Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

Comprehensive insights on treatment modalities with conventional and herbal drugs for the treatment of duodenal ulcers

Areas of the body accessible to gastric secretions, such as the stomach and duodenum, are most commonly damaged by circumscribed lesions of the upper gastrointestinal tract mucosa. Peptic ulcer disease is the term for this illness (PUD). About 80% of peptic ulcers are duodenal ulcers, with stomach ulcers accounting for the remaining 20%. Duodenal ulcers are linked to the two primary results about Helicobacter pylori infection and COX inhibitor users. Additional causes might include drinking, smoking, stress, and coffee consumption. The indications and symptoms of a duodenal ulcer depend on the patient's age and the lesion's location. For duodenal ulcers, proton pump inhibitors (PPIs) are the usual course of treatment. This comprehensive study included an in-depth literature search in the literature and methods section using electronic databases such as PubMed, ScienceDirect, and Google Scholar. The search method included publications published from the inception of the relevant database to the present. Inclusion criteria included studies investigating different treatment options for duodenal ulcer disease, including traditional pharmacotherapy and naturopathic treatments. Data mining includes information on treatment techniques, treatment outcomes, and possible synergies between conventional and herbal treatments. In addition, this review critically examines the available information on the effectiveness, safety, and possible side effects of different treatments. The inclusion of conventional and herbal treatments is intended to provide a comprehensive overview of the many treatment options available for duodenal ulcer disease. A more comprehensive and personalized treatment plan can be achieved by incorporating dietary changes, lifestyle modifications, and, if necessary, herbal therapies to complement other treatments normally.

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort

INTRODUCTION

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

METHODS

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

RESULTS

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

DISCUSSION

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Efficacy and safety of over-the-scope-clips in the therapy of acute nonvariceal upper gastrointestinal bleeding: Meta-analysis

BACKGROUND

Acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is a frequent life-threatening acute condition in gastroenterology associated with high morbidity and mortality. Over-the-scope-clip (OTSC) is a new endoscopic hemostasis technique, which is being used in ANVUGIB and is more effective.

AIM

To summarize and analyze the effects of the OTSC in prevention of recurrent bleeding, clinical success rate, procedure time, hospital stay, and adverse events in the treatment of ANVUGIB, to evaluate whether OTSC can replace standard endoscopic therapy as a new generation of treatment for ANVUGIB.

METHODS

The literature related to OTSC and standard therapy for ANVUGIB published before January 2023 was searched in PubMed, Web of Science, EMBASE, Cochrane, Google, and CNKI databases. Changes in recurrent bleeding (7 or 30 days), clinical results (clinical success rate, conversion rate to surgery, mortality), therapy time (procedure time, hospital stay), and adverse events in the OTSC intervention group were summarized and analyzed, and the MD or OR of 95%CI is calculated by Review Manager 5.3.

RESULTS

This meta-analysis involved 11 studies with 1266 patients. Total risk of bias was moderate-to-high. For patients in the OTSC group, 7- and 30-days recurrent bleeding rates, as well as procedure time, hospital stay, and intensive care unit stay, were greatly inhibited. OTSC could significantly improve the clinical success rate of ANVUGIB. OTSC therapy did not cause serious adverse and was effective in reducing patient mortality.

CONCLUSION

OTSC may provide more rapid and sustained hemostasis, and thus, promote recovery and reduce mortality in patients with ANVUGIB. In addition, the safety of OTSC is assured.

Development of a model for predicting acute cerebral infarction induced by non-variceal upper gastrointestinal bleeding

OBJECTIVE

To evaluate the risk factors for acute cerebral infarction(ACI) in patients with non-variceal upper gastrointestinal bleeding(NVUGIB), and construct a model for predicting ACI in NVUGIB patients.

METHODS

A model for predicting ACI induced by NVUGIB was established on the basis of a retrospective study that involved 1282 patients who were diagnosed with NVUGIB in the emergency department and Gastroenterology Department of Nanchang University Affiliated Ganzhou Hospital from January 2019 to December 2021. Receiver operating characteristic (ROC) curves were drawn to evaluate the sensitivity and specificity of the model and CHA2DS2-VASc score to predict ACI. Delong's test was used to compare AUCs of the present score and the CHA2DS2-VASc score.

RESULTS

There were 1282 patients enrolled in the study, including 69 in the ACI group and 1213 in the non-ACI group. Multivariate analysis revealed that hypertension, diabetes, red blood cell (RBC) transfusion, mechanical ventilation, D-dimer, rate pressure product (RPP), somatostatin and mean platelet volume (MPV) were factors associated with ACI induced by NVUGIB. A model based on the eight factors was established, Logit(P)= 0.265 + 1.382 × 1 + 1.120 × 2 + 1.769 × 3 + 0.839 × 4-1.549 × 5-0.361 × 6 + 0.045 × 7 + 1.158 × 8(or 1.069 ×9) (X1, hypertension=1; X2, diabetes=1; X3, RBC transfusion=1; X4, mechanical ventilation=1; X5, somatostatin=1; X6, MPV(fL); X7, D-dimer(ng/l); X8, low RPP= 1; X9, high RPP = 2). The area under ROC curve of the model was 0.873, the sensitivity and specificity were 0.768 and 0.887, respectively. The area under ROC curve of CHA2DS2-VASc score was 0.792, the sensitivity and specificity were 0.728 and 0.716, respectively. Delong's test showed the area under ROC curve of the present study was significantly larger than that of CHA2DS2-VASc score.

