aspirin, and clinical outcomes: pathobiology, diagnosis, and treatment

Peptic ulcer disease is a major cause of morbidity and mortality in the US with more than six million diagnoses annually. Ulcers are reported as the most common cause of hospitalization for upper gastrointestinal (GI) bleeding and are often a clinical concern due to the widespread use of aspirin and nonsteroidal anti-inflammatory drugs, both of which have been shown to induce ulcer formation. The finding that Helicobacter pylori infection (independent of aspirin use) is associated with the development of ulcers led to a more thorough understanding of the causes and pathogenesis of ulcers and an improvement in therapeutic options. However, many patients infected with H. pylori are asymptomatic and remain undiagnosed. Complicating matters is a current lack of understanding of the association between aspirin use and asymptomatic ulcer formation. Low-dose aspirin prescriptions have increased, particularly for cardioprotection. Unfortunately, the GI side effects associated with aspirin therapy continue to be a major complication in both symptomatic and asymptomatic patients. These safety concerns should be important considerations in the decision to use aspirin and warrant further education. The medical community needs to continue to improve awareness of aspirin-induced GI bleeding to better equip physicians and improve care for patients requiring aspirin therapy.

Correlation of gastric heterotopia and Meckel's diverticular bleeding in children: a unique association

PURPOSE

Meckel's diverticular bleeding is the commonest cause of major gastrointestinal (GI) haemorrhage in children. We hypothesise that gastric heterotopia (GH) is associated with increased risk of bleeding and, therefore, may affect initial management.

METHODS

Paediatric patients with histological diagnosis of Meckel's diverticulum (MD) following diverticulectomy from 1995 to 2011 were reviewed retrospectively, focusing on histological correlation to bleeding. GH identified on histology was regarded as GH+, and where GH was not found was regarded as GH-. Two-tailed Chi-square test and Fisher's exact test were used, p < 0.05 was statistically significant.

RESULTS

Thirty-nine patients underwent Meckel's diverticulectomy. The number of patients with GH+, GH-, and bowel necrosis were 21, 15, and 3. Eighteen children with MD had GI bleeding. GI bleeding was more commonly associated with GH+ (14/21) than GH- (4/15) (67 vs 27 %, p = 0.02). Further analysis revealed all four GH- bleeding originated from other sources than the MD. GH+ had no significant association with other presentations. GH+ was present in 8/8 (100 %) positive Meckel's scans and 2/5 (40 %) negative scans. Meckel's scan had a sensitivity of 8/10 (80 %), and specificity of 3/3 (100 %).

CONCLUSION

This study confirmed that GH positive MD is a unique entity presenting typically with GI bleeding.

Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: implications for early discharge?

BACKGROUND

There is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding.

AIMS

Identify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death).

METHODS

Secondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis.

RESULTS

Out of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoy's lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome.

CONCLUSIONS

The "good luck score" may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.

Reduced hemoglobin and increased C-reactive protein are associated with upper gastrointestinal bleeding

AIM: To investigate the early upper gastrointestinal endoscopy (endoscopy) significantly reduces mortality resulting from upper gastrointestinal (GI) bleeding.

METHODS: Upper GI bleeding was defined as 1a, 1b, 2a, and 2b according to the Forrest classification. The hemoglobin (Hb), and C-reactive protein (CRP) were examined at around the day of endoscopy and 3 mo prior to endoscopy. The rate of change was calculated as follows: (the result of blood examination on the day of endoscopy - the results of blood examination 3 mo prior to endoscopy)/(results of blood examination 3 mo prior to endoscopy). Receiver operating characteristic curves were created to determine threshold values.

RESULTS: Seventy-nine men and 77 women were enrolled. There were 17 patients with upper GI bleeding: 12 with a gastric ulcer, 3 with a duodenal ulcer, 1 with an acute gastric mucosal lesion, and 1 with gastric cancer. The area under the curve (AUC), threshold, sensitivity, and specificity of Hb around the day of endoscopy were 0.902, 11.7 g/dL, 94.1%, and 77.1%, respectively, while those of CRP were 0.722, 0.5 mg/dL, 70.5%, and 73%, respectively. The AUC, threshold, sensitivity, and specificity of the rate of change of Hb were 0.851, -21.3%, 76.4%, and 82.6%, respectively, while those of CRP were 0.901, 100%, 100%, and 82.5%, respectively.

