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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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2
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Allo G, Gülcicegi D, Gillessen J, Kasper P, Chon SH, Goeser T, Bürger M. Timing of endoscopy in patients with elevated lactate levels and acute upper gastrointestinal bleeding; a retrospective comparative study. Scand J Gastroenterol 2024; 59:512-517. [PMID: 38149333 DOI: 10.1080/00365521.2023.2298355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND/AIMS While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy. METHODS We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB. RESULTS Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p = 0.37), rebleeding (17.2% vs. 15.7%; p = 0.82) and mortality (9.4% vs. 11.4%; p = 0.7) did not differ significantly. CONCLUSION In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.
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Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
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Alali AA, Barkun AN. Assessment, Resuscitation and Medical Management of Variceal and Nonvariceal Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:189-203. [PMID: 38395478 DOI: 10.1016/j.giec.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Upper gastrointestinal bleeding (UGIB) continues to be an important cause for emergency room visits and carries significant morbidity and mortality. Early resuscitative measures form the basis of the management of patients presenting with UGIB and can improve the outcomes of such patients including lowering mortality. In this review, using an evidence-based approach, we discuss the initial assessment and resuscitation of patients presenting with UGIB including identifying clues from history and physical examination to confirm UGIB, preendoscopic risk assessment tools, the role of early fluid resuscitation, utilization of blood products, use of pharmacologic interventions, and the optimal timing of endoscopy.
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Affiliation(s)
- Ali A Alali
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, D7.346, Montréal, Quebec H3G1A4, Canada.
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Capela TL, Silva VM, Freitas M, Gonçalves TC, Cotter J. Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes? Dig Dis Sci 2024; 69:570-578. [PMID: 38117425 PMCID: PMC10861632 DOI: 10.1007/s10620-023-08185-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants. OBJECTIVE To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB. METHODS Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality. RESULTS From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups. CONCLUSION Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.
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Affiliation(s)
- Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal.
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal.
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal.
| | - Vítor Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Marta Freitas
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
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Ito N, Funasaka K, Fujiyoshi T, Nishida K, Satta Y, Furukawa K, Kakushima N, Furune S, Ishikawa E, Mizutani Y, Sawada T, Maeda K, Ishikawa T, Yamamura T, Ohno E, Nakamura M, Miyahara R, Sasaki Y, Haruta JI, Fujishiro M, Kawashima H. Risk factors for rebleeding in gastroduodenal ulcers. Ir J Med Sci 2024; 193:173-179. [PMID: 37432526 DOI: 10.1007/s11845-023-03450-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Rebleeding after hemostasis of the gastroduodenal ulcer (GDU) is one of the indicators associated with death among GDU patients. However, there are few studies on risk score that contribute to rebleeding after endoscopic hemostasis of bleeding peptic ulcers. AIMS The aim of this study was to identify factors associated with rebleeding, including patient factors, after endoscopic hemostasis of bleeding gastroduodenal ulcers and to stratify the risk of rebleeding. METHODS We retrospectively enrolled 587 consecutive patients who were treated for Forrest Ia to IIa bleeding gastroduodenal ulcers with endoscopic hemostasis at three institutions. Risk factors associated with rebleeding were assessed using univariate and multivariate logistic regression analyses. The Rebleeding Nagoya University (Rebleeding-N) scoring system was developed based on the extracted factors. The Rebleeding-N score was internally validated using bootstrap resampling methods. RESULTS Sixty-four patients (11%) had rebleeding after hemostasis of gastroduodenal ulcers. Multivariate logistic regression analysis revealed four independent rebleeding risk factors: blood transfusion, albumin <2.5, duodenal ulcer, and diameter of the exposed vessel ≧2 mm. Patients with 4 risk factors in the Rebleeding-N score had a 54% rebleeding rate, and patients with 3 risk factors had 44% and 25% rebleeding rates. In the internal validation, the mean area under the curve of the Rebleeding-N score was 0.830 (95% CI = 0.786-0.870). CONCLUSIONS Rebleeding after clip hemostasis of bleeding gastroduodenal ulcers was associated with blood transfusion, albumin <2.5, diameter of the exposed vessel ≧2 mm, and duodenal ulcer. The Rebleeding-N score was able to stratify the risk of rebleeding.