CONCLUSIONS

Hypertension, diabetes, RBC transfusion, mechanical ventilation, D-dimer, RPP, somatostatin and MPV were factors associated with ACI induced by NVUGIB. A model constructed based on these factors showed excellent prediction of ACI, and was superior to CHA2DS2-VASc score. However, this needs to be further validated by multi-center study with a larger sample size.

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

Background

In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.

Aim

To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.

Methods

We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.

Results

802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.

Conclusion

Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.

Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding.

METHODS

In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality.

RESULTS

Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods.

CONCLUSIONS

Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).

Laparoscopic versus open surgery for locally advanced and metastatic gastric cancer complicated with bleeding and/or stenosis: short- and long-term outcomes

Background

Laparoscopic surgery has justified its efficacy in the treatment of early gastric cancer. There are limited data indicating the eligibility of laparoscopic interventions in locally advanced gastric cancer. Publications describing the safety of laparoscopic techniques in the treatment of local and metastatic gastric cancer complicated by bleeding and stenosis are scarce.

Methods

The study included patients with histologically confirmed locally advanced and disseminated gastric cancer and complicated with bleeding and/or stenosis who underwent gastrectomy with vital indications between February 2012 and August 2018. Surgical and oncologic outcomes after laparoscopic surgery (laparoscopic surgery) and open surgery (OS) were compared.

Results

In total, 127 patients (LS, n = 52; OS, n = 75) were analyzed. Baseline characteristics were similar between the groups. Forty-four total gastrectomies with resection of the abdominal part of the esophagus, 63 distal subtotal (43 Billroth-I and 20 Billroth-II), and 19 proximal gastrectomies were performed. The median duration of surgery was significantly longer in the LS group, 253 min (interquartile range [IQR], 200–295) versus 210 min (IQR, 165–220) (p < 0.001), while median intraoperative blood loss in the LS group was significantly less, 180 ml (IQR, 146—214) versus 320 ml (IQR, 290–350), (p < 0.001). Early postoperative complications occurred in 35% in the LS group and in 45 % of patients in the OS group (p = 0.227). There was no difference in postoperative mortality rates between the groups (3 [6 %] versus 5 (7 %), p = 1.00). Median intensive care unit stay and median postoperative hospital stay were significantly shorter after laparoscopy, 2 (IQR, 1–2) versus 4 (IQR, 3–4) days, and 8 (IQR, 7–9) versus 10 (IQR, 8–12) days, both p < 0.001. After laparoscopy, patients started adjuvant chemotherapy significantly earlier than those after open surgery, 20 vs. 28 days (p < 0.001). However, overall survival rates were similar between the group. Three-year overall survival was 24% in the LS group and 27% in the OS groups.

Conclusions

Despite the technical complexity, in patients with complicated locally advanced and metastatic gastric cancer, laparoscopic gastrectomies were associated with longer operation time, reduced intraoperative blood loss, shorter reconvalescence, and similar morbidity, mortality rates and long-term oncologic outcomes compared to conventional open surgery.

Transarterial embolisation for gastroduodenal bleeding following endoscopic resection

OBJECTIVES

Transcatheter arterial embolisation (TAE) is widely used to treat gastrointestinal bleeding. This paper reports the safety and efficacy of TAE for bleeding following endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection.

METHODS

Fifteen consecutive patients (13 males, two females; mean age 62.2 years) from two tertiary medical centres who underwent TAE for gastroduodenal bleeding after endoscopic resection from November 2001 to December 2020 were included. Patient demographics, clinical presentations, angiographic findings, and TAE details were retrospectively reviewed.

RESULTS

Immediate bleeding during endoscopic resection was noted in four patients. Delayed bleeding 1-30 days after endoscopic resection in nine patients presented with haematochezia (n = 4), haematemesis (n = 6) and melaena (n = 1). Endoscopic haemostasis was attempted in 11 patients (73.3%) but failed due to continued bleeding despite haemostasis (n = 6), failure to secure endoscopic field (n = 3) and unstable vital signs (n = 2). Eleven patients had positive angiographic findings for bleeding, and all bleeding arteries were embolised except one owing to failed superselection of the bleeder. In the other four patients with negative angiographic findings, the left gastric artery with/without the right gastric artery or the accessory left gastric artery was empirically embolised using gelatin sponge particles. Both technical and clinical success rates were 93.3% (14/15). No procedure-related complications occurred during follow-up.

CONCLUSIONS

TAE is safe and effective in the treatment of immediate and delayed bleeding after endoscopic resection procedures.

ADVANCES IN KNOWLEDGE

This is the first and largest 20-year bicentric study published in English on this topic. Empirical TAE for angiographically negative bleeding sites was also effective without significant complications.

Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers

BACKGROUND

Acute peptic ulcer bleeding is still a major reason for hospital admission. Especially the management of bleeding duodenal ulcers needs a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers. Patient with these bleeding ulcers are often in a high-risk situation, which requires multidisciplinary treatment.

SUMMARY

This review provides a structured approach to modern management of bleeding duodenal ulcers and elucidates therapeutic practice in high-risk situations. Initial management including pharmacologic therapy, risk stratification, endoscopy, surgery, and transcatheter arterial embolization are reviewed and their role in the management of bleeding duodenal ulcers is critically discussed. Additionally, a future perspective regarding prophylactic therapeutic approaches is outlined.

