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He K, Pang K, Ying L, Yang D, Song K, Ciren Y, Yan X, Guo Z, Lyu C, Wang Q, Wu D. Meta-analysis: Over-the-scope clips in patients at high risk of re-bleeding following upper gastrointestinal tract bleeding. Aliment Pharmacol Ther 2024; 60:112-123. [PMID: 38818831 DOI: 10.1111/apt.18093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/12/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Acute non-variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re-bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over-the-scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain. AIMS To confirm the role of OTSC in patients with UGIB at high risk of re-bleeding. METHODS We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non-variceal UGIB with high re-bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. RESULTS We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08-1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re-bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30-0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30-day mortality, or length of hospital or ICU stay. CONCLUSIONS Moderate certainty evidence supports OTSC as a superior initial treatment for acute non-variceal UGIB with high re-bleeding risk. Further large-scale studies are needed to confirm OTSCs' role by exploring other prognostic outcomes and assessing cost-effectiveness and potential complications.
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Affiliation(s)
- Kun He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
| | - Ke Pang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lujing Ying
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Daiyu Yang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Kai Song
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yangjin Ciren
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
| | - Xiaxiao Yan
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ziqi Guo
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chengzhen Lyu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qiang Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Dong Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
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Pattarapuntakul T, Wong T, Wetwittayakhlang P, Netinatsunton N, Keeratichananont S, Kaewdech A, Jandee S, Chamroonkul N, Sripongpun P, Lakatos PL. Efficacy of Vonoprazan vs. Intravenous Proton Pump Inhibitor in Prevention of Re-Bleeding of High-Risk Peptic Ulcers: A Randomized Controlled Pilot Study. J Clin Med 2024; 13:3606. [PMID: 38930134 PMCID: PMC11204564 DOI: 10.3390/jcm13123606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Proton pump inhibitor (PPI) therapy is well-established for its effectiveness in reducing re-bleeding in high-risk peptic ulcer patients following endoscopic hemostasis. Vonoprazan (VPZ) has demonstrated the capacity to achieve gastric pH levels exceeding 4, comparable to PPIs. This study aims to evaluate the comparative efficacy of intravenous PPI infusion versus VPZ in preventing re-bleeding after endoscopic hemostasis in patients with high-risk peptic ulcers. Methods: A randomized, double-blind, controlled, and double-dummy design was employed. Patients with peptic ulcer bleeding (Forrest class IA/IB or IIA/IIB) who underwent endoscopic hemostasis were randomly assigned to either the PPI group or the VPZ group. Re-bleeding rates at 3, 7, and 30 days, the number of blood transfusions required, length of hospitalization, and ulcer healing rate at 56 days were assessed. Results: A total of 44 eligible patients were enrolled, including 20 patients (PPI group, n = 11; VPZ group, n = 9) with high-risk peptic ulcers. The mean age was 66 years, with 70% being male. Re-bleeding within 72 h occurred in 9.1% of the PPI group versus 0% in the VPZ group (p = 1.000). There was no significant difference in re-bleeding rates within 7 days and 30 days (18.2% vs. 11.1%, p = 1.000). Additionally, the ulcer healing rate did not significantly differ between the groups (87.5% vs. 77.8%). Conclusions: This pilot study demonstrates comparable efficacy between oral vonoprazan and continuous PPI infusion in preventing recurrent bleeding events among high-risk peptic ulcer patients following successful endoscopic hemostasis.
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Affiliation(s)
- Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Nisa Netinatsunton
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (N.N.); (S.K.)
| | - Suriya Keeratichananont
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (N.N.); (S.K.)
| | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Sawangpong Jandee
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Naichaya Chamroonkul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand; (T.P.); (T.W.); (A.K.); (S.J.); (N.C.); (P.S.)
| | - Peter L. Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, 1085 Budapest, Hungary
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Abe H, Tarasawa K, Hatta W, Koike T, Sato I, Ono Y, Ogata Y, Saito M, Jin X, Kanno T, Uno K, Asano N, Imatani A, Fujimori K, Fushimi K, Masamune A. Similar Effect of Vonoprazan and Oral Proton Pump Inhibitors for Preventing Rebleeding in Cases of Upper Gastrointestinal Bleeding. Intern Med 2024; 63:911-918. [PMID: 37558479 PMCID: PMC11045377 DOI: 10.2169/internalmedicine.2211-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
Objective The use of a proton pump inhibitor (PPI) reduces rebleeding and mortality in patients with upper gastrointestinal bleeding (UGIB). Vonoprazan is a novel oral agent with strong and sustained acid-inhibitory activity. We clarified the effect of vonoprazan compared with oral PPIs in such patients. Methods We analyzed the Diagnosis Procedure Combination database. The primary outcome was rebleeding, and secondary outcomes were in-hospital mortality and in-hospital mortality after rebleeding. Propensity score matching was performed to balance the comparison groups, and logistic regression analyses were used to compare the outcomes between vonoprazan and oral PPIs. Patients Patients on vonoprazan or oral PPIs who underwent endoscopic hemostasis for UGIB between 2014 and 2019 were included. Results We enrolled 78,964 patients, of whom 27,101 and 51,863 were prescribed vonoprazan and a PPI, respectively. After propensity score matching, the rebleeding rate of vonoprazan did not significantly differ from that of oral PPIs [6.4% vs. 6.1%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.98-1.13]; similarly, the in-hospital mortality rate (1.4% vs. 1.5%; OR, 0.91; 95% CI, 0.79-1.05) and in-hospital mortality after rebleeding (0.3% vs. 0.2%; OR, 1.09; 95% CI, 0.78-1.54) also did not significantly differ between the groups. The acquired findings were robust across dose-restricted analyses and several sensitivity analyses. Conclusion Rebleeding and in-hospital mortality risks in patients on vonoprazan were similar to those in patients on oral PPIs. Considering the higher cost of vonoprazan, oral PPIs might be an optimal oral agent as an acid-suppressive therapy in such patients.
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Affiliation(s)
- Hiroko Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Isao Sato
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Yoshitaka Ono
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Yohei Ogata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Xiaoyi Jin
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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Tari E, Frim L, Stolcz T, Teutsch B, Veres DS, Hegyi P, Erőss B. At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231190970. [PMID: 37655056 PMCID: PMC10467304 DOI: 10.1177/17562848231190970] [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: 03/01/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI). Objectives We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB. Design A systematic search was conducted in three medical databases in October 2021. Data sources and methods Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias. Results A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies. Conclusion Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI. Registration PROSPERO registration number: CRD42021285727.
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Affiliation(s)
- Edina Tari
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Levente Frim
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tünde Stolcz
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Tömő u. 25.-29., Budapest, 1083, Hungary
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Chan S, Pittayanon R, Wang HP, Chen JH, Teoh AY, Kuo YT, Tang RS, Yip HC, Ng SKK, Wong S, Mak JWY, Chan H, Lau L, Lui RN, Wong M, Rerknimitr R, Ng EK, Chiu PWY. Use of over-the-scope clip (OTSC) versus standard therapy for the prevention of rebleeding in large peptic ulcers (size ≥1.5 cm): an open-labelled, multicentre international randomised controlled trial. Gut 2023; 72:638-643. [PMID: 36307177 PMCID: PMC10086285 DOI: 10.1136/gutjnl-2022-327007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 09/28/2022] [Indexed: 12/08/2022]
Abstract
INTRODUCTION Over-the-scope clip (OTSC) has been used recently for primary haemostasis of peptic ulcers. This study aimed to compare the efficacy of OTSC to standard endoscopic therapy in primary treatment of patients with peptic ulcer bleeding that are of size ≥1.5 cm. The target population accounts for only 2.5% of all upper GI bleeders. METHODS This was a multicentre international randomised controlled trial from July 2017 to October 2020. All patients with Forest IIa or above peptic ulcers of ≥1.5 cm were included. Primary outcome was 30-day clinical rebleeding. Secondary endpoints include 3-day all-cause mortality, transfusion requirement, hospital stay, technical and clinical success, and further interventions. 100 patients are needed to yield a power of 80% to detect a difference of -0.15 at the 0.05 significance level (alpha) using a two-sided Z-test (pooled). RESULTS 100 patients were recruited. Success in achieving primary haemostasis was achieved in 46/50 (92%) and 48/50 (96%) in the OTSC and conventional arm, respectively. Among patients who had success in primary haemostasis, 2/46 (4.35%) patients in the OTSC arm and 9/48 (18.75%) patients in the conventional arm developed 30-day rebleeding (p=0.03). However, in an intention-to-treat analysis, there was no difference in rebleeding within 30 days (5/50 (10%) OTSC vs 9/50 (18%) standard, p=0.23) or all-cause mortality (2/50 (4%) OTSC vs 4/50 (8%) standard, p=0.68; OR=2.09, 95% CI 0.37 to 11.95). There was also no difference in transfusion requirement, hospital stay, intensive care unit admission and further interventions. CONCLUSION The routine use of OTSC as primary haemostasis in large bleeding peptic ulcers was not associated with a significant decrease in 30-day rebleeding. TRIAL REGISTRATION NUMBER NCT03160911.