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Affiliation(s)
- Nobuhito Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Toshihisa Fujiyoshi
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Kazuki Nishida
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Aichi, Japan
| | | | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | | | - Jun-Ichi Haruta
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Lucas Ramos J, Yebra Carmona J, Andaluz García I, Cuadros Martínez M, Mayor Delgado P, Ruiz Ramírez MÁ, Poza Cordón J, Suárez Ferrer C, Delgado Suárez A, Gonzalo Bada N, Froilán Torres C. Urgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding? GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:612-620. [PMID: 36803680 DOI: 10.1016/j.gastrohep.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial. MATERIAL AND METHODS Prospective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality. RESULTS A total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008). CONCLUSION Urgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy).
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Affiliation(s)
- Javier Lucas Ramos
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España.
| | - Jorge Yebra Carmona
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
| | | | | | | | | | - Joaquín Poza Cordón
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
| | | | - Ana Delgado Suárez
- Atención Primaria y Comunitaria, Hospital Universitario La Princesa, Madrid, España
| | - Nerea Gonzalo Bada
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid, España
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Garg T, Khorshidi F, Habibollahi P, Shrigiriwar A, Fang A, Sakiani S, Harfouche M, Diaz JJ, Nezami N. How I Do It: Endovascular Management of Acute Nonvariceal Gastrointestinal Bleeding. Semin Intervent Radiol 2023; 40:475-490. [PMID: 37927517 PMCID: PMC10622246 DOI: 10.1055/s-0043-1775850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fereshteh Khorshidi
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peiman Habibollahi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Apurva Shrigiriwar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Fang
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Melike Harfouche
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Jose J. Diaz
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
- The Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, Colleague Park, Maryland
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Singh N, Pahuja H, Kumar V, Popli BP, Kumar S. The Clinical and Endoscopic Profiles of Patients With Upper Gastrointestinal Bleeding (UGIB) and the Role of the Rockall Scoring System in Predicting Adverse Outcomes. Cureus 2023; 15:e40418. [PMID: 37456449 PMCID: PMC10349207 DOI: 10.7759/cureus.40418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is one of the common emergencies seen by physicians. Upper gastrointestinal (UGI) endoscopy remains a crucial tool in the identification of UGIB. OBJECTIVE The aim of the present study was to determine the clinical and endoscopic profiles of UGIB in an adult population. METHODS This prospective, cross-sectional study was conducted in Dayanand Medical College and Hospital (DMCH), Ludhiana, where 75 patients aged 18 years and above admitted to the hospital with a history of UGIB from July 1 to December 31, 2018, were enrolled in the study. After obtaining the demographic data, all patients underwent clinical examination, laboratory investigations, and video endoscopy. The Rockall scoring system was used to assess their prognosis. RESULTS The mean age of the study population was 52.19±6.65 years. The majority (33%) were in the age group of 51-60 years. Of the study population, 82.7% were male and 17.3% were female. Chronic alcohol intake was found to be the most common risk factor, followed by drug intake. On upper gastrointestinal endoscopy, esophageal varices (65.3%) were the most common finding, followed by peptic ulcer disease (25.2%), gastric erosions (2.6%), gastroduodenitis (1.3%), Mallory-Weiss tear (1.3%), carcinoma stomach (1.3%), Camron's lesion (1.3%), and Dieulafoy's lesion (1.3%). Mortality attributed to UGIB was found to be 8%. CONCLUSION The present study reported portal hypertension as the most common cause of UGIB, while the most common endoscopic lesions reported were esophageal varices. The factors associated with poor prognosis were age >60 years, shock, respiratory failure, low hemoglobin, low platelet count, deranged international normalized ratio (INR), variceal bleed, renal failure, rebleed, Rockall score ≥ 8, and late endoscopy (>24 hours of admission). Urgent appropriate hospital management definitely helps to reduce morbidity and mortality in patients with UGIB.
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Affiliation(s)
| | - Hardik Pahuja
- Medicine, Gian Sagar Hospital and Medical College, Rajpura, IND
| | - Vineet Kumar
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | | | - Sachin Kumar
- Anesthesiology, All India Institute of Medical Sciences, New Delhi, Delhi, IND
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Güven İE, Başpınar B, Durak MB, Yüksel İ. Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:178-184. [PMID: 35605821 DOI: 10.1016/j.gastrohep.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/20/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Data regarding early (within 24h) and urgent endoscopy (within 12h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB. PATIENTS AND METHODS From February 2020 to February 2021, consecutive high-risk (Glasgow-Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization. RESULTS 240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12h) and 88 (37%) patients underwent early endoscopy (12-24h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p=0.006), and the previous history of cancer (OR: 2.42, p=0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p=0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p=0.002 and p=0.040, respectively). CONCLUSIONS Urgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.