KEY MESSAGES

Beside pharmacotherapeutic and endoscopic advances, bleeding management of high-risk duodenal ulcers is still a challenge. When bleeding persists or rebleeding occurs and the gold standard endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding. Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay. In the meantime, transcatheter arterial embolization is recommended as an alternative to surgery and more often replaces surgery in the management of failed endoscopic hemostasis. Future studies are needed to improve risk stratification and therefore enable a better selection of high-risk ulcers and optimal treatment. Additionally, the promising approach of prophylactic embolization in high-risk duodenal ulcers has to be further investigated to reduce rebleeding and improve outcomes in these patients.

Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents

OBJECTIVES

To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality.

METHODS

Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008-2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors.

RESULTS

The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22-0.99; p = .047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13-50.14; p = .024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01-40.52; p = .047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10-10.74; p = .006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786).

CONCLUSIONS

Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding.

KEY POINTS

• Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.

Epidemiology of perforating peptic ulcer: A population-based retrospective study over 40 years

BACKGROUND

The incidence of peptic ulcer disease has decreased during the last few decades, but the incidence of reported peptic ulcer complications has not decreased. Perforating peptic ulcer (PPU) is a severe form of the disease.

AIM

To assess trends in the incidence, presentation, and outcome of PPU over a period of 40 years.

METHODS

This was a single-centre, retrospective, cohort study of all patients admitted to Levanger Hospital, Norway, with PPU from 1978 to 2017. The patients were identified in the Patient Administrative System of the hospital using International Classification of Diseases (ICD), revision 8, ICD-9, and ICD-10 codes for perforated gastric and duodenal ulcers. We reviewed the medical records of the patients to retrieve data. Vital statistics were available for all patients. The incidence of PPU was analysed using Poisson regression with perforated ulcer as the dependent variable, and sex, age, and calendar year from 1978 to 2017 as covariates. Relative survival analysis was performed to compare long-term survival over the four decades.

RESULTS

Two hundred and nine patients were evaluated, including 113 (54%) men. Forty-six (22%) patients were older than 80 years. Median age increased from the first to the last decade (from 63 to 72 years). The incidence rate increased with increasing age, but we measured a decline in recent decades for both sexes. A significant increase in the use of acetylsalicylic acid, from 5% (2/38) to 18% (8/45), was observed during the study period. Comorbidity increased significantly over the 40 years of the study, with 22% (10/45) of the patients having an American Society of Anaesthesiologists (ASA) score 4-5 in the last decade, compared to 5% (2/38) in the first decade. Thirty-nine percent (81/209) of the patients had one or more postoperative complications. Both 100-day mortality and long-term survival were associated with ASA score, without significant variations between the decades.

CONCLUSION

Declining incidence rates occurred in recent years, but the patients were older and had more comorbidity. The ASA score was associated with both short-term mortality and long-term survival.

Manejo endovascular de la hemorragia digestiva, experiencia del Hospital Universitario Clínica San Rafael

Introducción. La hemorragia digestiva ocasiona el 2 % de las hospitalizaciones; se clasifica en alta o baja, la primera se presenta en el 80 % de casos. Después de la estabilización hemodinámica, se determinan la causa y el tratamiento mediante la endoscopia; no obstante, esta falla en 10 a 20 % de los casos, y del 15 al 20 % requieren cirugía mayor, con una mortalidad de más del 40 %. El tratamiento para la hemorragia digestiva mediante la formación de émbolos de los vasos mesentéricos, es una conducta bien establecida, produce buenos resultados, evita la cirugía y disminuye la morbimortalidad. Objetivos. Determinar la indicación y el éxito del tratamiento endovascular para la hemorragia digestiva en nuestra institución. Materiales y métodos. estudio retrospectivo y descriptivo, se incluyeron 10 pacientes que requirieron la urgente formación de émbolos por falla o imposibilidad del manejo endoscópico, y que presentaban gran riesgo quirúrgico y anestésico con la técnica abierta. Se evaluaron la causa de la hemorragia, la arteria comprometida, los hallazgos angiográficos, la hemoglobina antes y después de la formación de los émbolos, la reincidencia de la hemorragia, las complicaciones, la necesidad de intervención quirúrgica, la eficacia del procedimiento y la mortalidad a 30 días. Resultados. Todos los pacientes se intervinieron por vía endovascular, para la oclusión selectiva de las arterias comprometidas. La hemorragia se controló en todos ellos. Se presentaron dos muertes tempranas (<30 días) no asociadas con el procedimiento. No hubo complicaciones secundarias a la formación de los émbolos o al acceso percutáneo y, tampoco, necesidad de cirugías mayores posteriores para controlar la hemorragia. Conclusión. Los métodos endovasculares para controlar la hemorragia digestiva son eficaces, no se acompañan de complicaciones, y disminuyen la morbimortalidad y la necesidad de cirugías mayores. Se requieren estudios con mayor número de pacientes para lograr un mayor grado de certeza.