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Affiliation(s)
- Shannon Chan
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Hsiu-Po Wang
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jiann-Hwa Chen
- Internal Medicine, Buddhist Tzu Chi General Hospital, Taipei, Taiwan
| | - Anthony Yb Teoh
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yu Ting Kuo
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Raymond Sy Tang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hon Chi Yip
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Stephen Ka Kei Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Wong
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joyce Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Heyson Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Louis Lau
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rashid N Lui
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Marc Wong
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Enders K Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Cha B, Noh JH, Ahn JY, Lee JS, Kim GH, Na HK, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical Outcomes of Patients with Benign Peptic Ulcer Bleeding After an Emergency Endoscopy Based on Patient Location. Dig Dis Sci 2022; 68:1539-1550. [PMID: 36284035 DOI: 10.1007/s10620-022-07708-0] [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: 02/02/2022] [Accepted: 09/20/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS In the efforts toward reducing bleeding-related mortality, it is crucial to determine the risk factors for rebleeding after endoscopic hemostasis in benign peptic ulcer (BPU). METHODS Between 2013 and 2017, the medical records of 864 BPU patients were selected from 5076 who had undergone emergency endoscopy for suspected upper gastrointestinal bleeding. Patients who visited the emergency room or were hospitalized for other illnesses were selected. The primary end point was rebleeding within 30 days after initial endoscopy. The risk factors of rebleeding and subgroup analyses according to patient location were evaluated. RESULTS Among 864 BPU bleeding patients, rebleeding after completion of BPU bleeding occurred in 140 (16.2%). Initial indicators of hypotension (OR 1.878, p = 0.005) and Forrest classes Ia (OR 25.53, p < 0.001), Ib (OR 27.91, p = 0.005), IIa (OR 21.41, p < 0.001), and IIb (OR 23.74, p < 0.001) were independent risk factors of rebleeding compared to Forrest class III, and being inpatients (OR 1.75, p = 0.01). Compared to the outpatients, the inpatients showed significantly higher rebleeding rates (25.6% vs 13.8%, p < 0.001), predictive bleeding scores, red blood transfusion counts, proportion of Forrest classes Ia, Ib, and IIb (p < 0.001), and overall mortality rates (68.8% vs 34.0%, p < 0.001). CONCLUSIONS Patient location was a novel predictive factor of BPU rebleeding. Particularly, being an inpatient correlated with increased rebleeding. Furthermore, Forrest classes Ia, Ib, IIa, and IIb were predictive of rebleeding not only the included BPUs, but also in the inpatient or outpatient groups.
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Affiliation(s)
- Boram Cha
- Department of Internal Medicine, Digestive Disease Center, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Jun Su Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ga Hee Kim
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Romstad KK, Detlie TE, Søberg T, Thomas O, Ricanek P, Jahnsen ME, Lerang F, Jahnsen J. Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study). Scand J Gastroenterol 2022; 57:8-15. [PMID: 34663154 DOI: 10.1080/00365521.2021.1988701] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients. MATERIALS AND METHODS A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled. RESULTS Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients. CONCLUSIONS Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.
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Affiliation(s)
- Katrine Kauczynska Romstad
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trond Espen Detlie
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Taran Søberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Owen Thomas
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Marte Eide Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
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8
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Abstract
B. Nulsen D. M. Jensen.
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9
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Hsieh HH, Wu TY, Chen CH, Hour MJ. Cost-effectiveness and clinical outcomes of intermittent/continuous proton pump inhibitors infusion in high bleeding risk of ulcers: A retrospective observational cohort study. Medicine (Baltimore) 2021; 100:e28064. [PMID: 34889253 PMCID: PMC8663891 DOI: 10.1097/md.0000000000028064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 11/11/2021] [Indexed: 01/05/2023] Open
Abstract
The purpose of this study was to evaluate the clinical outcomes, including patient prognosis and medication expense, of proton pump inhibitors administered by high-dose continuous infusion (HDC, 80 mg loading dose, then 8 mg/h for 72 hours) or non-high-dose intermittent infusion (NHDI, 40 mg qd or 40 mg q12 h, for 3 days) regimens in high-risk patients with bleeding peptic ulcers.In this retrospective cohort study, patients with peptic ulcers and endoscopic hemostasis between January, 2013 and December, 2015 were included. The primary endpoints were rebleeding and mortality rates within 7 days. The secondary endpoints were length of stay (LOS), transfusion units of packed red blood cells (PRBCs), and the number needed to treat.A total of 335 patients met the inclusion criteria during the 3-year follow-up period. The cumulative incidence of rebleeding within 7 days was 20.4% and 11.2% in the HDC and NHDI groups, respectively, with a significant difference (P = .021). The mortality rate was 12.1% and 7.3% in the HDC and NHDI groups, respectively, with no significant difference (P = .136). Univariate Cox proportional hazards model analysis showed that the risk of rebleeding within 7 days in the HDC group was higher than that in the NHDI group. The hazard ratio for HDC vs. NHDI was 1.93 (P = .021). There were significant differences in LOS (P = .034) and PRBC units (P = .005) for risk of rebleeding within 7 days, as well as in transfusion units of PRBCs for mortality rate analysis (p < 0.001), between the HDC and NHDI groups. The results showed that the NHDI regimen could reduce the risk of rebleeding within 7 days in 1 of 11 patients (number needed to treat = 11) and could reduce medication cost by US$ 400 to 800.The NHDI regimen showed a lower risk of rebleeding within 7 days, shorter LOS, and fewer PRBC units than that of the HDC regimen. Receiving NHDI has better cost-effective outcomes than that of HDC for patients with high-risk bleeding peptic ulcers.
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Affiliation(s)
- Hui-Hsia Hsieh
- Department of Pharmacy, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Pharmacy, China Medical University, Taichung, Taiwan
| | - Tien-Yuan Wu
- Department of Pharmacy, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Pharmacology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chi-Hua Chen
- Department of Pharmacy, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Mann-Jen Hour
- School of Pharmacy, China Medical University, Taichung, Taiwan
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10
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Hashash JG, Aoun R, El-Majzoub N, Khamis A, Rockey D, Akl EA, Barada K. Resuming aspirin in patients with non-variceal upper gastrointestinal bleeding: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:344-353. [PMID: 33948059 PMCID: PMC8079865 DOI: 10.20524/aog.2021.0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Our primary and secondary aims were to analyze the evidence surrounding mortality and re-bleeding risks in patients on aspirin with non-variceal upper gastrointestinal bleeding (NVUGIB) as a function of whether or not aspirin was resumed after the bleeding episode, and to determine whether aspirin intake upon admission affected the outcomes. Methods A search for randomized controlled trials (RCTs) and prospective observational studies was performed. Data extraction and risk of bias assessment were done. Generic inverse variance and random-effects model were employed. Heterogeneity across studies was assessed using the I2 test. Certainty of evidence was assessed using the GRADE approach for each comparison and outcome, and an evidence profile was created. Results Evidence from 1 RCT and 4 observational studies suggests that early aspirin resumption reduced mortality (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.06-0.63) while increasing re-bleeding risk (HR 1.90, 95%CI 0.60-6.00); moderate certainty of evidence. The observational evidence was inconsistent for both mortality (HR 0.84, 95%CI 0.54-1.33) and re-bleeding (HR 0.85, 95%CI 0.47-1.55); very low certainty of evidence. Nine observational studies addressed our secondary aim: 6 provided inconsistent results regarding mortality (pooled odds ratio [OR] 1.1, 95%CI 0.80-1.50) and 4 provided inconsistent results regarding re-bleeding risk (pooled OR 0.92, 95%CI 0.53-1.59); very low certainty of evidence for both outcomes. Conclusion Evidence supporting a protective effect of aspirin resumption soon after NVUGIB is of low-to-moderate certainty, and is not informative as to the optimal timing of aspirin resumption.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
| | - Roni Aoun
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
| | - Nadim El-Majzoub
- American University of Beirut, Riad El Solh, Beirut, Lebanon (Nadim El-Majzoub)
| | - Assem Khamis
- Clinical Research Institute, American University of Beirut, Riad El Solh, Beirut, Lebanon (Assem Khamis, Elie A. Akl)
| | - Don Rockey
- Division of Gastroenterology, Medical University of South Carolina, USA (Don Rockey)
| | - Elie A Akl
- Clinical Research Institute, American University of Beirut, Riad El Solh, Beirut, Lebanon (Assem Khamis, Elie A. Akl)
| | - Kassem Barada
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
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11
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Loffroy R, Desmyttere AS, Mouillot T, Pellegrinelli J, Facy O, Drouilllard A, Falvo N, Charles PE, Bardou M, Midulla M, Aho-Gléglé S, Chevallier O. Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents. Eur Radiol 2020; 31:3015-3026. [PMID: 33128601 DOI: 10.1007/s00330-020-07427-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/01/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France. .,Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079, Dijon Cedex, France.
