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Long B, Gottlieb M. Emergency medicine updates: Upper gastrointestinal bleeding. Am J Emerg Med 2024; 81:116-123. [PMID: 38723362 DOI: 10.1016/j.ajem.2024.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/20/2024] [Accepted: 04/27/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with UGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Capela TL, Silva VM, Freitas M, Gonçalves TC, Cotter J. Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes? Dig Dis Sci 2024; 69:570-578. [PMID: 38117425 PMCID: PMC10861632 DOI: 10.1007/s10620-023-08185-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants. OBJECTIVE To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB. METHODS Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality. RESULTS From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups. CONCLUSION Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.
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Affiliation(s)
- Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal.
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal.
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal.
| | - Vítor Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Marta Freitas
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
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Schuster KF, Thompson CC, Ryou M. Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding. Clin Endosc 2024; 57:73-81. [PMID: 37253640 PMCID: PMC10834283 DOI: 10.5946/ce.2022.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/14/2023] [Accepted: 03/06/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND/AIMS Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model. METHODS A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated. RESULTS All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract. CONCLUSION This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.
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Affiliation(s)
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Lucas Ramos J, Yebra Carmona J, Andaluz García I, Cuadros Martínez M, Mayor Delgado P, Ruiz Ramírez MÁ, Poza Cordón J, Suárez Ferrer C, Delgado Suárez A, Gonzalo Bada N, Froilán Torres C. Urgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding? GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:612-620. [PMID: 36803680 DOI: 10.1016/j.gastrohep.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial. MATERIAL AND METHODS Prospective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality. RESULTS A total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008). CONCLUSION Urgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy).
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Affiliation(s)
- Javier Lucas Ramos
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España.
| | - Jorge Yebra Carmona
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
| | | | | | | | | | - Joaquín Poza Cordón
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
| | | | - Ana Delgado Suárez
- Atención Primaria y Comunitaria, Hospital Universitario La Princesa, Madrid, España
| | - Nerea Gonzalo Bada
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
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Wang X, Yang M, Xu J, Kuai Y, Sun B. Risk analysis of 30-day rebleeding in acute non-variceal upper gastrointestinal bleeding. Arab J Gastroenterol 2023:S1687-1979(23)00033-3. [PMID: 37263819 DOI: 10.1016/j.ajg.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/02/2023] [Accepted: 05/09/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND STUDY AIMS This study aimed to compare the prognostic value of ABC, Glasgow-Blatchford, Rockall and AIMS65 scoring systems in predicting rebleeding rate within 30 days after endoscopic treatment of acute non-variceal upper gastrointestinal bleeding (ANVUGIB). PATIENTS AND METHODS A total of 93 patients with ANVUGIB were selected as the study subjects and they were divided into groups according to whether there was rebleeding in the 30 days' follow-up period. 7 patients with rebleeding within 30 days were included in the rebleeding group, and the other 86 patients without rebleeding were included in the non-rebleeding group. RESULTS By drawing ROC curve, we found that ABC scoring system had the highest accuracy (area under the receiver operating characteristic (AUROC) curve [95% confidence interval (CI), 0.65]) in predicting rebleeding within 30 days compared with the AIMS65 (0.56; P < 0.001), RS (0.51; P < 0.001), and GBS (0.61; P < 0.001). ABC scoring system showed the highest risk of rebleeding in 30 days. When the 4 scoring standards were judged as medium-high risk patients, the efficacy of the ABC scoring system in predicting the risk of rebleeding at 30 days for ANVUGIB was found to be the best in diagnostic sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy. CONCLUSION Comprehensive evaluation showed that ABC score had the highest prediction accuracy. The negative differential significance of each evaluation method was great, that is, the risk of rebleeding was generally low when judged as low risk patients, while the value of predicting rebleeding was limited when judged as medium and high risk patients.
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Affiliation(s)
- Xu Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China
| | - Meiling Yang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China
| | - Jianhua Xu
- Anhui Medical University, Hefei, Anhui 230032, China
| | - Yaxian Kuai
- Anhui Medical University, Hefei, Anhui 230032, China
| | - Bin Sun
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China.
