ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis

Prediction of esophagogastroduodenoscopy therapeutic usefulness for in-ICU suspected upper gastrointestinal bleeding: the SUGIBI score study

BACKGROUND

Suspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB.

METHODS

We conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort.

RESULTS

Two hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91-99) for hemostatic endotherapy [AUC of 0.81; 0.75-0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66-0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92-97).

CONCLUSIONS

Our study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD.

Independent prognostic importance of blood urea nitrogen to creatinine ratio in heart failure

AIM

Blood urea nitrogen (BUN) to creatinine ratio is associated with worse outcomes in acute heart failure (HF) but little is known about its importance in chronic HF.

METHODS AND RESULTS

We combined individual patient data from clinical trials (HF with reduced ejection fraction [HFrEF]: PARADIGM-HF, ATMOSPHERE and DAPA-HF, and HF with preserved ejection fraction [HFpEF]: PARAGON-HF and I-PRESERVE). The primary outcome examined was a composite time to first HF hospitalization or cardiovascular death; its components and all-cause death were also examined. Each HF phenotype was categorized according to median BUN/creatinine ratio, generating four groups that is, HFpEF ≤ and >median BUN/creatinine ratio and HFrEF ≤ and >median BUN/creatinine ratio. The association between BUN/creatinine ratio and outcomes was evaluated using the Kaplan-Meier estimator and Cox proportional hazard models. Overall, 28 820 patients were analysed. The median (IQR) BUN/creatinine ratio was 20.1 (Q1-Q3 16.7-24.7) in HFpEF and 18.7 (15.2-22.8) in HFrEF. In both HFpEF and HFrEF, higher BUN/creatinine ratio was associated with older age, female sex, and diabetes, but similar estimated glomerular filtration rate (eGFR). The risk of each outcome examined was significantly higher in patients with BUN/creatinine ratio ≥median, compared to

CONCLUSION

Higher BUN/creatinine ratio was associated with worse outcomes in patients with chronic HF across the spectrum of left ventricular ejection fraction, independently of eGFR and NT-proBNP. BUN/creatinine ratio may reflect neurohumoral activation (especially increased arginine vasopressin), altered renal blood flow or other pathophysiologic mechanisms not incorporated in conventional prognostic variables.

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Key Words

• Blood urea nitrogen
• Creatinine
• Heart failure

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MESH Headings

• Humans
• Female
• Heart Failure
• Prognosis
• Blood Urea Nitrogen
• Creatinine
• Stroke Volume/physiology
• Ventricular Function, Left
• Natriuretic Peptide, Brain
• Peptide Fragments

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Grants

• RE/18/6/34217 British Heart Foundation Centre of Research Excellence

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Affiliation(s)

Paolo Tolomeo British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
Jawad H Butt British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
Toru Kondo British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Gianluca Campo Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
Akshay S Desai Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
Pardeep S Jhund British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
Lars Køber Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
Martin P Lefkowitz Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
Jean L Rouleau Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
Scott D Solomon Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
Karl Swedberg Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
Muthiah Vaduganathan Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
Michael R Zile Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
Milton Packer Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
John J V McMurray British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK

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Stimulatory effect of dietary alpha-lipoic acid on growth performance, antioxidant capacity, liver enzymes, immunity and protection of African catfish, Clarias gariepinus (B.), Edwardsiella tarda infection