Management of Bleeding from Unresectable Gastric Cancer

Bleeding from unresectable gastric cancer (URGC) is not a rare complication. Two major ways in which the management of this issue differs from the management of benign lesions are the high rate of rebleeding after successful hemostasis and that not only endoscopic therapy (ET) and transcatheter arterial embolization (TAE) but palliative radiotherapy (PRT) can be applied in the clinical setting. However, there are no specific guidelines concerning the management of URGC with bleeding. We herein discuss strategies for managing bleeding from URGC. A high rate of initial hemostasis for active bleeding is expected when using various ET modalities properly. If ET fails in patients with hemostatic instability, emergent TAE is considered in order to avoid a life-threating condition due to massive bleeding. Early PRT, especially, regimens with a high biologically effective dose (BED) of ≥39 Gy should be considered not only for patients with hemostatic failure but also for those with successful hemostasis and inactive hemorrhage, as longer duration of response with few complications can be expected. Further prospective, comparative studies considering not only the hemostatic efficacy of these modalities but the patients' quality of life are needed in order to establish treatment strategies for bleeding from URGC.

Analysis of risk factors and development of scoring system to predict severity of upper gastrointestinal bleeding in children

BACKGROUND AND AIM

Upper gastrointestinal bleeding is a rare and potentially life-threatening condition in children. Herein, clinical features and risk factors in children with upper gastrointestinal bleeding were analyzed, and a clinical scoring system was constructed to assess severity.

METHODS

This retrospective cohort study involved 224 children hospitalized with upper gastrointestinal bleeding between January 2012 and April 2018. Demographic data, clinical information, and laboratory test results on admission were statistically examined.

RESULTS

Out of 224 upper gastrointestinal bleeding cases, 76 were diagnosed as severe and 148 as mild cases according to the rate of blood loss and severity. Severe group was significantly different from mild group in 23 items including age, number of patients aged more than 7 years, and so forth (P < 0.01 or P < 0.05). Positive detection rate of bleeding etiology was gradually decreased (P < 0.01) in relation to delay in timing of endoscopy. Analysis of logistic regression evinced five independent risk factors for severe cases to be associated with poor consciousness, hemoglobin < 80 g/L, hemoglobin drop of > 20 g/L, hematochezia, and anemic appearance (P < 0.01 or P < 0.05). Using these five parameters, a number of scoring models were tested. The most predictive resulted in a scoring system constructed with a total of 16 and a cutoff for intervention of 8.

CONCLUSIONS

Amalgamation of risk factors with the scoring system plays an important role in assessing upper gastrointestinal bleeding severity in children.

Clinical impact of upper gastrointestinal endoscopy in critically ill patients with suspected bleeding

BACKGROUND AND AIMS

Upper gastrointestinal endoscopies' (UGE) profitability is undisputable in patients admitted for an overt upper digestive tract bleeding. In critically ill subjects admitted for other causes, its performances have scarcely been investigated despite its broad use. We sought to question the performance of bedside UGE in intensive care unit (ICU) patients, admitted for another reason than overt bleeding.

METHODS

This was a six-year (January 2007-December 2012) retrospective observational study of all UGE performed in a medico-surgical ICU. Exclusion of those performed: in patients admitted for a patent upper digestive bleeding; for a second-look gastroscopy of a known lesion; as a planned interventional procedure. Main demographic and clinical data were recorded; UGE indication and profitability were rated according to its findings and therapeutic impact. Operative values of the indications of UGE were calculated. This study received approval from the Ethics Committee of the French Society of Intensive Care (n° 12-363).

RESULTS

Eighty-four patients (74% male, mean age 61 ± 14 years) underwent a diagnostic UGE, all for a suspected upper digestive tract bleeding. The main symptoms justifying the procedure were anemia (52%), digestive bleeding (27%), vomiting (15%), hemodynamic instability (3%) and hyperuremia (3%). The profitability of UGE was rated as major (n = 5; 5.8%); minor (n = 34; 40.5%); or null (n = 45; 53.6%).

CONCLUSIONS

When ICU admission is not warranted by a digestive bleeding, UGE has limited diagnostic and therapeutic interest, despite being often performed.

Trans Arterial Embolization of Non-variceal Upper Gastrointestinal Bleeding: Is the Use of Ethylene-Vinyl Alcohol Copolymer as Safe as Coils?

PURPOSE

The safety of liquid embolics over the conventional coils for the treatment of non-variceal upper gastrointestinal bleeding (UGIB) approach is still unclear. Purpose of this study is to assess the safety of ethylene-vinyl alcohol copolymer (EVOH 6%) over coils in the treatment of UGIB.

MATERIALS AND METHODS

All the upper gastrointestinal tract embolization procedures performed in a single center in a 6-year period were reviewed. Patients embolised with coils (Group A) versus those embolised with EVOH 6% (Group B) were compared. Technical/clinical success, bleeding recurrence, complication and mortality rates were analyzed.

RESULTS

A total 71 patients were included in the study (41 Group A and 30 Group B). Coagulopathy was present in 21% of Group A and 46% of Group B patients (p < 0.05). Technical and clinical success was 97.6 and 92.7% for Group A, and 100 and 93.3% for Group B respectively, (p > 0.05). Ten patients (17% Group A; 10% Group B) re-bled within the first 36 h and all of them were re-treated successfully with a second embolization. In Group A one major complication (bowel ischemia) occurred. No complication occurred in Group B. The survival rate in the first 30 days was 90.3% for group A and 90% for group B (p > 0.05).

CONCLUSION

This study demonstrated EVOH 6% appears to be as safe and effective as coils in the treatment of non-variceal UGIB.

Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery

OBJECTIVES

To compare the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) and surgery in the treatment of bleeding gastric and duodenal ulcers (BGDUs).