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Rammohan R, Joy MV, Saggar T, Magam SG, Sinha A, Natt D, Gomez S, Sheikh S, Anand P, Mustacchia P. Healthcare Disparities and Upper Gastrointestinal Bleeding: Exploring the Linkages. Cureus 2023; 15:e37977. [PMID: 37101799 PMCID: PMC10123219 DOI: 10.7759/cureus.37977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2023] [Indexed: 04/28/2023] Open
Abstract
Introduction Upper gastrointestinal bleeding (UGIB) refers to blood loss from a gastrointestinal (GI) source proximal or above the ligament of Treitz. Health equity means giving everyone an equal chance to achieve optimal health by addressing injustices, overcoming barriers, and eliminating health disparities. Healthcare providers must analyze racial and ethnic disparities in UGIB management to ensure all patients receive equal care. Identifying risk factors in specific populations leads to tailored interventions that improve outcomes. Our study aims to examine trends and identify disparities in upper gastrointestinal bleeding across races and ethnicities to promote health equity. Methods Retrospective data on upper gastrointestinal bleeding from June 2009 to June 2022 were collected and categorized into five groups based on race. The baseline characteristics of each group were matched to ensure equitable comparison. A joinpoint regression model was used to compare incidence trends, identifying potential healthcare disparities for different racial/ethnic groups over time. Patients aged 18-75 who suffered from upper gastrointestinal bleeding at Nassau University Medical Center in New York from 2010 to 2021 were selected, excluding those with incomplete baseline comorbidity information. Results This study examined 5103 cases of upper gastrointestinal bleeding, with 41.9% female. The cohort was diverse, with 29.4% African American, 15.6% Hispanic, 45.3% White, 6.8% Asian, and 2.9% of other races. Data were split into two groups; 49.9% occurred between 2009 and 2015 and 50.1% between 2016 and 2022. Findings showed increased UGIB among Hispanics and decreased bleeding among Asians during 2016-2021 compared to 2009-2015. However, no significant difference was found for African Americans, Whites, and other races. In addition, Hispanics had a rise in the annual percentage change (APC) rate, whereas Asians had a decrease. Conclusion Our study examined trends in upper gastrointestinal bleeding and potential healthcare disparities across races and ethnicities. Our findings highlight an increased incidence of UGIB in Hispanics and a decreased incidence in Asians. Additionally, we identified a significant increase in the annual percentage change rate in Hispanics and a decrease in Asians over time. Our study underscores the importance of identifying and addressing disparities in UGIB management to promote health equity. Future research can build on these findings to develop tailored interventions that improve patient outcomes.
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Affiliation(s)
- Rajmohan Rammohan
- Gastroenterology, Nassau University Medical Center, East Meadow, USA
| | - Melvin V Joy
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Tulika Saggar
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | | | - Atul Sinha
- Gastroenterology and Hepatology, Nassau University Medical Center, East Meadow, USA
| | - Dilman Natt
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Sandra Gomez
- Gastroenterology and Hepatology, Nassau University Medical Center, East Meadow, USA
| | - Saher Sheikh
- Gastroenterology and Hepatology, Nassau University Medical Center, East Meadow, USA
| | - Prachi Anand
- Rheumatology, Nassau University Medical Center, East Meadow, USA
| | - Paul Mustacchia
- Gastroenterology and Hepatology, Nassau University Medical Center, East Meadow, USA
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Wu PH, Hung SK, Ko CA, Chang CP, Hsiao CT, Chung JY, Kou HW, Chen WH, Hsieh CH, Ku KH, Wu KH. Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department. Medicina (B Aires) 2023; 59:medicina59030556. [PMID: 36984556 PMCID: PMC10057917 DOI: 10.3390/medicina59030556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.