Edwardsiella tarda is one of the most common causes of fish diseases that hinder aquaculture. Oxidative stress in farm animals can induce a number of pathological disorders, production and general animal welfare. The use of exogenous dietary nonenzymatic antioxidants such as alpha-lipoic acid (ALA) can stop a pro-oxidant state and thus appears to have the potential to modulate the immune system and protect fish from bacterial infection. Thus, this study investigates the stimulatory effect of dietary ALA on growth performance, antioxidant capacity, liver enzymes, immunity and protection of African catfish, Clarias gariepinus (B.), against an infection with E. tarda. Five isonitrogenous and isocaloric diets (400 g/kg of crude protein) containing ALA at doses of 0.0 (control), 500, 1000, 1500 or 2000 mg/kg diet were served to 300 juveniles of African catfish (mean weight = 8.2 ± 0.2 g) adequately thrice per day for 12 weeks. Thereafter, 0.1 mL of E. tarda (ATCC 15947; 1.0 × 108  CFU/mL) was intraperitoneally injected into 10 fish from each tank and was monitored for 14 days. The results showed that ALA-fortified diets significantly boosted the fish growth, feed consumption and utilization and feed conversion ratio but no did not affect fish survival rate. The highest final fish weight (g), weight growth (g) and weight gain (%) were all considerably higher in fish fed with ALA-fortified diets (p < 0.05), especially from 1000 to 200 mg/kg ALA than the control group. Also, an enhanced hemato-biochemical, antioxidant and immune indices were noticed in African catfish-fed ALA-enriched diets. In a dose-dependent order, the levels of haematological indices such Ht, Hb, RBCs, WBCs and platelets were markedly increased (p < 0.05). Additionally, fish fed with ALA-based diets showed substantial (p < 0.05) declines in aspartate and alanine aminotransferase values, with the lowest values being found in the 2000 mg/kg diet while control group had highest values. Further, African catfish fed the feed fortified with 2000 mg ALA/kg diet showed the highest levels of lysozyme, respiratory burst, proteases and esterase activities (p < 0.05). Following exposure of fish to E. tarda infection, a significant reduction in the mortality was obtained in African catfish fed with ALA-based diets, especially from 1500 to 2000 mg ALA/kg diet (3.3%); while fish fed with the control diet had highest mortality (86.7%). Therefore, diets supplemented with ALA evoked fish growth performance, antioxidants and nonspecific immunity of African catfish. Also, resistance of African catfish to E. Tarda infection were raised when fed ALA-fortified diets at optimum inclusion rate of 1300 mg ALA/kg diet.

Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis

OBJECTIVES

Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis.

METHODS

We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients.

RESULTS

Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%.

CONCLUSIONS

Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.

Diagnostic evaluation of urea nitrogen/creatinine ratio in dogs with gastrointestinal bleeding

Background

Urea nitrogen/creatinine ratio (UCR) is a marker for upper gastrointestinal bleeding (GIB) in people.

Objectives

To assess the usefulness of UCR to predict occult GIB and distinguish upper from lower GIB in dogs.

Animals

Eighty‐nine dogs with GIB and 65 clinically healthy dogs. Dogs were grouped according to 65 overt GIB and 24 occult GIB, and based on lesion localization (37 upper, 13 lower, and 8 both).

Methods

Seventy‐four dogs were included retrospectively and 15 dogs prospectively. Serum urea nitrogen and creatinine concentrations, UCR, hemoglobin concentration, hematocrit, mean corpuscular volume, and mean corpuscular hemoglobin concentration were compared between groups. Logistic regression models were fitted to assess if variables could distinguish occult GIB from being healthy and upper from lower GIB.

Results

The UCR was significantly higher in dogs with overt GIB compared to control dogs (P = .02) and dogs with occult GIB (P = .05). The UCR was not significantly associated with occult GIB vs being healthy, or upper vs lower GIB (P > .05 each). Dogs with higher hemoglobin concentration and hematocrit had significantly lower odds of having occult GIB than being healthy (P < .0001 each).

Conclusions and Clinical Importance

The UCR does not seem to be a clinically useful marker of occult GIB and appears to have poor discriminatory ability between upper and lower GIB. An increased UCR in a dog without signs of overt GIB, especially if its hematocrit is within the middle or upper reference interval, does not appear to warrant prompt prescription of gastrointestinal protectants.

Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding

BACKGROUND

Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination.

METHODS

From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow-Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement.

RESULTS

Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11.

CONCLUSIONS

Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.