MATERIALS AND METHODS

The study group comprised patients receiving TAE or surgery for BGDUs after failed endoscopic hemostasis in Helsinki University Hospital (HUH) during 2000-2015. Hospital medical records provided study data. 30-d mortality and rebleeding rates were the primary outcomes. Postoperative complications, blood transfusion rate, and the durations of intensive care and hospital admissions were the secondary outcomes.

RESULTS

During the study period, BGDUs lead to 1583 hospital admissions. TAE or surgery was necessary on 85 (5.4%) patients, 43 receiving surgery and 42 TAE. Out of 42, 16 received prophylactic TAE. Two underwent angiography and TAE to localize the bleeding. The remaining 24 received TAE for active or recurrent bleeding after endoscopy. The comparison of TAE (n = 24) and surgery (n = 43) included only patients with active or recurrent bleeding. Mortality rate was 12.5% after TAE and 25.6% after surgery (p = 0.347). Rebleeding rate was 25% after TAE and 16.3% after surgery (p = 0.641). Postprocedural complications were less frequent after TAE than surgery (37.5 vs. 67.4%, p = 0.018). Other secondary outcomes did not differ. Out of 85 procedures, 14 (16.5%) took place between midnight and 8 a.m., all nighttime interventions being surgeries.

CONCLUSIONS

Mortality and rebleeding rates did not differ between TAE and surgery. With less postoperative complications, TAE should be the preferred hemostatic method when endoscopy fails.

Association between ulcer site and outcome in complicated peptic ulcer disease: a Danish nationwide cohort study

OBJECTIVE

Mortality rates in complicated peptic ulcer disease are high. This study aimed to examine the prognostic importance of ulcer site in patients with peptic ulcer bleeding (PUB) and perforated peptic ulcer (PPU).

DESIGN

a nationwide cohort study with prospective and consecutive data collection.

POPULATION

all patients treated for PUB and PPU at Danish hospitals between 2003 and 2014.

DATA

demographic and clinical data reported to the Danish Clinical Registry of Emergency Surgery.

OUTCOME MEASURES

90- and 30-d mortality and re-intervention.

STATISTICS

the crude and adjusted association between ulcer site (gastric and duodenal) and the outcome measures of interest were assessed by binary logistic regression analysis.

RESULTS

Some 20,059 patients with PUB and 4273 patients with PPU were included; 90-d mortality was 15.3% for PUB and 29.8% for PPU; 30-d mortality was 10.2% and 24.7%, respectively. Duodenal bleeding ulcer, as compared to gastric ulcer (GU), was associated with a significantly increased risk of all-cause mortality within 90 and 30 d, and with re-intervention: adjusted odds ratio (OR) 1.47 (95% confidence interval 1.30-1.67); p < 0.001, OR 1.60 (1.43-1.77); p < 0.001, and OR 1.86 (1.68-2.06); p < 0.001, respectively. There was no difference in outcomes between gastric and duodenal ulcers (DUs) in PPU patients: adjusted OR 0.99 (0.84-1.16); p = 0.698, OR 0.93 (0.78 to 1.10); p = 0.409, and OR 0.97 (0.80-1.19); p = 0.799, respectively.

CONCLUSIONS

DU site is a significant predictor of death and re-intervention in patients with PUB, as compared to GU site. This does not seem to be the case for patients with PPU.

Timing or Dosing of Intravenous Proton Pump Inhibitors in Acute Upper Gastrointestinal Bleeding Has Low Impact on Costs

OBJECTIVES

High-dose intravenous proton pump inhibitors (PPIs) post endoscopy are recommended in non-variceal upper gastrointestinal bleeding (UGIB), as they improve outcomes of patients with high-risk lesions. Determine the budget impact of using different PPI regimens in treating non-variceal UGIB, including pre- and post-endoscopic use, continuous infusion (high dose), and intermittent bolus (twice daily) dosing.

METHODS

A budget impact analysis using a decision model informed with data from the literature adopting a US third party payer's perspective with a 30-day time horizon was used to determine the total cost per patient (US$2014) presenting with acute UGIB. The base-case employing high-dose pre- and post-endoscopic IV PPI was compared with using only post-endoscopic PPI. For each, continuous or intermittent dosing regimens were assessed with associated incremental costs. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

The overall cost per patient is $11,399 when high-dose IV PPIs are initiated before endoscopy. The incremental costs are all inferior in alternate-case scenarios: $106 less if only post-endoscopic high-dose IVs are used; with intermittent IV bolus dosing, the savings are $223 if used both pre and post endoscopy and $191 if only administered post endoscopy. Subgroup analysis suggests cost savings in patients with clean-base ulcers who are discharged early after endoscopy. Results are robust to sensitivity analysis.

CONCLUSIONS

The incremental costs of using different IV PPI regimens are modest compared with total per patient costs.