CONCLUSION: Predictors for upper GI bleeding were Hb < 11.7 g/dL, reduction rate in the Hb > 21.3% and an increase in the CRP > 100%, 3 mo before endoscopy.

Epidemiological Clinical Features and Evolution of Gastroduodenal Ulcer Bleeding in a Tertiary Care Hospital in Spain, during the Last Seven Years

Background. Gastroduodenal ulcer bleeding is a common medical emergency. The aim of this study was to analyze the characteristics of bleeding episodes and to identify changes in the clinical trends over seven years. Methods. Retrospective observational clinical study on a cohort of 272 consecutive adult patients with peptic ulcer bleeding, during the 2006–2012 period. Results. Mean annual admission rate was 12.8 per 100.000 inhabitants. Men were predominant (71%), with a mean age of 66.6 years. Comorbidities were present in 131 cases (48.2%) and 156 patients (57.4%) had received ulcerogenic drugs. Duodenal ulcer was the commonest location (61%). Endoscopic therapy was necessary in 183 cases (67.3%) and rebleeding occurred in 30 patients (11%). Overall mortality rate was 5.5%, with a significant association with the presence of comorbidities (P < 0.01). There were no differences in trends of annual hospitalization, clinical features at presentation, and outcomes during this 7-years period. Conclusions. Annual hospitalization rates and prognosis of peptic ulcer bleeding have remained unchanged in the study period. This may be due to the fact that the effect of improved approach on this condition is probably counteracted by risk factors such as older age, severe comorbidities, and ulcerogenic drugs consumption, which have also remained stable over recent years.

Impact of anti-aggregant, anti-coagulant and non-steroidal anti-inflammatory drugs on hospital outcomes in patients with peptic ulcer bleeding

BACKGROUND/AIMS

There are a limited number of studies including the impact of antiplatelet drugs use on hospital outcomes for nonvariceal upper gastrointestinal bleeding. The aim of this study was to determine the effect of anti-aggregant, anti-coagulant and non-steroidal anti-inflammatory drugs upon hospital outcomes in patients with peptic ulcer bleeding.

MATERIALS AND METHODS

The patients under treatment with antiaggregant, anticoagulant or non-steroidal anti-inflammatory drugs were categorized as exposed group (n = 118) and the patients who were not taking any of these drugs were categorized as non-exposed group (n = 81). We analyzed the data of drug intake, comorbid disease, blood transfusion, duration of hospital stay, Blatchford/total Rockall score and diagnosis of patients.

RESULTS

In total, 199 patients were included. Of these 59.3% (exposed group) were taking drugs. The patients in exposed group were significantly older than those in non-exposed group (62.9 ± 17.3 years; 55.5 ± 19.3 years, P = 0.005, respectively). Mean number of red blood cell units transfused (2.21 ± 1.51; 2.05 ± 1.87, P = 0.5), duration of hospital stay (3.46 ± 2.80 days; 3.20 ± 2.30 days, P = 0.532) and gastric ulcer rate (33% vs 23.4%, P = 0.172) were higher in exposed group than in non-exposed group but the differences were not statistically significant. Total Rockall and Blatchford scores of the patients were significantly higher in exposed group than in non-exposed group (3.46 ± 1.72 vs 2.94 ± 1.87, P = 0.045; 10.29 ± 3.15 vs 9.31 ± 3.40, P = 0.038).

CONCLUSION

Our study has shown that anticoagulants, antiaggregants and nonsteroidal anti-inflammatory drugs do not effect duration of hospital stay, red blood cell transfusion requirement and rebleeding for peptic ulcer bleeding.

Low-dose aspirin and comorbidities are significantly related to bleeding peptic ulcers in elderly patients compared with nonelderly patients in Japan

OBJECTIVE

The present study was conducted using data accumulated from our earlier study of bleeding peptic ulcers, focusing on elderly patients.

METHODS

A total of 461 patients with bleeding peptic ulcers underwent emergency endoscopy at Saga Medical School Hospital between 1999 and 2011. Risk factors for bleeding peptic ulcers were compared between two groups: an elderly group (≥65 years old) and a nonelderly group (<65 years old). The relationship between drug use and age was examined using multiple logistic regression models. In the elderly group, the factors were compared between Period I (1999-2005) and Period II (2006-2011).