| | - Anne-Solène Desmyttere
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Julie Pellegrinelli
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive and Visceral Surgery, François-Mitterrand University Hospital, Dijon, France
| | - Antoine Drouilllard
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Pierre-Emmanuel Charles
- Department of Anesthesia and Intensive Care, François-Mitterrand University Hospital, Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Serge Aho-Gléglé
- Department of Epidemiology and Biostatistics, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
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12
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Wong GLH, Ma AJ, Deng H, Ching JYL, Wong VWS, Tse YK, Yip TCF, Lau LHS, Liu HHW, Leung CM, Tsang SWC, Chan CW, Lau JYW, Yuen PC, Chan FKL. Machine learning model to predict recurrent ulcer bleeding in patients with history of idiopathic gastroduodenal ulcer bleeding. Aliment Pharmacol Ther 2019; 49:912-918. [PMID: 30761584 DOI: 10.1111/apt.15145] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/09/2018] [Accepted: 12/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with a history of Helicobacter pylori-negative idiopathic bleeding ulcers have an increased risk of recurring ulcer complications. AIM To build a machine learning model to identify patients at high risk for recurrent ulcer bleeding. METHODS Data from a retrospective cohort of 22 854 patients (training cohort) diagnosed with peptic ulcer disease in 2007-2016 were analysed to build a model (IPU-ML) to predict recurrent ulcer bleeding. We tested the IPU-ML in all patients with a diagnosis of gastrointestinal bleeding (n = 1265) in 2008-2015 from a different catchment population (independent validation cohort). Any co-morbid conditions which had occurred in >1% of study population were eligible as predictors. RESULTS Recurrent ulcer bleeding developed in 4772 patients (19.5%) in the training cohort, during a median follow-up period of 2.7 years. IPU-ML model built on six parameters (age, baseline haemoglobin, and presence of gastric ulcer, gastrointestinal diseases, malignancies, and infections) identified patients with bleeding recurrence within 1 year with an area under the receiver operating characteristic curve (AUROC) of 0.648. When we set the IPU-ML cutoff value at 0.20, 27.5% of patients were classified as high risk for rebleeding with a sensitivity of 41.4%, specificity of 74.6%, and a negative predictive value of 91.1%. In the validation cohort, the IPU-ML identified patients with a recurrence ulcer bleeding within 1 year with an AUROC of 0.775, and 84.3% of overall accuracy. CONCLUSION We developed a machine-learning model to identify those patients with a history of idiopathic gastroduodenal ulcer bleeding who are not at high risk for recurrent ulcer bleeding.
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Affiliation(s)
- Grace Lai-Hung Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Andy Jinhua Ma
- Department of Computer Science, Hong Kong Baptist University, Hong Kong, China.,School of Data and Computer Science, Sun Yat-Sen University, Guangzhou, China
| | - Huiqi Deng
- Department of Computer Science, Hong Kong Baptist University, Hong Kong, China.,School of Mathematics, Sun Yat-Sen University, Guangzhou, China
| | - Jessica Yuet-Ling Ching
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yee-Kit Tse
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Terry Cheuk-Fung Yip
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Louis Ho-Shing Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Chi-Man Leung
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | | | - Chun-Wing Chan
- Department of Medicine, Yan Chai Hospital, Hong Kong, China
| | - James Yun-Wong Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Pong-Chi Yuen
- Department of Computer Science, Hong Kong Baptist University, Hong Kong, China
| | - Francis Ka-Leung Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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13
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Kim JS, Kim BW, Park SM, Shim KN, Jeon SW, Kim SW, Lee YC, Moon HS, Lee SH, Jung WT, Kim JI, Kim KO, Park JJ, Chung WC, Kim JH, Baik GH, Oh JH, Kim SM, Kim HS, Yang CH, Jung JT, Lim CH, Song HJ, Kim YS, Kim GH, Kim JH, Chung JI, Lee JH, Choi MH, Choi JK. Factors Associated with Rebleeding in Patients with Peptic Ulcer Bleeding: Analysis of the Korean Peptic Ulcer Bleeding (K-PUB) Study. Gut Liver 2018; 12:271-277. [PMID: 29409302 PMCID: PMC5945258 DOI: 10.5009/gnl17138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/10/2017] [Accepted: 09/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background/Aims Rebleeding is associated with mortality in patients with peptic ulcer bleeding (PUB), and risk stratification is important for the management of these patients. The purpose of our study was to examine the risk factors associated with rebleeding in patients with PUB. Methods The Korean Peptic Ulcer Bleeding registry is a large prospectively collected database of patients with PUB who were hospitalized between 2014 and 2015 at 28 medical centers in Korea. We examined the basic characteristics and clinical outcomes of patients in this registry. Univariate and multivariate analyses were performed to identify the factors associated with rebleeding. Results In total, 904 patients with PUB were registered, and 897 patients were analyzed. Rebleeding occurred in 7.1% of the patients (64), and the 30-day mortality was 1.0% (nine patients). According to the multivariate analysis, the risk factors for rebleeding were the presence of co-morbidities, use of multiple drugs, albumin levels, and hematemesis/hematochezia as initial presentations. Conclusions The presence of co-morbidities, use of multiple drugs, albumin levels, and initial presentations with hematemesis/hematochezia can be indicators of rebleeding in patients with PUB. The wide use of proton pump inhibitors and prompt endoscopic interventions may explain the low incidence of rebleeding and low mortality rates in Korea.
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Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sung Min Park
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong Woo Jeon
- Deparment of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sang-Wook Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University School of Medicine, Daegu, Korea
| | - Woon Tae Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jin Il Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyoung Oh Kim
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Woo Chul Chung
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jung Hwan Oh
- Department of Internal Medicine, St. Paul Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Moon Kim
- Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - Hyun Soo Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Heon Yang
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Jin Tae Jung
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Chul Hyun Lim
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Yong Sik Kim
- Department of Internal Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Il Chung
- Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Ho Choi
- Department of Internal Medicine, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jong-Kyoung Choi
- Department of Internal Medicine, National Medical Center, Seoul, Korea
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14
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The Use of Higher Dose Steroids Increases the Risk of Rebleeding After Endoscopic Hemostasis for Peptic Ulcer Bleeding. Dig Dis Sci 2018; 63:3033-3040. [PMID: 30022453 DOI: 10.1007/s10620-018-5209-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/10/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Previous studies have shown that several factors such as hemodynamic instability at admission are risk factors for rebleeding of peptic ulcer bleeding. However, whether steroid use increases the risk of rebleeding remains elusive. AIMS This study aimed to clarify the risk factors for rebleeding after endoscopic hemostasis for peptic ulcer bleeding. METHODS A total of 185 patients who underwent endoscopic hemostasis for peptic ulcer bleeding at our institution between 2005 and 2017 were retrospectively analyzed. We evaluated factors, including comorbid conditions, in-hospital onset, and steroid use, associated with rebleeding by logistic regression analysis. In addition, we investigated the association between the dose of steroids and rebleeding. RESULTS The rebleeding rate after endoscopic hemostasis for peptic ulcer bleeding was 14.6%. In the multivariate analysis, the independent risk factors for rebleeding were steroid use (odds ratio 4.56, p = 0.015), multiple ulcers (4.43, p = 0.005), number of comorbidities ≥ 3 3.18, p = 0.026), hemodynamic instability (3.06, p = 0.039), and number of comorbidities ≥ 3 (2.93, p = 0.047). Furthermore, the use of higher dose steroids (≥ 20 mg per day in prednisolone; 10.55, p = 0.002), but not lower dose (< 20 mg per day in prednisolone), was an independent risk factor for rebleeding in the multivariate analysis. The relationship between steroid use and rebleeding was observed in a dose-dependent manner (p for trend = 0.002). CONCLUSIONS This study first revealed that using higher dose steroids was an independent risk factor for rebleeding after endoscopic hemostasis for peptic ulcer bleeding, with a dose-response relation.