Simple risk factors to predict urgent endoscopy in nonvariceal upper gastrointestinal bleeding pre-endoscopically

The goal of this study is to evaluate how to predict high-risk nonvariceal upper gastrointestinal bleeding (NVUGIB) pre-endoscopically. A total of 569 NVUGIB patients between Match 2011 and January 2015 were retrospectively studied. The clinical characteristics and laboratory data were statistically analyzed. The severity of NVUGIB was based on high-risk NVUGIB (Forrest I-IIb), and low-risk NVUGIB (Forrest IIc and III). By logistic regression and receiver-operating characteristic curve, simple risk score systems were derived which predicted patients' risks of potentially needing endoscopic intervention to control bleeding. Risk score systems combined of patients' serum hemoglobin (Hb) ≤75 g/L, red hematemesis, red stool, shock, and blood urine nitrogen ≥8.5 mmol/L within 24 hours after admission were derived. As for each one of these clinical signs, the relatively high specificity was 97.9% for shock, 96.4% for red stool, 85.5% for red hematemesis, 76.7% for Hb ≤75 g/L, and the sensitivity was 50.8% for red hematemesis, 47.5% for Hb ≤75 g/L, 14.2% for red stool, and 10.9% for shock. When these 5 clinical signs were presented as a risk score system, the highest area of receiver-operating characteristic curve was 0.746, with sensitivity 0.675 and specificity 0.733, which discriminated well with high-risk NVUGIB. These simple risk factors identified patients with high-risk NVUGIB of needing treatment to manage their bleeding pre-endoscopically. Further validation in the clinic was required.

Short article: Gastrointestinal bleeding in multiorgan failure

BACKGROUND AND AIMS

Gastrointestinal bleeding (GIB) may present as complication of multiorgan failure (MOF). The study aims to analyze the reasons for the limited success of hemostasis of GIB in MOF.

METHODS

Using a Markov process, GIB is modeled as one of several complications associated with multiorgan breakdown to study how the reversal of GIB affects clinical outcome.

RESULTS

Although endoscopic hemostasis can delay mortality in patients with severe systemic disease, its overall influence on survival is relatively small. In patients with a time-limited transition through an acute phase of increased mortality risk secondary to MOF, endoscopic hemostasis may substantially prolong survival in absolute terms. However, its relative contribution to overall survival still remains relatively small even in the scenario of transient risk only. The benefit of endoscopy is largest, if GIB is a major contributor to morbidity and mortality in comparison with all other disease complications.

CONCLUSION

Because disease outcome in MOF is ultimately determined by other complications than GIB alone, the influence of endoscopic hemostasis on patient survival often remains disappointingly small.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Predicting the Occurrence of Hypotension in Stable Patients With Nonvariceal Upper Gastrointestinal Bleeding: Point-of-Care Lactate Testing

OBJECTIVES

It is difficult to assess risk in normotensive patients with upper gastrointestinal bleeding. The aim of this study was to evaluate whether the initial lactate value can predict the in-hospital occurrence of hypotension in stable patients with acute nonvariceal upper gastrointestinal bleeding.

DESIGN

Retrospective, observational, single-center study.

SETTING

Emergency department of a tertiary-care, university-affiliated hospital during a 5-year period.

PATIENTS

Medical records of 3,489 patients with acute upper gastrointestinal bleeding who were normotensive at presentation to the emergency department. We analyzed the ability of point-of-care testing of lactate at emergency department admission to predict hypotension development (defined as systolic blood pressure <90 mm Hg) within 24 hours after emergency department admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 1,003 patients with acute nonvariceal upper gastrointestinal bleeding, 157 patients experienced hypotension within 24 hours. Lactate was independently associated with hypotension development (odds ratio, 1.6; 95% CI, 1.4-1.7), and the risk of hypotension significantly increased as the lactate increased from 2.5-4.9 mmol/L (odds ratio, 2.2) to 5.0-7.4 mmol/L (odds ratio, 4.0) and to greater than or equal to 7.5 mmol/L (odds ratio, 39.2) (p<0.001). Lactate elevation (≥2.5 mmol/L) was associated with 90% specificity and an 84% negative predictive value for hypotension development. When the lactate levels were greater than 5.0 mmol/L, the specificity and negative predictive value increased to 98% and 87%, respectively.

CONCLUSIONS

Point-of-care testing of lactate can predict in-hospital occurrence of hypotension in stable patients with acute nonvariceal upper gastrointestinal bleeding. However, subsequently, prospective validate research will be required to clarify this.

Emergency general surgery in the geriatric patient

BACKGROUND

Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care.

METHODS

This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient.

RESULTS

The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care.

CONCLUSION

Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.

Acute, nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Acute, nonvariceal upper gastrointestinal bleeding (UGIB) is a common medical emergency encountered worldwide. Despite medical and technological advances, it remains associated with significant morbidity and mortality.

RECENT FINDINGS

Rapid patient assessment and management are paramount. When indicated, upper endoscopy in patients presenting with acute UGIB is effective for both diagnosis of the bleeding site and provision of endoscopic hemostasis. Endoscopic hemostasis significantly reduces rebleeding rates, blood transfusion requirements, length of hospital stay, surgery, and mortality. Furthermore, early upper endoscopy, defined as being performed within 24 h of patient presentation, improves patient outcomes.

SUMMARY

A structured approach to the patient with acute UGIB that includes early hemodynamic resuscitation and stabilization, preendoscopic risk stratification using validated instruments, pharmacologic and endoscopic intervention, and postendoscopy therapy is important to optimize patient outcome and assure efficient use of medical resources.