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Affiliation(s)
- İbrahim Ethem Güven
- Department of Gastroenterology, Ankara City Hospital, Bilkent Avenue, 06800 Çankaya, Ankara, Turkey
| | - Batuhan Başpınar
- Department of Gastroenterology, Ankara City Hospital, Bilkent Avenue, 06800 Çankaya, Ankara, Turkey.
| | - Muhammed Bahaddin Durak
- Department of Gastroenterology, Ankara City Hospital, Bilkent Avenue, 06800 Çankaya, Ankara, Turkey
| | - İlhami Yüksel
- Department of Gastroenterology, Ankara City Hospital, Bilkent Avenue, 06800 Çankaya, Ankara, Turkey; Department of Gastroenterology, Ankara Yildirim Beyazit University School of Medicine, Bilkent Avenue, 06800 Çankaya, Ankara, Turkey
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10
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Rasheed W, Dharmarpandi G, Al-Jobory O, Dweik A, Anil M, Islam S. Increasing inpatient mortality of nonvariceal upper gastrointestinal bleeding during the COVID-19 pandemic: a nationwide retrospective cohort study. Proc AMIA Symp 2023; 36:286-291. [PMID: 37091770 PMCID: PMC10120561 DOI: 10.1080/08998280.2023.2177490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06-1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08-0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93-0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89-0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762-10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.
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Affiliation(s)
- Waqas Rasheed
- Department of Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, Texas
| | - Gnanashree Dharmarpandi
- Department of Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, Texas
| | - Ola Al-Jobory
- Department of Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, Texas
| | - Anass Dweik
- Department of Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, Texas
| | - Muhammad Anil
- Department of Internal Medicine, Beaumont Health Dearborn, Dearborn, Michigan
| | - Sameer Islam
- Department of Gastroenterology, Texas Tech University Health Sciences Center, Lubbock, Texas
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11
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Shiratori Y, Ishii N, Aoki T, Kobayashi K, Yamauchi A, Yamada A, Omori J, Aoyama T, Tominaga N, Sato Y, Kishino T, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Yamamoto K, Yoshimoto T, Takasu A, Ikeya T, Omata F, Fukuda K, Kaise M, Nagata N. Timing of colonoscopy in acute lower GI bleeding: a multicenter retrospective cohort study. Gastrointest Endosc 2023; 97:89-99.e10. [PMID: 35931139 DOI: 10.1016/j.gie.2022.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/22/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We aimed to determine the optimal timing of colonoscopy and factors that benefit patients who undergo early colonoscopy for acute lower GI bleeding. METHODS We identified 10,342 patients with acute hematochezia (CODE BLUE-J study) admitted to 49 hospitals in Japan. Of these, 6270 patients who underwent a colonoscopy within 120 hours were included in this study. The inverse probability of treatment weighting method was used to adjust for baseline characteristics among early (≤24 hours, n = 4133), elective (24-48 hours, n = 1137), and late (48-120 hours, n = 1000) colonoscopy. The average treatment effect was evaluated for outcomes. The primary outcome was 30-day rebleeding rate. RESULTS The early group had a significantly higher rate of stigmata of recent hemorrhage (SRH) identification and a shorter length of stay than the elective and late groups. However, the 30-day rebleeding rate was significantly higher in the early group than in the elective and late groups. Interventional radiology (IVR) or surgery requirement and 30-day mortality did not significantly differ among groups. The interaction with heterogeneity of effects was observed between early and late colonoscopy and shock index (shock index <1, odds ratio [OR], 2.097; shock index ≥1, OR, 1.095; P for interaction = .038) and performance status (0-2, OR, 2.481; ≥3, OR, .458; P for interaction = .022) for 30-day rebleeding. Early colonoscopy had a significantly lower IVR or surgery requirement in the shock index ≥1 cohort (OR, .267; 95% confidence interval, .099-.721) compared with late colonoscopy. CONCLUSIONS Early colonoscopy increased the rate of SRH identification and shortened the length of stay but involved an increased risk of rebleeding and did not improve mortality and IVR or surgery requirement. Early colonoscopy particularly benefited patients with a shock index ≥1 or performance status ≥3 at presentation.
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Affiliation(s)
- Yasutoshi Shiratori
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan.