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15
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Gweon TG, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jinsu Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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16
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Vergara-Duarte M, Borrell C, Pérez G, Martín-Sánchez JC, Clèries R, Buxó M, Martínez-Solanas È, Yasui Y, Muntaner C, Benach J. Sentinel Amenable Mortality: A New Way to Assess the Quality of Healthcare by Examining Causes of Premature Death for Which Highly Efficacious Medical Interventions Are Available. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5456074. [PMID: 30246022 PMCID: PMC6139231 DOI: 10.1155/2018/5456074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/08/2018] [Accepted: 05/09/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Amenable mortality, or premature deaths that could be prevented with medical care, is a proven indicator for assessing healthcare quality when adapted to a country or region's specific healthcare context. This concept is currently used to evaluate the performance of national and international healthcare systems. However, the levels of efficacy and effectiveness determined using this indicator can vary greatly depending on the causes of death that are included. We introduce a new approach by identifying a subgroup of causes for which there are available treatments with a high level of efficacy. These causes should be considered sentinel events to help identify limitations in the effectiveness and quality of health provision. METHODS We conducted an extensive literature review using a list of amenable causes of death compiled by Spanish researchers. We complemented this approach by assessing the time trends of amenable mortality in two high-income countries that have a similar quality of healthcare but very different systems of provision, namely, Spain and the United States. This enabled us to identify different levels of efficacy of medical interventions (high, medium, and low). We consulted a group of medical experts and combined this information to help make the final classification of sentinel amenable causes of death. RESULTS Sentinel amenable mortality includes causes such as surgical conditions, thyroid diseases, and asthma. The remaining amenable causes of death either have a higher complexity in terms of the disease or need more effective medical interventions or preventative measures to guarantee early detection and adherence to treatment. These included cardiovascular diseases, diabetes, hypertension, all amenable cancers, and some infectious diseases such as pneumonia, influenza, and tuberculosis. CONCLUSIONS Sentinel amenable mortality could act as a good sentinel indicator to identify major deficiencies in healthcare quality and provision and detect inequalities across populations.
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Affiliation(s)
- Montse Vergara-Duarte
- CAP El Clot and Unitat d'Avaluació, Sistemes d'Informació i Qualitat Assistencial, Gerència Territorial de Barcelona, Institut Català de la Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Carme Borrell
- Agència de Salut Pública de Barcelona, Barcelona, Spain
- CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Glòria Pérez
- Agència de Salut Pública de Barcelona, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Juan Carlos Martín-Sánchez
- Biostatistics Unit, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | - Ramon Clèries
- Pla Director d'Oncología, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Universitat de Barcelona, Barcelona, Spain
| | - Maria Buxó
- Girona Biomedical Research Institute (IDIBGI), Salt, Spain
| | - Èrica Martínez-Solanas
- CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- ISGlobal, Center for Research in Environmental Epidemiology (CREAL), Spain
| | - Yutaka Yasui
- Department of Epidemiology & Cancer Control (S6050), St. Jude Children's Research Hospital, Memphis, TN, USA
- School of Public Health, University of Alberta, 4-274, Edmonton Clinic Health Academy, Edmonton, AB, Canada
| | - Carles Muntaner
- Bloomberg Faculty of Nursing and Dalla Lana School of Public Health, University of Toronto, Canada
| | - Joan Benach
- Health Inequalities Research Group-Employment Conditions Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- Johns Hopkins University, Public Policy Center, Barcelona, Spain
- Grupo de Investigación Transdisciplinar sobre Transiciones Socioecológicas (GinTRANS2), Universidad Autónoma de Madrid, Madrid, Spain
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Characteristics and outcomes of gastroduodenal ulcer bleeding: a single-centre experience in Lithuania. GASTROENTEROLOGY REVIEW 2018; 12:277-285. [PMID: 29358997 PMCID: PMC5771452 DOI: 10.5114/pg.2017.72103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 10/29/2016] [Indexed: 11/29/2022]
Abstract
Introduction Despite the optimal use of combined endoscopic haemostasis and pharmacologic control of acid secretion in the stomach, mortality in patients with peptic ulcer bleeding (PUB) has remained constant. Recent data has shown that the majority of patients with PUB die of non-bleeding-related causes. Aim To provide an overview of our experience of PUB management, with emphasis on the effect of age, gender, comorbidities, and drug use on the characteristics and outcomes of gastroduodenal ulcer bleeding. Material and methods We retrospectively reviewed the medical records of all patients admitted with the primary diagnosis of acute, chronic or unspecified gastric and/or duodenal ulcer with haemorrhage during 2008–2012. Results Two hundred and nineteen patients were identified. 46.6% of patients were ≥ 65 years old (elderly) and 53.4% were < 65 years old (young). The young patients were more likely to have duodenal ulcers and liver failure at admission. Previous use of medications was more regularly observed in gastric ulcer patients than in duodenal ulcer patients. Rebleeding occurred in 43 (19.6%) patients and death in 5 (2.3%) patients. Increased risk of mortality in our patients was associated with age ≥ 65 years (RR = 2.21; 95% CI: 1.90–2.56; p = 0.021). Conclusions Management of peptic ulcer bleeding should aim at reducing the risk of multiorgan failure and cardiopulmonary death instead of focusing merely on successful haemostasis.
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Chan SM, Lau JYW. Can we now recommend OTSC as first-line therapy in case of non-variceal upper gastrointestinal bleeding? Endosc Int Open 2017; 5:E883-E885. [PMID: 28924594 PMCID: PMC5595577 DOI: 10.1055/s-0043-111722] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 05/02/2017] [Indexed: 01/29/2023] Open
Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - James YW Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Zamparini E, Ahmed P, Belhassan M, Horaist C, Bouguerba A, Ayed S, Barchasz J, Boukari M, Goldgran-Toledano D, Yaacoubi S, Bornstain C, Nahon S, Vincent F. Orientation des patients adultes consultant aux urgences pour hémorragie digestive (hors hypertension portale prouvée ou présumée) : intérêt des scores pronostiques. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Thongbai T, Thanapirom K, Ridtitid W, Rerknimitr R, Thungsuk R, Noophun P, Wongjitrat C, Luangjaru S, Vedkijkul P, Lertkupinit C, Poonsab S, Ratanachu-ek T, Hansomburana P, Pornthisarn B, Mahachai V, Treeprasertsuk S. Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.1002.471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Background
Acute upper gastrointestinal bleeding (UGIB) is a common gastrointestinal disease emergency and a cause of morbidity and mortality.
Objectives
To assess the clinical outcomes and explore predictive factors for mortality of elderly patients with acute UGIB.
Methods
During the study period from January 2010 to September 2011, we prospectively enrolled 981 patients presenting with UGIB from 11 hospitals (mean age ± standard deviation (SD), 59.4 ± 14.9 years; range, 17–94 years; including 661 men). Of these 981 patients, 499 (50.9%) were elderly. Basic demographic data and clinical findings, and Rockall scores were collected and calculated.
Results
We studied 499 elderly patients. Their mean age ± SD was 71.63 ± 7.65 years. The 30-day mortality rate was 9% and rebleeding was just 1%. Regression analysis showed a pulse rate >100 beats per min at first visit, red blood in a nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL were independent predictive factors of 30-day mortality.
Conclusions
Peptic ulcer bleeding is a major cause of acute UGBI in the elderly. We recommend patients with predictive factors of mortality, pulse rate >100 beats per min at first visit, red blood in nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL be closely monitored and treated promptly. Reducing mortality from peptic ulcer bleeding should focus on preventing peptic ulcer occurrence as a result of ulcerogenic medications.
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Affiliation(s)
- Thirada Thongbai
- Division of Gastroenterology , Bangkok Metropolitan Administration General Hospital , Bangkok 10100 , Thailand
| | - Kessarin Thanapirom
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Rattikorn Thungsuk
- Division of Gastroenterology , Sawanpracharak Hospital , Nakhon Sawan 60000 , Thailand
| | - Phadet Noophun
- Division of Gastroenterology , Surin Hospital , Surin 32000 , Thailand
| | - Chatchawan Wongjitrat
- Division of Gastroenterology , HRH Princess Maha Chakri Sirindhorn Medical Center–MSMC Hospital , Nakhon Nayok 26120 , Thailand
| | - Somchai Luangjaru
- Division of Gastroenterology , Maharat Nakhonratchasima Hospital , Nakhon Ratchasima 30000 , Thailand
| | - Padet Vedkijkul
- Division of Gastroenterology , Maharaj Nakhonsithammarat Hospital , Nakhon Sithammarat 80000 , Thailand
| | - Comson Lertkupinit
- Division of Gastroenterology , Chonburi Hospital , Chonburi 20000 , Thailand
| | - Swangphong Poonsab
- Division of Gastroenterology , Bangkok Hospital , Bangkok 10310 , Thailand
| | | | | | - Bubpha Pornthisarn
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Thammasat University Hospital , Pathum Thani 12120 , Thailand
| | - Varocha Mahachai
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology , Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
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Is Endoscopic Therapy Safe for Upper Gastrointestinal Bleeding in Anticoagulated Patients With Supratherapeutic International Normalized Ratios? Am J Ther 2016; 23:e995-e1003. [DOI: 10.1097/mjt.0000000000000002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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The Novel Scoring System for 30-Day Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2016; 61:2002-10. [PMID: 26921080 DOI: 10.1007/s10620-016-4087-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/13/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although the mortality rates for non-variceal upper gastrointestinal bleeding (NVUGIB) have recently decreased, it remains a significant medical problem. AIM The main aim of this prospective multicenter database study was to construct a clinically useful predictive scoring system by using our predictors and compare its prognostic accuracy with that of the Rockall scoring system. METHODS Data were collected from consecutive patients with NVUGIB. Logistic regression analysis was performed to identify the independent predictors of 30-day mortality. Each independent predictor was assigned an integral point proportional to the odds ratio (OR) and we used the area under the curve to compare the discrimination ability between the new predictive model and the Rockall score. RESULTS The independent predictors of mortality included age >65 years [OR 2.627; 95 % confidence interval (CI) 1.298-5.318], hemodynamic instability (OR 2.217; 95 % CI 1.069-4.597), serum blood urea nitrogen level >40 mg/dL (OR 1.895; 95 % CI 1.029-3.490), active bleeding at endoscopy (OR 2.434; 95 % CI 1.283-4.616), transfusions (OR 3.811; 95 % CI 1.640-8.857), comorbidities (OR 3.481; 95 % CI 1.405-8.624), and rebleeding (OR 10.581; 95 % CI 5.590-20.030). The new predictive model showed a high discrimination capability and was significantly superior to the Rockall score in predicting the risk of death (OR 0.837;95 % CI 0.818-0.855 vs. 0.761; 0.739-0.782; P = 0.0123). CONCLUSIONS The new predictive score was significantly more accurate than the Rockall score in predicting death in NVUGIB patients. We need to prospectively validate the accuracy of this score for predicting mortality in NVUGIB patients.