Prospective cost analysis of early video capsule endoscopy versus standard of care in non-hematemesis gastrointestinal bleeding: a non-inferiority study

Background and aim: A non-inferiority cost analysis was performed to assess if the early capsule approach would incur higher costs than the standard of care approach in patients presenting with non-hematemesis gastrointestinal bleeding.Methods: A prospective non-inferiority cost analysis was performed on patients receiving either an early video capsule as the first diagnostic procedure or an endoscopic procedure as determined by gastroenterology staff that were not involved in the study. Primary outcome was total direct costs incurred in both groups.Results: Forty-five patients and 42 patients were enrolled into the early capsule and standard of care arms, respectively. There was no difference in total direct cost per inpatient case in both groups ($7,362 vs $7,148, p = 0.77 [CI = -2,285-2,315, equivalent margin = -$3,100]). Localization of a bleeding source after the first diagnostic procedure was identified more frequently in the early capsule group (69.2% vs 27.9%, p = 0.0003). If patients were discharged after their last non-diagnostic evaluation, then length of stay could be decreased by 50% in both groups (58.5 to 31.6 h, p = 0.02 in the early capsule group and 69.4 to 39.2 h in the standard of care group p = 0.001). Projections indicate the fastest a patient with non-diagnostic evaluations could be discharged is 0.88 days in the early capsule group vs 1.63 days in the standard of care group (p = 0.0005).Discussion: In patients with non-hematemesis bleeding, video capsule endoscopy may be a more efficient diagnostic approach than the standard of care approach, since it detects bleeding significantly more often without an increase in healthcare costs.

Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania

Background

Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania.

Methods

This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality.

Results

During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32–64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3–4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7–29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8–22.8).

Conclusions

In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Updates on management of nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Upper gastrointestinal bleeding (UGIB) is a common and life-threatening condition in the United States and worldwide.

RECENT FINDINGS

There have been several exciting recent advances in the endoscopic management of UGIB. One such advance is the recent approval of Hemospray by US Food and Drug Administration in May 2018. Another one is the emerging role of video capsule endoscopy as a triage and localization tool for UGIB patients. Finally, the development of new reversal agents for antithrombotic medications is an important advance in the management of life-threatening upper gastrointestinal bleed.

SUMMARY

In this article, we will broadly review the management of nonvariceal UGIB, focusing primarily on the data addressing these new advances.

Acute Kidney Injury Masked by Malnutrition: A Case Report and the Problem of Protein

Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutrition considerations in the management of AKI, including fluid balance, electrolyte and acid-base disturbances, protein provision, and management of comorbid conditions. The optimal amount of protein provision for patients with AKI who are not on renal replacement therapy (RRT) has been a topic of debate for years. Excessive protein provision may contribute to azotemia in these patients, but inadequate protein intake may harm nutrition status and result in poorer clinical outcomes. This review discusses a patient case of AKI masked by malnutrition and muscle loss and reviews the current literature on optimal protein intake in AKI (not on RRT). Based on a structured search strategy, 4 articles were reviewed. We conclude that the available evidence suggests that significant restrictions in protein intake are not necessary for those critically ill patients with AKI. However, the studies reviewed here showed significant heterogeneity in protein dose and delivery, estimation of protein needs, patient population, and definition of AKI, and thus further research is needed to systematically determine the optimal dose of protein for critically ill adults with AKI.

The association between blood urea nitrogen to creatinine ratio and mortality in patients with upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Azotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients.

PATIENTS AND METHODS

This study was conducted prospectively at a university-affiliated teaching hospital with approximate 70,000 annual emergency department (ED) visits. Data from a total of 258 adult UGIB patients were collected between March 1, 2011 and March 1, 2012. Cox regression analysis was used to identify risk factors for 30-day mortality.