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Affiliation(s)
- Po-Han Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Shang-Kai Hung
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chien-An Ko
- Department of Otorhinolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Department of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei City 106, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Wan-Hsuan Chen
- Department of Pediatric, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chiao-Hsuan Hsieh
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Kai-Hsiang Ku
- Department of Emergency Medicine, Sijhih Cathay General Hospital, New Taipei City 221, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
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Evaluation of 30-day mortality in patients undergoing gastrointestinal endoscopy in a tertiary hospital: a 3-year retrospective survey. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000977. [DOI: 10.1136/bmjgast-2022-000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/15/2022] [Indexed: 11/11/2022] Open
Abstract
ObjectiveDespite international guidelines recommendations to use mortality as a quality criterion for gastrointestinal (GI) procedures, recent studies reporting these data are lacking. Our objective was to report death causes and rate following GI endoscopies in a tertiary university hospital.DesignWe retrospectively reviewed all GI procedures made between January 2017 and December 2019 in our tertiary hospital in Switzerland. Data from patients who died within 30 days of the procedure were recorded.ResultsOf 18 233 procedures, 251 patients died within 30 days following 345 (1.89%) procedures (244/9180 gastroscopies, 53/5826 colonoscopies, 23/2119 endoscopic ultrasound, 19/911 endoscopic retrograde cholangiopancreatography, 6/197 percutaneous endoscopic gastrostomies). Median age was 70 years (IQR 61–79) and 173/251 (68.92%) were male. Median Charlson Comorbidity Index was 5 (IQR 3–7), and 305/345 procedures (88.4%) were undertaken on patients with an ASA score ≥3. Most frequent indications were suspected GI bleeding (162/345; 46.96%) and suspected cancer or tumourous staging (50/345; 14.49%). Major causes of death were oncological progression (72/251; 28.68%), cardiopulmonary failure or cardiac arrest of unkown origin (62/251; 24,7%) and liver failure (20/251; 7.96%). No deaths were caused by complications such as perforation or bleeding.ConclusionsProgression of malignancies unrelated to the procedure was the leading cause of short-term death following a GI procedure. After improvements in periprocedural care in the last decades, we should focus on patient selection in this era of new oncological and intensive care therapies. Death rate as a quality criterion is subject to caution as it depends on indication, setting and risk benefit ratio.
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Timing of endoscopy in patients with upper gastrointestinal bleeding. Sci Rep 2022; 12:6833. [PMID: 35477727 PMCID: PMC9046398 DOI: 10.1038/s41598-022-10897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/11/2022] [Indexed: 11/08/2022] Open
Abstract
The optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding (UGIB) remains controversial. In this study, we investigated the clinical outcomes of urgent endoscopy in patients with UGIB compared with elective endoscopy. From January 2016 to December 2018, consecutive patients who visited the emergency department and underwent endoscopy for clinical manifestations of acute UGIB, including variceal bleeding, were eligible. Urgent endoscopy (within 6 h) and elective endoscopy (after 6 h) were defined as the time taken to perform endoscopy after presentation to the emergency department. The primary outcome was mortality rate within 30 days. A total of 572 patients were included in the analysis. Urgent endoscopy was performed in 490 patients (85.7%). The 30-day mortality rate did not differ between the urgent and elective endoscopy groups (5.3% and 6.1%, p = 0.791). There was no difference regarding the recurrent bleeding rate, total amount of transfusion, or length of hospital between the groups. In multivariate analysis, age and the amount of transfusion were associated with mortality. Urgent endoscopy was not associated with a lower 30-day mortality rate compared with elective endoscopy in patients with acute UGIB.
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El-Dallal M, Walradt TJ, Stein DJ, Khrucharoen U, Feuerstein JD. Pros and Cons of Performing Early Endoscopy in Geriatric Patients Admitted with Non-variceal Upper Gastrointestinal Bleeding: Analysis of the US National Inpatient Database. Dig Dis Sci 2022; 67:826-833. [PMID: 33710436 DOI: 10.1007/s10620-021-06924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/23/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Age greater than 65 years is a well-defined risk factor for increased mortality in patients with non-variceal upper gastrointestinal bleeding (NVGIB). Endoscopy is indicated in most patients at any age but presents unique risks in the elderly cohort, and ideal timing is unclear. This study examined the association between outcomes and early (within 24 h) esophagogastroduodenoscopy (EGD) among elderly patients with NVGIB. METHODS All patients over age 65 admitted primarily for NVGIB who underwent EGD were included from the National Inpatient Sample 2016-2017. Clinical outcomes stratified by early EGD versus late EGD were compared after adjustment for comorbidities and bleeding severity using inverse probability of treatment weighting with survey-adjusted linear and logistic regression. RESULTS Out of estimated 625,530 admissions with a primary diagnosis of NVGIB, 120,835 met eligibility criteria; 24,830 underwent early EGD. Mean length of stay and total charges decreased by 1.17 days (95%CI 1.04-1.30, P < 0.001) and $5717.24 (95%CI 4034.57-7399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95%CI 1.06-1.64, P 0.01) and transfer to other hospitals 1.48 (95%CI 1.22-1.81, P < 0.001). No change was seen in the requirement for surgery or angiography. Rates of discharge to a nursing facility or home health were similar. CONCLUSION In a comprehensive cohort of geriatric patients with NVGIB, early EGD is associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer. Further research is needed to determine the optimal management of this vulnerable population.