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Camus M, Jensen DM, Kovacs TO, Jensen ME, Markovic D, Gornbein J. Independent risk factors of 30-day outcomes in 1264 patients with peptic ulcer bleeding in the USA: large ulcers do worse. Aliment Pharmacol Ther 2016; 43:1080-9. [PMID: 27000531 PMCID: PMC4837138 DOI: 10.1111/apt.13591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 05/30/2015] [Accepted: 03/01/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeds (PUBs) are essential indicators because of significant morbidity and mortality rates of PUBs. However those have been infrequently reported since changes in medical therapy (PPI, proton pump inhibitors) and application of newer endoscopic haemostatic technique. AIMS To determine: (i) independent risk factors for 30-day rebleeding, surgery, and death and (ii) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB after successful endoscopic haemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists - H2RAs). METHODS A large prospectively followed population of patients hospitalised with severe PUBs between 1993 and 2011 at two US tertiary care academic medical centres, stratified by stigmata of recent haemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors for each outcome (rebleeding, surgery and death) up to 30 days were analysed. Effects for medical treatment (H2RA patients 1993-2005 vs. PPIs 2006-2011) were also analysed. RESULTS A total of 1264 patients were included. For ulcers ≥10 mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95% CI 1.02-1.10, P = 0.0053). Other risk factors for 30-day rebleeding were major SRH, in-patient start of bleeding, and prior GI bleeding. Major SRH and ulcer size≥10 mm were predictors of 30-day surgery. Risk factors for 30-day death were major SRH, in-patient bleeding, and any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and out-patient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95% CI 1.02-1.14, P = 0.0095). Ulcer size was a significant independent variable for both time periods. CONCLUSIONS Ulcer size is a risk factor for worse outcomes after PUB and should be carefully recorded at initial endoscopy to improve patient triage and management.
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Affiliation(s)
- Marine Camus
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Department of Gastroenterology, Cochin Hospital, APHP, University Paris 5, France
| | - Dennis M. Jensen
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Gastroenterology Division at VA GLAHC, Los Angeles, CA, United States
| | - Thomas O. Kovacs
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Gastroenterology Division at VA GLAHC, Los Angeles, CA, United States
| | - Mary Ellen Jensen
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
| | - Daniela Markovic
- Department of Biomathematics, University of California, Los Angeles, California
| | - Jeffrey Gornbein
- Department of Biomathematics, University of California, Los Angeles, California
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Tsurukiri J, Akamine I, Sato T, Sakurai M, Okumura E, Moriya M, Yamanaka H, Ohta S. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med 2016; 24:13. [PMID: 26861070 PMCID: PMC4748599 DOI: 10.1186/s13049-016-0205-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/02/2016] [Indexed: 02/01/2023] Open
Abstract
Background Haemorrhagic shock is a major cause of death in the acute care setting. Since 2009, our emergency department has used intra-aortic balloon occlusion (IABO) catheters for resuscitative endovascular balloon occlusion of the aorta (REBOA). Methods REBOA procedures were performed by one or two trained acute care physicians in the emergency room (ER) and intensive care unit (ICU). IABO catheters were positioned using ultrasonography. Collected data included clinical characteristics, haemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality. Results Subjects comprised 25 patients (trauma, n = 16; non-trauma, n = 9) with a median age of 69 years and a median shock index of 1.4. REBOA was achieved in 22 patients, but failed in three elderly trauma patients. Systolic blood pressure significantly increased after REBOA (107 vs. 71 mmHg, p < 0.01). Five trauma patients (20 %) died in ER, and mortality rates within 24 h and 60 days were 20 % and 12 %, respectively. No REBOA-related complications were encountered. The total occlusion time of REBOA was significantly lesser in survivors than that in non-survivors (52 vs. 97 min, p < 0.01). Significantly positive correlations were found between total occlusion time of REBOA and shock index (Spearman’s r = 0.6) and lactate concentration (Spearman’s r = 0.7) in survivors. Conclusion REBOA can be performed in ER and ICU with a high degree of technical success. Furthermore, correlations between occlusion time and initial high lactate levels and shock index may be important because prolonged occlusion is associated with a poorer outcome.
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Affiliation(s)
- Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan.
| | - Itsurou Akamine
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Takao Sato
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Masatsugu Sakurai
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Eitaro Okumura
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Mariko Moriya
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Hiroshi Yamanaka
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Shoichi Ohta
- Emergency and Disaster Medicine, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku , Shinjuku, Tokyo, 160-0023, Japan
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25
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Lee YJ, Min BR, Kim ES, Park KS, Cho KB, Jang BK, Chung WJ, Hwang JS, Jeon SW. Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding. Korean J Intern Med 2016; 31:54-64. [PMID: 26767858 PMCID: PMC4712435 DOI: 10.3904/kjim.2016.31.1.54] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/28/2014] [Accepted: 11/13/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency that can be life threatening. This study evaluated predictive factors of 30-day mortality in patients with this condition. METHODS A prospective observational study was conducted at a single hospital between April 2010 and November 2012, and 336 patients with symptoms and signs of gastrointestinal bleeding were consecutively enrolled. Clinical characteristics and endoscopic findings were reviewed to identify potential factors associated with 30-day mortality. RESULTS Overall, 184 patients were included in the study (men, 79.3%; mean age, 59.81 years), and 16 patients died within 30 days (8.7%). Multivariate analyses revealed that comorbidity of diabetes mellitus (DM) or metastatic malignancy, age ≥ 65 years, and hypotension (systolic pressure < 90 mmHg) during hospitalization were significant predictive factors of 30-day mortality. CONCLUSIONS Comorbidity of DM or metastatic malignancy, age ≥ 65 years, and hemodynamic instability during hospitalization were predictors of 30-day mortality in patients with NVUGIB. These results will help guide the management of patients with this condition.
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Affiliation(s)
- Yoo Jin Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Bo Ram Min
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Eun Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Correspondence to Eun Soo Kim, M.D. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: +82-53-250-8096 Fax: +82-53-250-7442 E-mail:
| | - Kyung Sik Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang Bum Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Byoung Kuk Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Seok Hwang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Woo Jeon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Nemiroski A, Ryou M, Thompson CC, Westervelt RM. Swallowable fluorometric capsule for wireless triage of gastrointestinal bleeding. LAB ON A CHIP 2015; 15:4479-4487. [PMID: 26490455 DOI: 10.1039/c5lc00770d] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Real-time detection of gastrointestinal bleeding remains a major challenge because there does not yet exist a minimally invasive technology that can both i) monitor for blood from an active hemorrhage and ii) uniquely distinguish it from blood left over from an inactive hemorrhage. Such a device would be an important tool for clinical triage. One promising solution, which we have proposed previously, is to inject a fluorescent dye into the blood stream and to use it as a distinctive marker of active bleeding by monitoring leakage into the gastrointestinal tract with a wireless fluorometer. This paper reports, for the first time to our knowledge, the development of a swallowable, wireless capsule with a built-in fluorometer capable of detecting fluorescein in blood, and intended for monitoring gastrointestinal bleeding in the stomach. The embedded, compact fluorometer uses pinholes to define a microliter sensing volume and to eliminate bulky optical components. The proof-of-concept capsule integrates optics, low-noise analog sensing electronics, a microcontroller, battery, and low power Zigbee radio, all into a cylindrical package measuring 11 mm × 27 mm and weighing 10 g. Bench-top experiments demonstrate wireless fluorometry with a limit-of-detection of 20 nM aqueous fluorescein. This device represents a major step towards a technology that would enable simple, rapid detection of active gastrointestinal bleeding, a capability that would save precious time and resources and, ultimately, reduce complications in patients.