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan; Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan; Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, and Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuki Yamamoto
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Takaaki Yoshimoto
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Ayaka Takasu
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Fumio Omata
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
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12
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Dai L, Jiang C, Hong D, He X, Zeng X, Li H, Li S, Li D, Wang W. A prospective, open-labeled, and randomized trial for assessing safety and clinical utility of gastric biopsies during emergency gastroscopy for patients with bleeding gastric ulcers. Scand J Gastroenterol 2022; 58:549-557. [PMID: 36384392 DOI: 10.1080/00365521.2022.2147275] [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] [Indexed: 11/18/2022]
Abstract
OBJECTIVE There is no consensus on whether a gastroscopic biopsy is necessary during the emergency treatment of gastrointestinal (GI) diseases such as gastric ulcer bleeding. In this study, we examined the clinical utility and safety of an emergency gastroscopic biopsy for the assessment of gastric ulcer bleeding. METHODS We enrolled 150 patients with a single bleeding gastric ulcer after emergency gastroscopy (EG) from April 2020 to April 2022. The patients were randomly divided into the biopsy and no biopsy groups, and they were followed-up until June 2022 to examine whether recurrent gastric ulcer bleeding had occurred. RESULTS Re-bleeding occurred in 15 out of 150 (10%) patients. We diagnosed malignancies in 17 (11.3%) patients and validated 14 (9.3%) of them during the initial gastroscopy procedure. Factors that could predict the occurrence of gastric ulcer re-bleeding with biopsy during EG included an absence of ischemic heart disease (odds ratio [OR] = 0.395, confidence interval [CI]: 0.24-0.65, p ≤ .005), renal disease (OR = 1.74, CI: 0.77-1.59, p ≤ .005), and using warfarin or oral anticoagulants (OR = 11.953, CI: 3.494-39.460, p ≤ .005). No significant differences were observed in 60-day bleeding (p = .077) and the duration of hospitalization (p = .700) between the two groups. CONCLUSIONS Patients undergoing biopsy during EG did not exhibit an increased risk of re-bleeding compared with those who did not undergo a biopsy. An early biopsy facilitates an early pathologic diagnosis, early clinical intervention, safe discharge of low-risk patients, and improved outcomes in high-risk patients.
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Affiliation(s)
- Lingshuang Dai
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Chuanshen Jiang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Donggui Hong
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Xiaojian He
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Xiangpeng Zeng
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Han Li
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Shenglan Li
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Dazhou Li
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China.,Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People's Liberation Army, Fuzhou, China
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13
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Early Identification of High-Risk Factors for Upper Gastrointestinal Bleeding. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5641394. [PMID: 36276848 PMCID: PMC9584689 DOI: 10.1155/2022/5641394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022]
Abstract
Objective To identify simple and accurate pre-endoscopy risk factors for early identification of high-risk upper gastrointestinal bleeding. Methods Patients who were admitted to Suzhou Hospital of Integrated Traditional Chinese and Western Medicine from January 1, 2016, to December 31, 2019, due to upper gastrointestinal bleeding were retrieved, and the detailed clinical data of the above patients were collected. Patients with a definite diagnosis of bleeding from esophageal/and gastric varices were assigned to the high-risk group. Patients with bleeding not caused by varices were divided into a high-risk and a low-risk group according to the Forrest grading and scoring standard (high-risk group Forrest Ia-IIb, low-risk group Forrest IIc-III). Univariate analysis, t-test, chi-square test, binary logistic regression, ROC curve (Receiver-operating characteristic curve), etc. were employed for analysis in order to identify some simple and accurate risk factors for high-risk upper digestion tract bleeding before endoscopy. Results A total of 916 patients were collected. Three risk factors among the screened risk factors (1) hemoglobin ≤ 85 g/L, (2) vomiting red blood, and (3) “red bloody stool” were analyzed by ROC curve analysis. The specificities of each factor were 78.4%, 94.5%, and 96.7%, respectively, and the sensitivities were 71.8%, 55.9%, and 23.1%, respectively. We also derived a risk prediction scoring system for the three factors that meet the high risk such as (1) hemoglobin ≤ 83 g/L, (2)vomiting red blood, and (3) “red bloody stool.” The area under the ROC curve (AUROC), sensitivity, and specificity were 0.877, 0.904, and 0.746. Conclusion Hemoglobin ≤ 85 g/L, vomiting red blood, and red bloody stool were included in a simple scoring standard for predicting high-risk UGIB patients before endoscopy. The new risk prediction scoring system requires only three indicators and has the advantages of high accuracy, short time-consuming, and easy application.