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Affiliation(s)
- Mohammed El-Dallal
- Division of Hospital Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA. .,Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA.
| | - Trent J Walradt
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel J Stein
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Usah Khrucharoen
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA
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11
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Birda CL, Kumar A, Samanta J. Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1731962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.
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Affiliation(s)
- Chhagan L. Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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13
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Papaefthymiou A, Koffas A, Kountouras J, Doulberis M, Kaltsa A, Tsiopoulos F, Christodoulidis G, Kapsoritakis A, Potamianos S. The impact of COVID-19 pandemic on gastrointestinal diseases: a single-center cross-sectional study in central Greece. Ann Gastroenterol 2021; 34:323-330. [PMID: 33948056 PMCID: PMC8079870 DOI: 10.20524/aog.2021.0600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/30/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The current COVID-19 pandemic induced a suppressive environment for healthcare professionals and patients, especially during the lockdown period. Except for the direct burden of the COVID-19, collateral damage has been identified concerning other diseases. The aim of this study was to evaluate the potential impact of the lockdown on the non-COVID-19 patients' outcome in a tertiary gastroenterology department. METHODS Patients admitted to our department during the lockdown period (23 March- 4 May 2020) and during the respective previous year's timeframe were recruited. Sex, age, comorbidities, presenting symptoms, final diagnosis, therapeutic management, duration of hospitalization, and outcome were evaluated. A direct comparison was performed to investigate the potential impact of the lockdown on the duration of hospitalization and the final outcome. RESULTS A total of 161 patients were included to our analysis with 1:1 male:female ratio and mean age 70.86 years. Most of the cases experienced gastrointestinal tract bleeding, biliary stone disease manifestations, or gastrointestinal malignancy complications, and 85.1% were discharged. Fewer patients were hospitalized during the lockdown period (40%), whereas the duration of hospitalization was significantly longer (7.69±4.55 vs. 5.76±4.36 days). Binary logistic regression analysis and sensitivity analysis demonstrated that the quarantine was associated with increased prevalence of negative outcomes (odds ratio 5.21, 95% confidence interval 1.66-16.34; P=0.005), especially in cases with gastrointestinal malignancy and acute pancreatitis (P=0.045 and P=0.041, respectively). CONCLUSION The increase in the negative outcomes of common gastrointestinal diseases and the duration of hospitalization during the lockdown raise reasonable concerns regarding healthcare policies against further outbreaks.
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Affiliation(s)
- Apostolis Papaefthymiou
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
- Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Macedonia, Greece (Apostolis Papaefthymiou, Jannis Kountouras, Michael Doulberis)
| | - Apostolos Koffas
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
| | - Jannis Kountouras
- Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Macedonia, Greece (Apostolis Papaefthymiou, Jannis Kountouras, Michael Doulberis)
| | - Michael Doulberis
- Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Macedonia, Greece (Apostolis Papaefthymiou, Jannis Kountouras, Michael Doulberis)
- Division of Gastroenterology and Hepatology, Medical University Department, Kantonsspital Aarau, Switzerland (Michael Doulberis)
| | - Agoritsa Kaltsa
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
| | - Fotis Tsiopoulos
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
| | | | - Andreas Kapsoritakis
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
| | - Spyros Potamianos
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece (Apostolis Papaefthymiou, Apostolos Koffas, Agoritsa Kaltsa, Fotis Tsiopoulos, Andreas Kapsoritakis, Spyros Potamianos)
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14
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CT for Gastrointestinal Bleeding: A Primer for Residents. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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