Improvement of Short-Term Outcomes for High-Risk Bleeding Peptic Ulcers With Addition of Argon Plasma Coagulation Following Endoscopic Injection Therapy: A Randomized Controlled Trial

A second endoscopic method together with injection therapy is recommended to treat high-risk bleeding peptic ulcers. This study investigated whether additional argon plasma coagulation (APC) treatment could influence hemostatic efficacy following endoscopic injection therapy to treat high-risk bleeding ulcers.From October 2010 to January 2012, eligible patients with high-risk bleeding ulcers were admitted to our hospital. They prospectively randomly underwent either APC therapy along with distilled water injection or distilled water injection alone. Episodes of rebleeding were retreated with endoscopic combination therapy. Patients in whom retreatment was ineffective underwent emergency surgery or transarterial embolization (TAE).A total of 116 enrolled patients were analyzed. The hemostatic efficacy in 58 patients treated with APC along with distilled water injection was compared with that in 58 patients treated with distilled water injection alone. The 2 treatment groups were similar with respect to all baseline characteristics. Initial hemostasis was accomplished in 56 patients treated with combined therapy, and 55 patients treated with distilled water injection therapy (97% vs 95%, P = 0.648). Bleeding recurred in 2 patients treated with combined therapy, and 9 patients treated with distilled water injection (3.6% vs 16%, P = 0.029). Treatment method was the only independent prognostic factor for recurrent bleeding (odds ratio 0.17; 95% confidence interval 0.03-0.84; P = 0.029). The 2 groups did not differ significantly in hospital stay, TAE, surgery, and mortality.Endoscopic therapy with APC following distilled water injection is more effective than distilled water injection alone for preventing rebleeding of peptic ulcer.

Injection and Cautery Methods for Nonvariceal Bleeding Control

Upper gastrointestinal bleeding remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Endoscopic management of nonvariceal bleeding has been shown to improve clinical outcomes, with significant reduction of recurrent bleeding, need for surgery, and mortality. Early upper gastrointestinal endoscopy is recommended in all patients presenting with upper gastrointestinal bleeding within 24 hours of presentation, although appropriate resuscitation, stabilization of hemodynamic parameters, and optimization of comorbidity before endoscopy are essential.

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

BACKGROUND AND STUDY AIMS

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

METHODS

We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

RESULTS

The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

CONCLUSIONS

Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Laboratory test variables useful for distinguishing upper from lower gastrointestinal bleeding

AIM: To distinguish upper from lower gastrointestinal (GI) bleeding.

METHODS: Patient records between April 2011 and March 2014 were analyzed retrospectively (3296 upper endoscopy, and 1520 colonoscopy). Seventy-six patients had upper GI bleeding (Upper group) and 65 had lower GI bleeding (Lower group). Variables were compared between the groups using one-way analysis of variance. Logistic regression was performed to identify variables significantly associated with the diagnosis of upper vs lower GI bleeding. Receiver-operator characteristic (ROC) analysis was performed to determine the threshold value that could distinguish upper from lower GI bleeding.

RESULTS: Hemoglobin (P = 0.023), total protein (P = 0.0002), and lactate dehydrogenase (P = 0.009) were significantly lower in the Upper group than in the Lower group. Blood urea nitrogen (BUN) was higher in the Upper group than in the Lower group (P = 0.0065). Logistic regression analysis revealed that BUN was most strongly associated with the diagnosis of upper vs lower GI bleeding. ROC analysis revealed a threshold BUN value of 21.0 mg/dL, with a specificity of 93.0%.

CONCLUSION: The threshold BUN value for distinguishing upper from lower GI bleeding was 21.0 mg/dL.

Endoscopic management of refractory gastrointestinal non-variceal bleeding using Histoacryl (N-butyl-2-cyanoacrylate) glue

Background: Histoacryl glue (N-butyl-2-cyanoacrylate) has well-established utility in the endoscopic management of gastrointestinal variceal bleeding. The role of Histoacryl glue in non-variceal bleeding is less clear, and there are few articles describing its use in this setting.

Methods: Six patients with intractable non-variceal gastrointestinal bleeding were managed using injection of Histoacryl glue. All patients had previously failed conventional endostasis and/or interventional angioembolization and were not suitable for emergency salvage surgery due to serious comorbidities or unacceptable anaesthetic risk. An endoscopic Lipiodol-Histoacryl-Lipiodol sandwich injection technique was used in these patients. The clinical outcomes and complications were evaluated.

Results: There were four females and two males with a mean age of 55 years. Bleeding lesions included gastric ulcers (n = 2), duodenal ulcers (n = 2), duodenal gastrointestinal stromal tumor (GIST) (n = 1) and rectal ulcers (n = 1). All patients had successful Histoacryl endostasis without the requirement for salvage surgery. There was no treatment-related morbidity and no mortality. Two patients had further bleeding after initial Histoacryl endostasis, which was successfully controlled with further endoscopic Histoacryl injection.

Conclusion: Histoacryl endostasis should be included in the treatment algorithm for refractory non-variceal gastrointestinal bleeding.

Stress-related mucosal disease in the critically ill patient

Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.

Clinical effects of preventive interventional therapy in gastrointestinal bleeding patients with negative digital subtraction angiography findings

AIM: To assess the clinical effects and value of preventive interventional treatment in gastrointestinal hemorrhage patients with negative digital subtraction angiography (DSA) findings.

METHODS: Seventy-eight gastrointestinal hemorrhage patients with negative DSA findings treated at our hospital from June 2010 to June 2014 were randomly divided into two groups to receive gastroduodenal artery embolization combined with superior mesenteric arterial hypophysin infusion (interventional therapy group, n = 39) and traditional internal medicine conservative treatment (control group n = 39), respectively. Therapeutic effects and the incidence of complications were compared between the two groups.