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14
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Ito N, Funasaka K, Fujiyoshi T, Furukawa K, Kakushima N, Furune S, Ishikawa E, Mizutani Y, Sawada T, Maeda K, Ishikawa T, Yamamura T, Ohno E, Nakamura M, Kawashima H, Miyahara R, Hirooka Y, Haruta JI, Fujishiro M. Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis. Dig Endosc 2022; 34:1157-1165. [PMID: 35396885 DOI: 10.1111/den.14323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/02/2022] [Accepted: 04/07/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis. METHODS We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients. RESULTS Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%. CONCLUSIONS Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.
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Affiliation(s)
- Nobuhito Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Toshihisa Fujiyoshi
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Jun-Ichi Haruta
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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15
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Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Hemorrhage: A Retrospective Analysis. Curr Med Sci 2022; 42:856-862. [DOI: 10.1007/s11596-022-2551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
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16
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Guo CLT, Wong SH, Lau LHS, Lui RNS, Mak JWY, Tang RSY, Yip TCF, Wu WKK, Wong GLH, Chan FKL, Lau JYW, Sung JJY. Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study. Gut 2022; 71:1544-1550. [PMID: 34548338 PMCID: PMC9279843 DOI: 10.1136/gutjnl-2020-323054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/08/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE While it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess whether endoscopy timing postadmission would affect outcomes. DESIGN We conducted a retrospective, territory-wide, cohort study with healthcare data from all public hospitals in Hong Kong. Adult patients (age ≥18) that presented with AUGIB between 2013 and 2019 and received therapeutic endoscopy within 48 hours (n=6474) were recruited. Patients were classified based on endoscopic timing postadmission: urgent (t≤6), early (6<t≤24) and late (24<t≤48). Baseline characteristics were balanced with inverse probability of treatment weighting. 30-day all-cause mortality, repeated therapeutic endoscopy rate, intensive care unit (ICU) admission rate and other endpoints were compared. RESULTS Results showed that urgent timing (n=1008) had worse outcomes compared with early endoscopy (n=3865), with higher 30-day all-cause mortality (p<0.001), repeat endoscopy rates (p<0.001) and ICU admission rates (p<0.001). Late endoscopy (n=1601) was associated with worse outcomes, with higher 30-day mortality (p=0.003), in-hospital mortality (p=0.022) and 30-day transfusion rates (p=0.018). CONCLUSION Compared with urgent and late endoscopy among patients who have received therapeutic endoscopies, early endoscopy was associated with superior outcomes especially among patients with non-variceal bleeding. This supports the notion that non-variceal AUGIB patients should receive endoscopy within 24 hours, but also emphasises the importance of prior resuscitation and pharmacotherapy.
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Affiliation(s)
- Cosmos L T Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Louis H S Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rashid N S Lui
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Terry C F Yip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K K Wu
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - James Y W Lau
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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17
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Sasaki Y, Abe T, Kawamura N, Keitoku T, Shibata I, Ohno S, Ono K, Makishima M. Prediction of the need for emergency endoscopic treatment for upper gastrointestinal bleeding and new score model: a retrospective study. BMC Gastroenterol 2022; 22:337. [PMID: 35820868 PMCID: PMC9277905 DOI: 10.1186/s12876-022-02413-8] [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: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 12/02/2022] Open
Abstract
Background Gastrointestinal bleeding is one of the major gastrointestinal diseases. In this study, our objective was to compare Glasgow-Blatchford score (GBS), AIMS65 score, MAP score, Modified GBS, and Iino score as outcome measures for upper gastrointestinal bleeding. In addition, we extracted factors associated with hemostatic procedures including endoscopy, and proposed a new robust score model. Methods From January 2015 to December 2019, 675 patients with symptoms such as hematemesis who visited the National Hospital Organization Disaster Medical Center and underwent urgent upper endoscopy with diagnosis of suspected non-variceal upper gastrointestinal bleeding were retrospectively reviewed. We evaluated the GBS, AIMS65 score, MAP score, Modified GBS, and Iino score, and assessed the outcomes of patients requiring hemostatic treatments at the subsequent emergency endoscopy. We performed logistic regression analysis of factors related to endoscopic hemostasis and upper gastrointestinal bleeding, created a new score model, and evaluated the prediction of hemostatic treatment and mortality in the new score and the existing scores. Results The factors associated with endoscopic treatment were hematemesis, heart rate, HB (hemoglobin), blood pressure, blood urea nitrogen (BUN). Based on these predictors and the partial regression coefficients, a new score named H3B2 (using the initial letters of hematemesis, heart rate, HB, blood pressure, and BUN) was generated. H3B2 score was slightly more discriminatory compared to GBS and Modified GBS (area under the receiver operating characteristic curves (AUROC): 0.73 versus 0.721 and 0.7128, respectively) in predicting hemostatic treatment in emergency endoscopy. The H3B2 score also showed satisfactory prediction accuracy for subsequent deaths (AUROC: 0.6857. P < 0.001). Conclusions We proposed a new score, the H3B2 score, consisting of simple and objective indices in cases of suspected upper gastrointestinal bleeding. The H3B2 score is useful in identifying high-risk patients with suspected upper gastrointestinal bleeding who require urgent hemostatic treatment including emergency endoscopy.