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Affiliation(s)
- A Nemiroski
- Department of Chemistry and Chemical Biology, Harvard University, 12 Oxford St., Cambridge, MA 02138, USA.
| | - M Ryou
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - C C Thompson
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - R M Westervelt
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA and Department of Physics, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA.
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Hoffmann V, Neubauer H, Heinzler J, Smarczyk A, Hellmich M, Bowe A, Kuetting F, Demir M, Pelc A, Schulte S, Toex U, Nierhoff D, Steffen HM. A Novel Easy-to-Use Prediction Scheme for Upper Gastrointestinal Bleeding: Cologne-WATCH (C-WATCH) Risk Score. Medicine (Baltimore) 2015; 94:e1614. [PMID: 26402828 PMCID: PMC4635768 DOI: 10.1097/md.0000000000001614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the leading indication for emergency endoscopy. Scoring schemes have been developed for immediate risk stratification. However, most of these scores include endoscopic findings and are based on data from patients with nonvariceal bleeding. The aim of our study was to design a pre-endoscopic score for acute UGIB--including variceal bleeding--in order to identify high-risk patients requiring urgent clinical management. The scoring system was developed using a data set consisting of 586 patients with acute UGIB. These patients were identified from the emergency department as well as all inpatient services at the University Hospital of Cologne within a 2-year period (01/2007-12/2008). Further data from a cohort of 322 patients who presented to our endoscopy unit with acute UGIB in 2009 served for external/temporal validation.Clinical, laboratory, and endoscopic parameters, as well as further data on medical history and medication were retrospectively collected from the electronic clinical documentation system. A multivariable logistic regression was fitted to the development set to obtain a risk score using recurrent bleeding, need for intervention (angiography, surgery), or death within 30 days as a composite endpoint. Finally, the obtained risk score was evaluated on the validation set. Only C-reactive protein, white blood cells, alanine-aminotransferase, thrombocytes, creatinine, and hemoglobin were identified as significant predictors for the composite endpoint. Based on the regression coefficients of these variables, an easy-to-use point scoring scheme (C-WATCH) was derived to estimate the risk of complications from 3% to 86% with an area under the curve (AUC) of 0.723 in the development set and 0.704 in the validation set. In the validation set, no patient in the identified low-risk group (0-1 points), but 38.7% of patients in the high-risk group (≥ 2 points) reached the composite endpoint. Our easy-to-use scoring scheme is able to distinguish high-risk patients requiring urgent endoscopy, from low-risk cases who are suitable candidates for outpatient management or in whom endoscopy may be postponed. Based on our findings, a prospective validation of the C-WATCH score in different patient populations outside the university hospital setting seems warranted.
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Affiliation(s)
- Vera Hoffmann
- From the Clinic for Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Str. 62, Köln, Germany (HV, NH, HJ, SA, BA, KF, DM, PA, SS, TU, ND, SHM); Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Str. 62, Köln, Germany (HM)
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Cassana A, Scialom S, Segura ER, Chacaltana A. [Validation of the Glasgow-Blatchford Scoring System to predict mortality in patients with upper gastrointestinal bleeding in a hospital of Lima, Peru (June 2012-December 2013)]. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107:476-82. [PMID: 26228950 DOI: 10.17235/reed.2015.3745/2015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM Upper gastrointestinal bleeding is a major cause of hospitalization and the most prevalent emergency worldwide, with a mortality rate of up to 14%. In Peru, there have not been any studies on the use of the Glasgow-Blatchford Scoring System to predict mortality in upper gastrointestinal bleeding. The aim of this study is to perform an external validation of the Glasgow-Blatchford Scoring System and to establish the best cutoff for predicting mortality in upper gastrointestinal bleeding in a hospital of Lima, Peru. METHODS This was a longitudinal, retrospective, analytical validation study, with data from patients with a clinical and endoscopic diagnosis of upper gastrointestinal bleeding treated at the Gastrointestinal Hemorrhage Unit of the Hospital Nacional Edgardo Rebagliati Martins between June 2012 and December 2013. We calculated the area under the curve for the receiver operating characteristic of the Glasgow-Blatchford Scoring System to predict mortality with a 95% confidence interval. RESULTS A total of 339 records were analyzed. 57.5% were male and the mean age (standard deviation) was 67.0 (15.7) years. The median of the Glasgow-Blatchford Scoring System obtained in the population was 12. The ROC analysis for death gave an area under the curve of 0.59 (95% CI 0.5-0.7). Stratifying by type of upper gastrointestinal bleeding resulted in an area under the curve of 0.66 (95% CI 0.53-0.78) for non-variceal type. CONCLUSIONS In this population, the Glasgow-Blatchford Scoring System has no diagnostic validity for predicting mortality.
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Chiu PWY, Chan FKL, Lau JYW. Endoscopic Suturing for Ulcer Exclusion in Patients With Massively Bleeding Large Gastric Ulcer. Gastroenterology 2015; 149:29-30. [PMID: 25962937 DOI: 10.1053/j.gastro.2015.04.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/25/2015] [Accepted: 04/13/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Philip Wai Yan Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
| | | | - James Yun Wong Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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Simon TG, Travis AC, Saltzman JR. Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:429-42. [PMID: 26142029 DOI: 10.1016/j.giec.2015.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.
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Affiliation(s)
- Tracey G Simon
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Abstract
Peptic ulcer bleeding is a common emergency. Management of ulcer bleeding requires prompt risk stratification, initiation of pharmacotherapy, and timely evaluation for endoscopy. Although endoscopy can achieve primary hemostasis in more than 90% of peptic ulcer bleeding, rebleeding may occur in up to 15% of patients after therapeutic endoscopy and is associated with heightened mortality. Early identification of high-risk patients for rebleeding is important. Depending on bleeding severity and center availability, patients with rebleeding may be managed by second endoscopy, transarterial angiographic embolization, or surgery. This article reviews the current management of peptic ulcers with an emphasis on rebleeding.
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Affiliation(s)
- Sunny H Wong
- State Key Laboratory of Digestive Disease, Faculty of Medicine, Institute of Digestive Disease, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China
| | - Joseph J Y Sung
- State Key Laboratory of Digestive Disease, Faculty of Medicine, Institute of Digestive Disease, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China.
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Park WG, Shaheen NJ, Cohen J, Pike IM, Adler DG, Inadomi JM, Laine LA, Lieb JG, Rizk MK, Sawhney MS, Wani S. Quality indicators for EGD. Gastrointest Endosc 2015; 81:17-30. [PMID: 25480101 DOI: 10.1016/j.gie.2014.07.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
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de Groot N, van Oijen M, Kessels K, Hemmink M, Weusten B, Timmer R, Hazen W, van Lelyveld N, Vermeijden, Curvers W, Baak L, Verburg R, Bosman J, de Wijkerslooth L, de Rooij J, Venneman N, Pennings M, van Hee K, Scheffer R, van Eijk R, Meiland R, Siersema P, Bredenoord A. Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding. United European Gastroenterol J 2014; 2:197-205. [PMID: 25360303 DOI: 10.1177/2050640614531574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/08/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding. METHODS WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes. RESULTS We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively). CONCLUSIONS Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.
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Affiliation(s)
- Nl de Groot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Mgh van Oijen
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; University of California Los Angeles/Veterans Affairs Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA ; Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - K Kessels
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M Hemmink
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Wl Hazen
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - N van Lelyveld
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Vermeijden
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Wl Curvers
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Lc Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - R Verburg
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands
| | - Jh Bosman
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Lrh de Wijkerslooth
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - J de Rooij
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Ng Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - M Pennings
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - K van Hee
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rch Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rl van Eijk
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - R Meiland
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - Pd Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Aj Bredenoord
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
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Chiu PWY, Lau JYW. What if endoscopic hemostasis fails?: Alternative treatment strategies: surgery. Gastroenterol Clin North Am 2014; 43:753-63. [PMID: 25440923 DOI: 10.1016/j.gtc.2014.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.