RESULTS

Malignancy and Rockall score were associated with increased risk of 30-day mortality (Unadjusted hazard ratio (HR): 3.87, 95% CI: 1.59-9.41, p = 0.0029; HR: 1.31, 95% CI: 1.02-1.71, p = 0.0476, respectively). However, BUN/Cr > 30 was associated with lower risk of 30-day mortality (HR: 0.32, 95% CI: 0.11-0.97, p = 0.0441).

CONCLUSIONS

A BUN/Cr ratio of >30 was found to be an independent risk factor for mortality and may be useful for pre-endoscopic assessment. Development of future risk scoring systems might warrant consideration of including BUN/Cr ratio as a parameter for estimating risk.

Lower Endoscopic Diagnostic Yields Observed in Non-hematemesis Gastrointestinal Bleeding Patients

BACKGROUND

Location of bleeding can present a diagnostic challenge in patients without hematemesis more so than those with hematemesis.

AIM

To describe endoscopic diagnostic yields in both hematemesis and non-hematemesis gastrointestinal bleeding patient populations.

METHODS

A retrospective analysis on a cohort of 343 consecutively identified gastrointestinal bleeding patients admitted to a tertiary care center emergency department with hematemesis and non-hematemesis over a 12-month period. Data obtained included presenting symptoms, diagnostic lesions, procedure types with diagnostic yields, and hours to diagnosis.

RESULTS

The hematemesis group (n = 105) took on average 15.6 h to reach a diagnosis versus 30.0 h in the non-hematemesis group (n = 231), (p = 0.005). In the non-hematemesis group, the first procedure was diagnostic only 53% of the time versus 71% in the hematemesis group (p = 0.02). 25% of patients in the non-hematemesis group required multiple procedures versus 10% in the hematemesis group (p = 0.004). Diagnostic yield for a primary esophagogastroduodenoscopy was 71% for the hematemesis group versus 50% for the non-hematemesis group (p = 0.01). Primary colonoscopies were diagnostic in 54% of patients and 12.5% as a secondary procedure in the non-hematemesis group. A primary video capsule endoscopy yielded a diagnosis in 79% of non-hematemesis patients (n = 14) and had a 70% overall diagnostic rate (n = 33).

CONCLUSION

Non-hematemesis gastrointestinal bleeding patients undergo multiple non-diagnostic tests and have longer times to diagnosis and then compared those with hematemesis. The high yield of video capsule endoscopy in the non-hematemesis group suggests a role for this device in this context and warrants further investigation.

Both Full Glasgow-Blatchford Score and Modified Glasgow-Blatchford Score Predict the Need for Intervention and Mortality in Patients with Acute Lower Gastrointestinal Bleeding

BACKGROUND

Glasgow-Blatchford score (GBS) has been developed for risk stratification in management of acute upper gastrointestinal (GI) bleeding. However, the performance of GBS in patients with lower GI bleeding is unknown.

AIM

To evaluate the performance of full or modified GBS and modified GBS in prediction of major clinical outcomes in patients with lower GI bleeding.

METHODS

A retrospective study of patients admitted to a tertiary care center with either non-variceal upper GI bleeding or lower GI bleeding was conducted. The full and modified GBS were calculated for all patients. The primary outcome was a combined outcome of inpatient mortality, need for endoscopic, surgical, or radiologic procedure to control the bleed or treat the underlying source, and need for blood transfusion.

RESULTS

A total of 1026 patients (562 cases for upper GI and 464 cases for lower GI) were included in the study. Hospital-based interventions and mortality were significantly higher in upper GI bleeding group. The performance of the full GBS in lower GI bleeding (area under the receiver operating curve (AUROC) 0.78, 95% CI 0.74-0.82) was comparable to full GBS in upper GI bleeding (AUROC 0.77, 95% CI 0.73-0.81) in predicting the primary outcome. Similarly, the performance of modified GBS in lower GI bleeding was shown to be comparable to modified GBS in upper GI bleeding (AUROC 0.78, 95% CI 0.74-0.83 vs. AUROC 0.76 95% CI 0.72-0.80).