RESULTS

The proportion of men and the incidence of Helicobacter pylori infection were lower in the elderly group than in the nonelderly group. The use of low-dose aspirin, antithrombotic drugs and corticosteroids, but not nonsteroidal anti-inflammatory drugs, was higher in the elderly group. A multiple logistic regression analysis of prescribed medications indicated that low-dose aspirin was more frequently used in the elderly group. The rate of comorbidities was higher and the hemoglobin levels were lower in the elderly group. The rates of rebleeding within one week and death within one month did not differ in the elderly group. Compared with that observed in Period I, the incidence of Helicobacter pylori infection was decreased and the rate of comorbidities was increased in Period II.

CONCLUSION

This study indicates that factors related to bleeding peptic ulcers in elderly patients have shifted from Helicobacter pylori infection to comorbidities associated with low-dose aspirin, suggesting a close relationship between low-dose aspirin therapy and comorbidities in elderly patients with peptic ulcers.

Optimum duration of regimens for Helicobacter pylori eradication

BACKGROUND

The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta-analysis to investigate the optimal duration of multiple H. pylori eradication regimens.

OBJECTIVES

The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori. The primary outcome was H. pylori persistence. The secondary outcome was adverse events.

SEARCH METHODS

The Cochrane Library, MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search.

SELECTION CRITERIA

Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded.

DATA COLLECTION AND ANALYSIS

Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random-effects model was used. Subgroup analyses and sensitivity analyses were planned a priori.

MAIN RESULTS

In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth-based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H2-receptor antagonist (H₂RA) bismuth quadruple therapy (n = 3), H₂RA bismuth-based triple therapy (n = 2), H₂RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations.For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylori eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations.Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H₂RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data.

AUTHORS' CONCLUSIONS

Increasing the duration of PPI-based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens.

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed.

METHODS

A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding.

RESULTS

Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding.

CONCLUSION

An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.

Management of GI emergencies: peptic ulcer acute bleeding

Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.

Role of proton pump inhibitors in the occurrence and the prognosis of spontaneous bacterial peritonitis in cirrhotic patients with ascites

BACKGROUND

Proton pump inhibitors (PPIs) facilitate intestinal bacterial translocation. No robust data exist demonstrating that PPIs increase the risk of spontaneous bacterial peritonitis (SBP) and that PPIs worsen the prognosis of SBP patients. PPI use might be unsuitable for cirrhotic patients.

AIMS

To analyse: (i) the role of PPIs in the occurrence of SBP in cirrhotic patients; (ii) their impact on the prognosis of SBP patients; and (iii) the suitability of their use.

METHODS

In this retrospective case-control study, PPI use was first assessed in cirrhotic patients consecutively admitted with SBP (group I) and in a control group that included the same number of uninfected cirrhotic patients with ascites (group II). Afterwards, the impact of PPIs on SBP was assessed in group I by comparing survival of patients with and without PPIs.

RESULTS

A total of 102 patients were included, 51 in each group. (i) SBP patients were more frequently treated by PPIs than controls (49 vs. 25%, P = 0.014). (ii) In group I, patients with (n = 25) and without (n = 26) PPIs had similar survival rates at 1 month (64.0 ± 9.6% vs. 59.4 ± 10.0%), 3 months (41.2 ± 10.2% vs. 44.6 ± 10.6%), and 1 year (26.6 ± 9.6% vs. 28.9 ± 10.1%), and similar median age at death (53 vs. 57 years). (iii) The reason for PPI use was inappropriate or undocumented in 34% of group I and II.

CONCLUSIONS

Proton pump inhibitors were more frequently used in SBP patients than in controls, but did not influence the prognosis in SBP. Overuse of PPIs was encountered in one-third of cirrhotic patients and should be avoided.

Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management

Acute upper gastrointestinal bleeding (UGIB) is the most common reason that the 'on-call' gastroenterologist is consulted. Despite the diagnostic and therapeutic capabilities of upper endoscopy, there is still significant associated morbidity and mortality in patients experiencing acute UGIB, thus this is a true GI emergency. Acute UGIB is divided into non-variceal and variceal causes. The most common type of acute UGIB is 'non-variceal' and includes diagnoses such as peptic ulcer (gastric and duodenal), gastroduodenal erosions, Mallory-Weiss tears, erosive oesophagitis, arterio-venous malformations, Dieulafoy's lesion, and upper GI tract tumours and malignancies. This article focuses exclusively on initial management strategies for acute upper GI bleeding. We discuss up to date and evidence-based strategies for patient risk stratification, initial patient management prior to endoscopy, potential causes of UGIB, role of proton pump inhibitors, prokinetic agents, prophylactic antibiotics, vasoactive pharmacotherapies, and timing of endoscopy.