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Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China.
| | - James Yun Wong Lau
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China
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Tammaro L, Buda A, Di Paolo MC, Zullo A, Hassan C, Riccio E, Vassallo R, Caserta L, Anderloni A, Natali A. A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding. Dig Liver Dis 2014; 46:783-7. [PMID: 24953205 DOI: 10.1016/j.dld.2014.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/02/2014] [Accepted: 05/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pre-endoscopic triage of patients who require an early upper endoscopy can improve management of patients with non-variceal upper gastrointestinal bleeding. AIMS To validate a new simplified clinical score (T-score) to assess the need of an early upper endoscopy in non variceal bleeding patients. Secondary outcomes were re-bleeding rate, 30-day bleeding-related mortality. METHODS In this prospective, multicentre study patients with bleeding who underwent upper endoscopy were enrolled. The accuracy for high risk endoscopic stigmata of the T-score was compared with that of the Glasgow Blatchford risk score. RESULTS Overall, 602 patients underwent early upper endoscopy, and 472 presented with non-variceal bleeding. High risk endoscopic stigmata were detected in 145 (30.7%) cases. T-score sensitivity and specificity for high risk endoscopic stigmata and bleeding-related mortality was 96% and 30%, and 80% and 71%, respectively. No statistically difference in predicting high risk endoscopic stigmata between T-score and Glasgow Blatchford risk score was observed (ROC curve: 0.72 vs. 0.69, p=0.11). The two scores were also similar in predicting re-bleeding (ROC curve: 0.64 vs. 0.63, p=0.4) and 30-day bleeding-related mortality (ROC curve: 0.78 vs. 0.76, p=0.3). CONCLUSIONS The T-score appeared to predict high risk endoscopic stigmata, re-bleeding and mortality with similar accuracy to Glasgow Blatchford risk score. Such a score may be helpful for the prediction of high-risk patients who need a very early therapeutic endoscopy.
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Affiliation(s)
- Leonardo Tammaro
- Gastroenterology and Digestive Endoscopy, San Giovanni Addolorata Hospital, Rome, Italy.
| | - Andrea Buda
- Division of Gastroenterology, University of Padua, Italy
| | - Maria Carla Di Paolo
- Gastroenterology and Digestive Endoscopy, San Giovanni Addolorata Hospital, Rome, Italy
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy.
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | | | - Roberto Vassallo
- Gastroenterology and Endoscopy, Buccheri La Ferla, Fatebenefratelli Hospital, Palermo, Italy
| | - Luigi Caserta
- Gastroenterology and Digestive Endoscopy, IRCCS San Martino Genova, Italy
| | - Andrea Anderloni
- Digestive Endoscopy, Istituto Clinico Humanitas, Rozzano, Milan, Italy
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Chiu PWY, Chan FKL. Upper gastrointestinal bleeding: risk scores and clinical judgment in predicting outcomes of UGIB. Nat Rev Gastroenterol Hepatol 2014; 11:399-401. [PMID: 24935417 DOI: 10.1038/nrgastro.2014.98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Predicting outcomes in upper gastrointestinal bleeding (UGIB) is important for identifying patients at high risk of morbidity and mortality who would benefit from early intervention. Various scoring systems have been developed to this end, but could clinical judgment replace or complement these risk stratification scores?
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Affiliation(s)
- Philip W Y Chiu
- Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine & Therapeutics, Prince of Wales Hospital, 30-32 Ngan Shing Street, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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Abu Daya H, Eloubeidi M, Tamim H, Halawi H, Malli AH, Rockey DC, Barada K. Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding. J Dig Dis 2014; 15:283-92. [PMID: 24593260 DOI: 10.1111/1751-2980.12140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB). METHODS The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded. RESULTS Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6). CONCLUSIONS Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.
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Affiliation(s)
- Hussein Abu Daya
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
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Rotondano G, Cipolletta L, Koch M, Bianco MA, Grossi E, Marmo R. Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: implications for early discharge? Dig Liver Dis 2014; 46:231-6. [PMID: 24361122 DOI: 10.1016/j.dld.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 09/25/2013] [Accepted: 10/28/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding. AIMS Identify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death). METHODS Secondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis. RESULTS Out of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoy's lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome. CONCLUSIONS The "good luck score" may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.
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Affiliation(s)
| | | | - Maurizio Koch
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Gastroenterology ACO San Filippo Neri, Roma, Italy
| | | | - Enzo Grossi
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Medical Department, Bracco, Milano, Italy
| | - Riccardo Marmo
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Gastroenterology Hospital Curto, Polla, Italy
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Epidemiological Clinical Features and Evolution of Gastroduodenal Ulcer Bleeding in a Tertiary Care Hospital in Spain, during the Last Seven Years. Gastroenterol Res Pract 2014; 2013:584540. [PMID: 24385981 PMCID: PMC3872235 DOI: 10.1155/2013/584540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 11/04/2013] [Indexed: 11/25/2022] Open
Abstract
Background. Gastroduodenal ulcer bleeding is a common medical emergency. The aim of this study was to analyze the characteristics of bleeding episodes and to identify changes in the clinical trends over seven years. Methods. Retrospective observational clinical study on a cohort of 272 consecutive adult patients with peptic ulcer bleeding, during the 2006–2012 period. Results. Mean annual admission rate was 12.8 per 100.000 inhabitants. Men were predominant (71%), with a mean age of 66.6 years. Comorbidities were present in 131 cases (48.2%) and 156 patients (57.4%) had received ulcerogenic drugs. Duodenal ulcer was the commonest location (61%). Endoscopic therapy was necessary in 183 cases (67.3%) and rebleeding occurred in 30 patients (11%). Overall mortality rate was 5.5%, with a significant association with the presence of comorbidities (P < 0.01). There were no differences in trends of annual hospitalization, clinical features at presentation, and outcomes during this 7-years period. Conclusions. Annual hospitalization rates and prognosis of peptic ulcer bleeding have remained unchanged in the study period. This may be due to the fact that the effect of improved approach on this condition is probably counteracted by risk factors such as older age, severe comorbidities, and ulcerogenic drugs consumption, which have also remained stable over recent years.
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Chiu PWY. Second look endoscopy in acute non-variceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2013; 27:905-11. [PMID: 24182610 DOI: 10.1016/j.bpg.2013.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 09/20/2013] [Accepted: 09/25/2013] [Indexed: 01/31/2023]
Abstract
Bleeding peptic ulcer remained an important cause of hospitalization worldwide. Primary endoscopic hemostasis achieved more than 90% of initial hemostasis for bleeding peptic ulcer. Recurrent bleeding amounted to 15% after therapeutic endoscopy, and rebleeding is an important risk factor to peptic ulcer related mortality. Routine second look endoscopy was one of the strategies targeted at prevention of rebleeding. The objective of second look endoscopy was to treat persistent stigmata of recent hemorrhage before rebleeding. Three meta-analyses showed that performance of routine second look endoscopy significantly reduced ulcer rebleeding especially when the endoscopic therapy was performed with thermal coagulation. Two cost-effectiveness analyses, however, demonstrated that selective instead of routine second look endoscopy is the most cost-effective approach to prevent ulcer rebleeding. While international consensus and guidelines did not recommend routine performance of second look endoscopy for prevention of ulcer rebleeding, further research should focus on identification of patients with high risk of rebleeding and investigate the effect of selective second look endoscopy in prevention of rebleeding among these patients.
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Affiliation(s)
- Philip Wai Yan Chiu
- Institute of Digestive Disease, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China.
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Cesaro P, Kohn A, Petruziello L, Angelico M, Franceschi F, Gigliozzi A, Lamazza A, Tammaro L, Boschetto S, Brighi S, Antoniozzi A, Baiocchi L. A survey on mortality from non-variceal upper gastrointestinal bleeding: Is the emergency referral system adequate? Dig Liver Dis 2013; 45:953-6. [PMID: 23746421 DOI: 10.1016/j.dld.2013.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/11/2013] [Accepted: 04/25/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important cause of mortality and morbidity worldwide. Little information is available on the clinical management of non-variceal upper gastrointestinal bleeding in Italy in relation to the current organization of the Italian Emergency Health Services into Level-I and Level-II Emergency Departments (ED), the latter being more complex structures with greater resources. METHODS A retrospective survey on clinical, endoscopic, and survival data was conducted by the regional sections of the 3 main Italian gastroenterological societies, AIGO, SIED and SIGE, recording all consecutive episodes of non-variceal upper gastrointestinal bleeding referred to 7 centres (4 of which were Level-II Emergency Departments) in Rome, Italy, during a one-year period. A total of 624 consecutive patients (64% males, mean age 67.6 ± 16.2 years) were included. Thirty-day mortality was 4.6%. Main factors associated with survival at both univariate and multivariate analysis were the presence of full Rockall score <5 and the admission to a Level-II Emergency Departments (p<0.001). Level-I Emergency Departments admitted patients with a full Rockall score ≥ 5 (p=0.02) more frequently than patients with negative endoscopic findings (p<0.001). CONCLUSIONS Referral of non-variceal upper gastrointestinal bleeding patients to Emergency Departments with more resources (Level-II) is associated with reduced mortality. Yet, unfortunately, high-risk patients were more often admitted to Level-I Emergency Departments, which suggests the need for a better organization of the emergency referral system.
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Affiliation(s)
- Paola Cesaro
- Policlinico Universitario "Agostino Gemelli", Rome, Italy
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Wong SH, Sung JJY. Management of GI emergencies: peptic ulcer acute bleeding. Best Pract Res Clin Gastroenterol 2013; 27:639-47. [PMID: 24160924 DOI: 10.1016/j.bpg.2013.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/18/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.
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Affiliation(s)
- Sunny H Wong
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong.