CONCLUSION

In patients with lower GI bleeding, both full GBS and modified GBS can predict the need for hospital-based interventions and mortality.

Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.

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.

CT for Evaluation of Acute Gastrointestinal Bleeding

Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. ^©RSNA, 2018.

Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence

The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines. Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localization of bleeding? 3) Can nasogastric aspiration identify high risk patients that might benefit from earlier endoscopy? 4) Is there evidence for benefit in terms of outcomes from using nasogastric aspiration? 5) Is nasogastric intubation safe in patients with possible esophageal varices? Our review was conducted according to PRISMA guidelines. Expert commentary: Based on the available literature, nasogastric lavage or aspiration cannot be routinely recommended unless a large properly designed randomized trial (which is currently lacking) proves otherwise. It is a painful and time-consuming procedure with no demonstrated benefit for the patient in terms of outcomes. Other clinical and laboratory parameters, and risk scores, are less invasive and are effective for guiding the stratification and management of patients, while pre-endoscopic erythromycin infusion is a good if not better alternative for improving visualization of the stomach.

Management of non variceal upper gastrointestinal bleeding: position statement of the Catalan Society of Gastroenterology

In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

Blatchford Score Is Superior to AIMS65 Score in Predicting the Need for Clinical Interventions in Elderly Patients with Nonvariceal Upper Gastrointestinal Bleed

Background. Blatchford and AIMS65 scores were developed to risk stratify patients with upper gastrointestinal bleed (UGIB). We sought to assess the performance of Blatchford and AIMS65 scores in predicting outcomes in elderly patients with nonvariceal UGIB. Methods. A retrospective cohort study of elderly patients (over 65 years of age) with nonvariceal UGIB admitted to a tertiary care center. Primary outcome was a combined outcome of in-hospital mortality, need for any therapeutic endoscopic, radiologic, or surgical intervention, rebleeding within 30 days, or blood transfusion. Secondary outcome was a combined outcome of in-hospital mortality or need for an intervention to control the bleed. Results. 164 patients were included. The primary outcome occurred in 119 (72.5%) patients. The secondary outcome occurred in 12 patients (7.2%). Blatchford score was superior to AIMS65 score in predicting the primary outcome (area under the receiver-operator curve (AUROC) 0.84 versus 0.68, resp., p < 0.001). Both scores performed poorly in predicting the secondary outcome (AUROC 0.56 versus 0.52, resp., p = 0.18). Conclusions. Blatchford score could be useful in predicting the need for hospital based interventions in elderly patients with nonvariceal UGIB. Blatchford and AIMS65 scores are poor predictors of the need for a therapeutic intervention to control bleeding.

Availability of blood urea nitrogen/creatinine ratio in gastrointestinal bleeding with melena in children

PURPOSE

The aims of our study were to evaluate the blood urea nitrogen to creatinine ratio (BUN/Cr ratio) for distinguishing between an upper and lower gastrointestinal bleeding (GIB), and differentiating between the two most common causes of upper gastrointestinal bleeding (UGIB) presenting with melena in children.

METHODS

Retrospective data of patients with GIB presenting with melena were analyzed. The data from 60 cases were reviewed including demographics, laboratory findings, diagnostic modalities and results, treatments, and transfusions.

RESULTS

Among the 60 cases, UGIB and lower gastrointestinal bleeding (LGIB) were found in 35 cases (58.3%) and 14 cases (23.3%), respectively. The two common causes of UGIB were varices (37.1%), and peptic ulcer diseases (PUD) (31.4%). The BUN/Cr ratio of 30 or greater was higher in UGIB than LGIB (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 1.3-37.2). In UGIB, the BUN/Cr ratio of the varices group was higher than that of the PUD group (p=0.015). The OR for the BUN/Cr ratio appeared as 1.2 per unit increase in the varices group than the PUD group (95% CI, 1.03-1.3). There was no difference between the PUD group and Meckel's diverticulum group.