RESULTS: Short- and long-term success rates of hemostasis were significantly higher in the interventional treatment group than in the control group (92.31% vs 64.10%, 82.05% vs 58.97%, P < 0.05). The amount of blood transfusion (154.56 mL ± 10.37 mL vs 186.21 mL ± 11.34 mL, P < 0.05) was significantly less and hospitalization time (10.35 d ± 2.46 d vs 13.02 d ± 3.03 d, P < 0.05) was significantly shorter in the interventional treatment group than in the control group, while the incidence of adverse reactions showed no significant difference between the two groups (P > 0.05).

CONCLUSION: Preventive gastroduodenal artery embolization combined with superior mesenteric arterial hypophysin infusion has a good therapeutic effect in gastrointestinal bleeding patients with negative DSA findings.

Management of overt upper gastrointestinal bleeding in a low resource setting: a real world report from Nigeria

Background

Upper gastrointestinal bleeding (UGIB) remains a common medical problem worldwide that has significant associated morbidity, mortality, and health care resource use. This study outlines the aetiology, clinical presentation, and treatment outcomes of patients with UGIB in a Nigerian low resource health facility.

Methods

This was a descriptive study of consecutive patients who underwent upper gastrointestinal (GI) endoscopy for upper GI bleeding in the endoscopy unit of the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria from January 2007 to December 2013.

Results

During the study period, 287 (12.4%) of 2,320 patients who underwent upper GI endoscopies had UGIB. Of these, 206 (72.0%) patients were males and their ages ranged from 3 to 100 years with a median age of 49 years. The main clinical presentation included passage of melaena stool in 268 (93.4%) of individuals, 173 (60.3%) had haematemesis, 110 (38.3%) had haematochezia, and 161 (56.1%) were dizzy at presentation. Observed in 88 (30.6%) of UGIB patients, duodenal ulcer was the most common cause, followed by varices [52 (18.1%)] and gastritis [51 (17.1%)]. For variceal bleeding, 15 (28.8%) and 21 (40.4%) of patients had injection sclerotherapy and variceal band ligation, respectively. The overall rebleeding rate for endoscopic therapy for varices was 16.7%. For patients with ulcers, only 42 of 55 who had Forrest grade Ia to IIb ulcers were offered endoscopic therapy. Endoscopic therapy was áin 90.5% of the cases. No rebleeding followed endoscopic therapy for the ulcers. The obtained Rockall scores ranged from 2 to 10 and the median was 5.0. Of all patients, 92.7% had medium or high risk scores. An increase in Rockall score was significantly associated with length of hospital stay and mortality (p < 0.001). The overall mortality rate was 5.9% (17 patients).

Conclusion

Endoscopic therapy for UGIB in a resource-poor setting such as Nigeria is feasible, significantly reduces morbidity and mortality, and is cost effective. Efforts should be made to improve the accessibility of these therapeutic procedure for patients with UGIB in Nigeria.

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.

Endoscopic treatment of acute non-variceal upper gastrointestinal bleeding

AIM: To assess the safety and effectiveness of endoscopic treatment of acute non-variceal upper gastrointestinal bleeding (ANVUGIB).

METHODS: Clinical data for 112 patients with ANVUGIB were analyzed, including general data, bleeding site, Forrest classification, Rockall score, Blatchford score, and endoscopic treatment. A comparative analysis of treatment outcomes between 52 cases (Forrest classification Ⅱa-Ⅱb) undergoing endoscopic treatment and 63 cases (Forrest classification Ⅱa-Ⅱb) undergoing conservative treatment was also performed.

RESULTS: Endoscopic hemostasis was successful in 101 of 112 cases, and the success rate was 90.2%. Eleven patients after endoscopic hemostatic treatment still had active bleeding, of whom 5 underwent repeated endoscopic hemostasis (2-3 times) and combined internal conservative treatment, 3 underwent surgical treatment, 2 underwent intervention hemostasis, and 1 died. The higher the Rockall score, the lower the endoscopic treatment success rate. For Forrest Ⅱa-Ⅱb patients, positive and effective endoscopic treatment may improve the success rate of hemostasis.

CONCLUSION: Endoscopic therapy of ANVUGIB is safe and effective.

What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems

BACKGROUND

Mortality rates in perforated peptic ulcer (PPU) have remained unchanged. The aim of this study was to compare known clinical factors and three scoring systems (American Society of Anesthesiologists (ASA), Boey and peptic ulcer perforation (PULP)) in the ability to predict mortality in PPU.

MATERIAL AND METHODS

This is a consecutive, observational cohort study of patients surgically treated for perforated peptic ulcer over a decade (January 2001 through December 2010). Primary outcome was 30-day mortality.

RESULTS

A total of 172 patients were included, of whom 28 (16 %) died within 30 days. Among the factors associated with mortality, the PULP score had an odds ratio (OR) of 18.6 and the ASA score had an OR of 11.6, both with an area under the curve (AUC) of 0.79. The Boey score had an OR of 5.0 and an AUC of 0.75. Hypoalbuminaemia alone (≤37 g/l) achieved an OR of 8.7 and an AUC of 0.78. In multivariable regression, mortality was best predicted by a combination of increasing age, presence of active cancer and delay from admission to surgery of >24 h, together with hypoalbuminaemia, hyperbilirubinaemia and increased creatinine values, for a model AUC of 0.89.

CONCLUSION

Six clinical factors predicted 30-day mortality better than available risk scores. Hypoalbuminaemia was the strongest single predictor of mortality and may be included for improved risk estimation.