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Improving quality of care in peptic ulcer bleeding: nationwide cohort study of 13,498 consecutive patients in the Danish Clinical Register of Emergency Surgery. Am J Gastroenterol 2013; 108:1449-57. [PMID: 23732464 DOI: 10.1038/ajg.2013.162] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 04/23/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB. METHODS All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality. RESULTS A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010-2011 vs. 89% in 2004-2006, relative risk (RR) 1.06 (95% confidence intervals 1.04-1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10-1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59-0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66-0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78-1.00)). CONCLUSIONS QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.
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Yang JY, Lee TC, Montez-Rath ME, Chertow GM, Winkelmayer WC. Risk factors of short-term mortality after acute nonvariceal upper gastrointestinal bleeding in patients on dialysis: a population-based study. BMC Nephrol 2013; 14:97. [PMID: 23621917 PMCID: PMC3639820 DOI: 10.1186/1471-2369-14-97] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 04/24/2013] [Indexed: 11/16/2022] Open
Abstract
Background Impaired kidney function is an established predictor of mortality after acute nonvariceal upper gastrointestinal bleeding (ANVUGIB); however, which factors are associated with mortality after ANVUGIB among patients undergoing dialysis is unknown. We examined the associations among demographic characteristics, dialysis-specific features, and comorbid conditions with short-term mortality after ANVUGIB among patients on dialysis. Methods Design: Retrospective cohort study. Setting: United States Renal Data System (USRDS), a nation-wide registry of patients with end-stage renal disease. Participants: All ANVUGIB episodes identified by validated algorithms in Medicare-covered patients between 2003 and 2007. Measurements: Demographic characteristics and comorbid conditions from 1 year of billing claims prior to each bleeding event. We used logistic regression extended with generalized estimating equations methods to model the associations among risk factors and 30-day mortality following ANVUGIB events. Results From 2003 to 2007, we identified 40,016 eligible patients with 50,497 episodes of ANVUGIB. Overall 30-day mortality was 10.7% (95% CI: 10.4-11.0). Older age, white race, longer dialysis vintage, peritoneal dialysis (vs. hemodialysis), and hospitalized (vs. outpatient) episodes were independently associated with a higher risk of 30-day mortality. Most but not all comorbid conditions were associated with death after ANVUGIB. The joint ability of all factors captured to discriminate mortality was modest (c=0.68). Conclusions We identified a profile of risk factors for 30-day mortality after ANVUGIB among patients on dialysis that was distinct from what had been reported in non-dialysis populations. Specifically, peritoneal dialysis and more years since initiation of dialysis were independently associated with short-term death after ANVUGIB.
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Affiliation(s)
- Ju-Yeh Yang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, 1070 Arastradero Rd,, Suite 313, Palo Alto, CA 94304, USA
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Jo YW, Choi JY, Ha CY, Min HJ, Lee OJ. The Clinical Features and Prognostic Factors of Nonvariceal Upper Gastrointestinal Bleeding in the Patients with Liver Cirrhosis. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2013. [DOI: 10.7704/kjhugr.2013.13.4.235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Yoon-Won Jo
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ja-Yoon Choi
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chang-Yoon Ha
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Hyun-Ju Min
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Ok-Jae Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
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Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:537-43. [PMID: 22891179 DOI: 10.1155/2012/862905] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB). OBJECTIVE To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them. METHODS The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected. RESULTS Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices. CONCLUSIONS Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.
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Stanley AJ. Update on risk scoring systems for patients with upper gastrointestinal haemorrhage. World J Gastroenterol 2012; 18:2739-44. [PMID: 22719181 PMCID: PMC3374976 DOI: 10.3748/wjg.v18.i22.2739] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 02/20/2012] [Accepted: 04/21/2012] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.
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Chen CC, Lee JY, Fang YJ, Hsu SJ, Han ML, Tseng PH, Liou JM, Hu FC, Lin TL, Wu MS, Wang HP, Lin JT. Randomised clinical trial: high-dose vs. standard-dose proton pump inhibitors for the prevention of recurrent haemorrhage after combined endoscopic haemostasis of bleeding peptic ulcers. Aliment Pharmacol Ther 2012; 35:894-903. [PMID: 22369682 DOI: 10.1111/j.1365-2036.2012.05047.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 12/30/2011] [Accepted: 02/06/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimal dosage of intravenous proton pump inhibitors (PPIs) for the prevention of peptic ulcer rebleeding remains unclear. AIM To compare the rebleeding rate of high-dose and standard-dose PPI use after endoscopic haemostasis. METHODS A total of 201 patients with bleeding ulcers undergoing endoscopic treatment with epinephrine injection and heater probe thermocoagulation were randomised to receive a high-dose regimen (80 mg bolus, followed by pantoprazole 8 mg/h infusion, n = 100) or a standard-dose regimen (pantoprazole 40 mg bolus daily, n = 101). After 72 h, all patients were given 40 mg pantoprazole daily orally for 27 days. RESULTS There were no statistical differences in mean units of blood transfused, length of hospitalisation ≦5 days, surgical or radiological interventions and mortality within 30 days between two groups. Bleeding recurred within 30 days in six patients [6.2%, 95% confidence interval (CI) 1.3-11.1%] in the high-dose group, as compared to five patients (5.2%, 95% CI 0.6-9.7%) in the standard-dose group (P = 0.77). The stepwise Cox regression analysis showed end-stage renal disease, haematemesis, chronic obstructive pulmonary disease (hazard ratio: 37.15, 10.07, 9.12, 95% CI: 6.76-204.14, 2.07-49.01, 1.66-50.00 respectively) were independent risk factors for rebleeding and Helicobacter pylori infection was associated with lower risk of rebleeding (hazard ratio: 0.20, 95% CI: 0.04-0.94). CONCLUSIONS Following combined endoscopic haemostasis of bleeding ulcers, co-morbidities, haematemesis and H. pylori Status, but not PPI dosage, are associated with rebleeding (http://www.Clinical Trials.gov.ID: NCT00709046).
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Affiliation(s)
- C-C Chen
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Douliou, Taiwan
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Marmo R, Del Piano M, Rotondano G, Koch M, Bianco MA, Zambelli A, Di Matteo G, Grossi E, Cipolletta L, Prometeo Investigators. Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy. Gastrointest Endosc 2012; 75:263-72, 272.e1. [PMID: 22000792 DOI: 10.1016/j.gie.2011.07.066] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 07/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. OBJECTIVE To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). DESIGN Secondary analysis of prospectively collected data from 3 national databases. SETTINGS Community and teaching hospitals. PATIENTS Consecutive patients admitted for acute nonvariceal UGIB. INTERVENTIONS Early endoscopy, medical and endoscopic treatment as appropriate. MAIN OUTCOME MEASUREMENTS Thirty-day mortality, recurrent bleeding, and need for surgery. RESULTS A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). LIMITATIONS No data on the American Society of Anesthesiologists class score in the Prometeo study. CONCLUSIONS Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.
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Affiliation(s)
- Riccardo Marmo
- Division of Gastroenterology, Hospital Curto, Polla, Italy
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Suk KT, Kim HS, Lee CS, Lee IY, Kim MY, Kim JW, Baik SK, Kwon SO, Lee DK, Ham YL. Clinical outcomes and risk factors of rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Clin Endosc 2011; 44:93-100. [PMID: 22741119 PMCID: PMC3363058 DOI: 10.5946/ce.2011.44.2.93] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 07/28/2011] [Accepted: 11/07/2011] [Indexed: 01/10/2023] Open
Abstract
Background/Aims Rebleeding after endoscopic therapy for non-variceal upper gastrointestinal hemorrhage (NGIH) is the most important predictive factor of mortality. We evaluated the risk factors of rebleeding in patients undergoing endoscopic therapy for the NGIH. Methods Between January 2003 and January 2007, 554 bleeding events in 487 patients who underwent endoscopic therapy for NGIH were retrospectively enrolled. We reviewed the clinicoendoscopical characteristics of patients with rebleeding and compared them with those of patients without rebleeding. Results The incidence of rebleeding was 21.7% (n=120). In the multivariate analysis, initial hemoglobin level ≤9 g/dL (p=0.002; odds ratio [OR], 2.433), inexperienced endoscopist with less than 2 years of experience in therapeutic endoscopy (p=0.001; OR, 2.418), the need for more 15 cc of epinephrine (p=0.001; OR, 2.570), injection therapy compared to thermal and injection therapy (p=0.001; OR, 2.840), and comorbidity with chronic renal disease (p=0.004; OR, 2.908) or liver cirrhosis (p=0.010; OR, 2.870) were risk factors for rebleeding following endoscopic therapy. Conclusions Together with patients with low hemoglobin level at presentation, chronic renal disease, liver cirrhosis, the need for more 15 cc of epinephrine, or therapy done by inexperienced endoscopist were risk factors for the development of rebleeding.
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Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
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