CONCLUSION

The BUN/Cr ratio was not uneven in differentiating UGIB from LGIB of children with melena in our study. This suggests that BUN/Cr ratio should be interpreted carefully.

How to differentiate sites of gastrointestinal bleeding in patients with hematochezia by using clinical factors?

Hematochezia is one of common gastrointestinal complaint at the Emergency Department (ED). Causes may be due to upper (UGIB) or lower (LGIB) gastrointestinal tract bleeding. Here, clinical factors were studied to differentiate sites of bleeding in patients with hematochezia. All patients with an age of more than 18 years who were diagnosed with GIB at the ED, Ramathibodi Hospital, Thailand were enrolled. Patients who presented with hematochezia and received complete workups to identify causes of bleeding were studied and categorized as being in the UGIB or LGIB groups. There were 1,854 patients who presented with GIB at the ED. Of those, 76 patients presented with hematochezia; 30 patients were in the UGIB group, while 43 patients were in the LGIB group. Clinical variables between both groups were mostly comparable. Three clinical factors were significantly associated with UGIB causes in patients with hematochezia including systolic blood pressure, hematocrit level, and BUN/Cr ratio. The adjusted odds ratios for all three factors were 0.725 (per 5 mmHg increase), 0.751 (per 3% increase), and 1.11 (per unit increase). Physicians at the ED could use these clinical factors as a guide for further investigation in patients who presented with hematochezia.

Multidetector CT angiography in acute gastrointestinal bleeding: why, when, and how

Acute gastrointestinal (GI) bleeding remains an important cause of emergency hospital admissions, with substantial related morbidity and mortality. Bleeding may relate to the upper or lower GI tract, with the dividing anatomic landmark between these two regions being the ligament of Treitz. The widespread availability of endoscopic equipment has had an important effect on the rapid identification and treatment of the bleeding source. However, the choice of upper or lower GI endoscopy is largely dictated by the clinical presentation, which in many cases proves misleading. Furthermore, there remains a large group of patients with negative endoscopic results or failed endoscopy, in whom additional techniques are required to identify the source of GI bleeding. Multidetector computed tomography (CT) with its speed, resolution, multiplanar techniques, and angiographic capabilities allows excellent visualization of both the small and large bowel. Multiphasic multidetector CT allows direct demonstration of bleeding into the bowel and is helpful in the acute setting for visualization of the bleeding source and its characterization. Thus, multidetector CT angiography provides a time-efficient method for directing and planning therapy for patients with acute GI bleeding. The additional information provided by multidetector CT angiography before attempts at therapeutic angiographic procedures leads to faster selective catheterization of bleeding vessels, thereby facilitating embolization. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.313105206/-/DC1.

Dizzy and confused: a step-by-step evaluation of the clinician's favorite chief complaint

This article covers the general approach to patients who present to the emergency department with a complaint of dizziness or vertigo, and altered mentation. Patients' histories and physical examination findings are discussed first, then a pertinent differential diagnosis, ranging from neurological causes and poor perfusion states to toxicologic causes, is described along with the distinguishing features and potential diagnostic pitfalls of each problem. Case scenarios are presented and the treatment and disposition of patients from the emergency department are discussed.

Does Ramadan Fasting Increase Acute Upper Gastrointestinal Haemorrhage?

The epidemiological characteristics and clinical results of patients who presented with acute upper gastrointestinal haemorrhage (AUGIH) during the month of Ramadan (October 2007) were compared with those who presented with AUGIH during another, non-Ramadan, month (December 2007). The following were evaluated: age, gender, symptoms, gastrointestinal disease history, risk factors, co-existing diseases, results of rectal, nasogastric and endoscopic examinations, treatment modalities and clinical outcomes. Significantly more patients were diagnosed with AUGIH during Ramadan compared with the non-Ramadan month (43 versus 28, respectively). Significantly more patients diagnosed during Ramadan had a history of previous haemorrhage compared with the non-Ramadan month (72.1% versus 42.9%, respectively). Peptic ulcer was the most common event in both groups and overall endoscopy findings differed between the groups. No other significant differences were found. In conclusion, the number of patients presenting with AUGIH during Ramadan was significantly higher than that of an ordinary month, which suggests that fasting during Ramadan reactivates and aggravates preexisting gastrointestinal diseases.