Role of interventional radiology in the emergent management of acute upper gastrointestinal bleeding

Approximately 100,000 cases of upper gastrointestinal bleeding (UGIB) require inpatient admission annually in the United States. When medical management and endoscopic therapy are inadequate, endovascular intervention can be lifesaving. These emergent situations highlight the importance of immediate competence of the interventional radiologist in the preangiographic evaluation as well as the endovascular treatment of UGIB. We describe a case of UGIB managed with endovascular embolization and detail the angiographic techniques used. The case description is followed by a detailed discussion of the treatment approach to UGIB, with attention to both nonvariceal and variceal algorithms.

Improving quality of care in peptic ulcer bleeding: nationwide cohort study of 13,498 consecutive patients in the Danish Clinical Register of Emergency Surgery

OBJECTIVES

The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB.

METHODS

All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality.

RESULTS

A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010-2011 vs. 89% in 2004-2006, relative risk (RR) 1.06 (95% confidence intervals 1.04-1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10-1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59-0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66-0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78-1.00)).

CONCLUSIONS

QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.

More favorable outcomes with peptic ulcer bleeding due to Helicobacter pylori

BACKGROUND

Acute upper gastrointestinal bleeding is a common complication of peptic ulcer disease, often caused by Helicobacter pylori and nonsteroidal anti-inflammatory drug (NSAID) use. The purpose of this study was to determine whether the cause and biologic behavior of ulcers associated with acute upper gastrointestinal bleeding might lead to divergent patient outcomes.

METHODS

In this Institutional Review Board-approved study, we compared clinical features and outcomes of patients with acute upper gastrointestinal bleeding due to ulcers categorized into 4 groups: Helicobacter pylori positive or negative combined with NSAID usage positive or negative. Likelihood chi-squared analyses were utilized for group comparisons and stepwise multiple logistic regression models were utilized to determine which factors were related to bleeding outcomes.

RESULTS

Of 2242 patients with upper gastrointestinal bleeding, 575 (26%) had gastroduodenal ulcer disease, and of those with appropriate diagnostic testing, approximately half (228, 10% overall) had evidence of Helicobacter pylori infection and half (216, 10% overall) had no evidence of Helicobacter pylori infection. Patients without Helicobacter pylori infection had significantly more comorbid conditions than those with Helicobacter pylori and higher Charlson Index comorbidity scores (2.6 ± 2.6 [mean and SD] vs 1.9 ± 2.3, P = .003). Hospital length of stay was significantly longer for Helicobacter pylori-negative patients (mean 11.4 ± 21.7 vs 6 ± 8.5 days and median 5.5 vs 3 days, P <.001 and <.001, respectively). Rebleeding events within 30 days were more frequent in Helicobacter pylori-negative patients than Helicobacter pylori-positive patients (11% vs 5%, P = .009). Rebleeding was most frequent in patients without Helicobacter pylori and with no reported use of NSAIDS (18%, P = .01).

CONCLUSIONS

Helicobacter pylori-negative ulcers were associated with poorer outcomes regardless of use of NSAIDs. Patients with ulcers negative for Helicobacter pylori and no history of NSAID use had the worst outcomes and had more severe systemic disease.

Outcome of endoscopic therapy for cancer bleeding in patients with unresectable gastric cancer

BACKGROUND AND AIM

Gastric cancer bleeding is not rare complication in patients with advanced gastric cancer (AGC). The aim of this study was to evaluate the efficacy and clinical outcomes of endoscopic therapy (ET) for upper gastrointestinal bleeding (UGIB) from unresectable AGC.

METHODS

Data from 113 patients with UGIB from unresectable AGC who underwent ET at the National Cancer Center, Korea were analyzed retrospectively. Success rates of endoscopic hemostasis, rebleeding rates, mortality at 30 days, and overall survival (OS) rate after initial hemostasis were investigated.

RESULTS

The initial hemostasis rate was 92.9% (105/113). Electrocoagulation was the most common method used (92.0%, 104/113), and combination ET was required in 34 patients (30.1%). Rebleeding occurred in 43 patients (41.0%); 3-day and 30-day rebleeding rates were 18.1% and 29.5%, respectively. Multivariate logistic regression analysis showed that transfusion of packed red blood cells (> 5 units) was associated with early rebleeding (≤ 3 days after initial hemostasis) (odd ratio, 4.75; 95% confidential interval, 1.45-15.57; P = 0.010). ET was attempted in 18 patients with rebleeding; hemostasis was achieved in 88.9%. The 30-day mortality rate after initial bleeding event was 15.9%. Median OS after initial hemostasis was 3.2 months. OS was lower for patients with early rebleeding than for those with late rebleeding (> 3 days after initial hemostasis) or without rebleeding (1.0, 3.1, and 4.3 months, respectively; P = 0.004).

CONCLUSIONS

ET, primarily endoscopic electrocoagulation, achieved a high initial hemostasis rate for UGIB in patients with unresectable AGC. However, rebleeding frequently occurred, and early rebleeding was associated with poor survival.

Platelet aggregation measurement for assessment of hemostasis failure mechanisms in patients with gastroduodenal ulcer bleeding

Background

The purpose of this study was to identify factors associated with the risk of unsustainable hemostasis in patients with gastric and duodenal ulcer bleeding by in vitro assessment of platelet reactivity using artificial neural networks.

Methods

Patients with gastroduodenal ulcers complicated by bleeding were studied. Platelet aggregation was measured using aggregometry with adenosine diphosphate 5 μM, epinephrine 2.5 μM, 5-hydroxytryptophan 10 μM, collagen 1 μM, and thrombin 0.06 NIH Unit/mL as agonists. Multiple logistic regression was used to evaluate the independent relationship between demographic, clinical, endoscopic, and laboratory data and in vitro assessment of platelet reactivity and local parameters of hemostasis in patients with ulcer bleeding.

Results

Analysis of platelet aggregation in patients with gastroduodenal ulcer bleeding allowed the variability of platelet response to different agonists used in effective concentration which induces 50% platelet aggregation (EC₅₀) to be established. The relationship between platelet aggregation and the spatial-temporal characteristics of ulcers complicated by bleeding was demonstrated. Adrenoreactivity of platelets was associated with time elapsed since the start of ulcer bleeding and degree of hemorrhage. The lowest platelet response to collagen and thrombin was detected in patients with active bleeding (P < 0.001) and unsustainable recent bleeding (P < 0.01). Decreased adenosine diphosphate-induced platelet aggregation in patients with ulcer bleeding was correlated with the platelet response to thrombin (r = 0.714, P < 0.001) and collagen (r = 0.584, P < 0.01).

Conclusion

Estimation of platelet reactivity in vitro indicates the key mechanisms of failure of hemostasis in patients with ulcer bleeding. In addition to gender, an important determinant of unsustainable hemostasis was a decreased platelet response to thrombin and adenosine diphosphate.

Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review

Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated.

DATA SOURCES

 MEDLINE including MeSH, EMBASE, and the Cochrane Library.

PARTICIPANTS

patients in the ICU.

INTERVENTIONS

pharmacological and non-pharmacological SUP.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.

Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding

BACKGROUND

Treatment with proton pump inhibitors (PPIs) improves clinical outcomes in patients with peptic ulcer bleeding. However, the optimal dose and route of administration of PPIs remains controversial.

OBJECTIVES

To evaluate the efficacy of different regimens of PPIs in the management of acute peptic ulcer bleeding using evidence from direct comparison randomized controlled trials (RCTs).We specifically intended to assess the differential effect of the dose and route of administration of PPI on mortality, rebleeding, surgical intervention, further endoscopic haemostatic treatment (EHT), length of hospital stay, transfusion requirements and adverse events.

SEARCH METHODS

We searched CENTRAL (in The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE (from inception to September 2010) and proceedings of major gastroenterology meetings (January 2000 to September 2010), without language restrictions. Original investigators were contacted to request missing data.

SELECTION CRITERIA

RCTs that compared at least two different regimens of the same or a different PPI in patients with acute peptic ulcer bleeding, diagnosed endoscopically.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies, extracted data and assessed risk of bias. We synthesized data using the Mantel-Haenszel random-effects method and performed multivariate meta-regression with random permutations based on Monte Carlo simulation. We measured heterogeneity with the I² statistic and Cochrane Q test and assessed publication bias with funnel plots and Egger's test. We graded the overall quality of evidence using the GRADE approach.