Superselective embolization for lower gastrointestinal hemorrhage: an institutional review over 7 years

INTRODUCTION

Superselective embolization of visceral arterial branches has become integral in the management of acute lower gastrointestinal (GI) hemorrhage. The present study aimed to evaluate the success of superselective embolization as a primary therapeutic modality in the control of lower GI hemorrhage and to identify factors associated with rebleeding and surgical intervention after the procedure.

METHODS

We performed a retrospective review of all cases of superselective embolization for acute lower GI bleeding during a 7-year period (December 2000-October 2007) in a single 1,300-bed hospital in Singapore. Hemostasis was achieved with microcoils, polyvinyl alcohol particles, gelfoam, or by selective vasopressin infusion. Various clinical and hematologic factors were analyzed against rebleeding and surgical intervention after the procedure.

RESULTS

A total of 265 patients underwent mesenteric angiography for GI hemorrhage. Superselective embolization of visceral vessels for lower GI hemorrhage was performed in 32 patients (12%) whose median age was 66 years (range: 34-82 years). The group was of similar gender distribution, and the median follow-up was 8 months (range: 1-32 months). Location was the small bowel in 19% and the colon in 81%. The underlying etiologies included diverticular disease (59%), angiodysplasia (19%), ulcers (19%), and malignancy (3%). In 31 patients (97%) technical success was achieved, with immediate cessation of hemorrhage in every case. Clinical success was achieved in 20 patients (63%), all of whom were discharged well with no further intervention. Seven patients rebled, and 9 underwent surgery: 1 for incomplete hemostasis, 4 for rebleeding, 1 for infarcted bowel postembolization, and 3 on the basis of the surgeon's decision. There were 2 anastomotic leaks; 1 after surgery for postembolization ischemia and 1 after surgery for rebleeding. Overall mortality in this series was 9%. Rebleeding was more likely to occur if the site of bleeding was located in the small bowel compared to the colon (OR: 8.33, 95% CI 1.03-66.67). It was also more likely in patients with a hematocrit level </=20.0% (OR: 7.52, 95% CI: 1.14-50.00) and a platelets level </=140 x 10(9)/l (OR: 9.35, 95% CI: 1.36-62.5) just before the procedure. Surgical resection was also more likely in patients with a hematocrit level </=20.0% just before embolization (OR: 12.66, 95% CI: 1.96-83.33), and it appeared to be more likely if the underlying cause was diverticular disease (OR 8.70, 95% CI: 0.93-83.33).

CONCLUSIONS

The use of superselective mesenteric embolization for the treatment of lower GI bleeding is highly successful and relatively safe-97% technical success and 3% postembolization ischemia in our series. In 63% of cases it is definitive without any further intervention. Postembolization ischemia and surgery may be associated with a higher risk of anastomotic leak. Greater vigilance must be adopted in treating patients who have active hemorrhage from the small bowel and in those with a hematocrit </=20.0%.

"You wanna do what?!" Modern indications for nasogastric intubation

Through the years, patients have asked their physicians why they needed nasogastric inbutation (NGI), a painful test. Some recent studies have also questioned the utility of NGI for several indications, enabling physicians to use judgment in offering it to patients. This article reviews the use of NGI for its traditional indications: gastrointestinal bleeding, presenting with or without hematemesis; gastric decompression; and the administration of treatment. It concludes with suggestions for limiting the pain of the procedure for patients who need it.