MAIN RESULTS

Twenty two RCTs were included; risk of bias was high in 17 and unclear in 5. The main analysis included 13 studies (1716 patients) comparing "high" dose regimens (72-hour cumulative dose > 600 mg of intravenous PPI) to other doses; there was no significant heterogeneity for any clinical outcome. We found low quality evidence that did not exclude a potential reduction or increase in mortality, rebleeding, surgical interventions or endoscopic haemostatic treatment (EHT) with "high" dose regimens. For mortality, pooled risk ratio (RR) was 0.85 (95% confidence interval (CI) 0.47 to 1.54); pooled risk difference (RD) was 0 more deaths per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more deaths per 100 treated). For rebleeding, pooled RR was 1.27 (95% CI 0.96 to 1.67); pooled RD was 2 more rebleeding events per 100 patients treated with "high" dose (95% CI from 0 fewer to 5 more rebleeding events per 100 treated). For surgical interventions, pooled RR was 1.33 (95% CI 0.63 to 2.77); pooled RD was 1 more surgical intervention per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more surgical interventions per 100 treated). For further EHT, pooled RR was 1.39 (95% CI 0.88 to 2.18), pooled RD was 2 more events per 100 patients treated with "high" dose PPI (95% CI from 1 fewer to 5 more events per 100 treated). We found moderate quality evidence suggesting no important difference between the two regimens with regards to length of hospital stay (mean difference (MD) 0.26 days; 95% CI -0.08 to 0.6 days) or blood transfusion requirements (MD 0.05 units; 95% CI -0.21 to 0.3 units). There was visual and statistical evidence of "inverse" publication bias for mortality (missing small studies with favourable outcomes for "high" dose), but not for any other outcome. The results were similar for all subgroup analyses (according to risk of bias, geographical location, route of administration for non-"high" dose regimens, continuous infusion vs. bolus administration for intravenous non-"high" regimens group), sensitivity analyses (restriction to patients who had EHT for high risk stigmata, use of different dose thresholds for comparative regimens) and post hoc analyses (inclusion of all studies (N = 22) that compared at least two PPI regimens with different cumulative 72 hour doses; restriction of the previous analysis to patients who had EHT for high risk stigmata). Meta-regression analysis did not show any statistically significant associations between treatment effect (for the outcomes of mortality, rebleeding and surgical intervention) and the three study-level factors that were assessed (geographical location (Asia versus not Asia), route of PPI administration (intravenous versus oral), within-study ratio among the 72-hour cumulative doses of the two PPI regimens).

AUTHORS' CONCLUSIONS

There is insufficient evidence for concluding superiority, inferiority or equivalence of high dose PPI treatment over lower doses in peptic ulcer bleeding.

Indications and safety of proton pump inhibitor drug use in patients with cancer

INTRODUCTION

Although the exact prevalence of proton pump inhibitor (PPI) use in cancer patients is not known, it is generally perceived to be widespread. PPIs are generally well tolerated and carry an excellent safety profile. However, increasing and longer term PPI use has raised concerns about the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events.

AREAS COVERED

We conducted a PubMed search of English language articles addressing the safety and adverse events associated with PPI use with particular emphasis in cancer patients.

EXPERT OPINION

PPIs, frequently used in cancer patients, are generally well tolerated and carry an excellent safety profile. PPI-induced acid suppression may increase the risk of Clostridium difficile or other enteric infections, nutritional deficiencies and community acquired pneumonia, all particularly important in cancer patients. The indications for PPI use in cancer patients should be carefully reviewed prior to use.

The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding

INTRODUCTION

We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB).

OBJECTIVE

To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS).

DESIGN

Retrospective cohort study.

PATIENTS

Adults with a primary diagnosis of UGIB.

PRIMARY OUTCOME

inpatient mortality.

SECONDARY OUTCOMES

composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.

RESULTS

Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes.

LIMITATIONS

Retrospective, single-center study.

CONCLUSION

The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

State-of-the-art management of acute bleeding peptic ulcer disease

The management of patients with non variceal upper gastrointestinal bleeding has evolved, as have its causes and prognosis, over the past 20 years. The addition of high-quality data coupled to the publication of authoritative national and international guidelines have helped define current-day standards of care. This review highlights the relevant clinical evidence and consensus recommendations that will hopefully result in promoting the effective dissemination and knowledge translation of important information in the management of patients afflicted with this common entity.