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Affiliation(s)
- Yoshihiro Sasaki
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan. .,Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Tomoko Abe
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Norio Kawamura
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Taisei Keitoku
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Isamu Shibata
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Shino Ohno
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Keiichi Ono
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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18
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Götz M, Biecker E, Dechêne A, Schilling D, Zipprich A, Trebicka J. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1139-1145. [PMID: 35817045 DOI: 10.1055/a-1788-3501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Martin Götz
- Medizinische Klinik IV - Gastroenterologie/Onkologie, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland
| | - Erwin Biecker
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Zollernalb Klinikum Balingen, Balingen, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 mit Schwerpunkt Gastroenterologie, Klinikum Nord, Nürnberg, Deutschland
| | - Dieter Schilling
- Medizinische Klinik II mit Schwerpunkt Gastroenterologie, Diakonissenkrankenhaus Mannheim, Mannheim, Deutschland
| | - Alexander Zipprich
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
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19
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Khazi ZM, Marjara J, Nance M, Ghouri Y, Hammoud G, Davis R, Bhat A. Gastroduodenal artery embolization for peptic ulcer hemorrhage refractory to endoscopic intervention: A single-center experience. J Clin Imaging Sci 2022; 12:31. [PMID: 35769094 PMCID: PMC9235422 DOI: 10.25259/jcis_45_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the efficacy of gastroduodenal artery embolization (GDAE) for bleeding peptic ulcers that failed endoscopic intervention. To identify incidence and risk factors for failure of GDAE. Materials and Methods A retrospective review of patients who underwent GDAE for hemorrhage from peptic ulcer disease refractory to endoscopic intervention were included in the study. Refractory to endoscopic intervention was defined as persistent hemorrhage following at least two separate endoscopic sessions with two different endoscopic techniques (thermal, injection, or mechanical) or one endoscopic session with the use of two different techniques. Demographics, comorbidities, endoscopic and angiographic findings, significant post-embolization pRBC transfusion, and index GDAE failure were collected. Failure of index GDAE was defined as the need for re-intervention (repeat embolization, endoscopy, or surgery) for rebleeding or mortality within 30 days after GDAE. Multivariate analyzes were performed to identify independent predictors for failure of index GDAE. Results There were 70 patients that underwent GDAE after endoscopic intervention for bleeding peptic ulcers with a technical success rate of 100%. Failure of index GDAE rate was 23% (n = 16). Multivariate analysis identified ≥2 comorbidities (odds ratio [OR]: 14.2 [1.68-19.2], P = 0.023), days between endoscopy and GDAE (OR: 1.43 [1.11-2.27], P = 0.028), and extravasation during angiography (OR: 6.71 [1.16-47.4], P = 0.039) as independent predictors of index GDAE failure. Endoscopic Forrest classification was not a significant predictor for the failure of index GDAE (P > 0.1). Conclusion The study demonstrates safety and efficacy of GDAE for hemorrhage from PUD that is refractory to endoscopic intervention. Days between endoscopy and GDAE, high comorbidity burden, and extravasation during angiography are associated with increased risk for failure of index GDAE.
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Affiliation(s)
- Zain M Khazi
- Department of Radiology, University of Missouri, Columbia, Missouri, United States,
| | - Jasraj Marjara
- Department of Radiology, University of Missouri, Columbia, Missouri, United States,
| | - Michael Nance
- Department of Internal medicine, Mercy Hospital St. Louis, Saint Louis, Missouri, United States,
| | - Yezaz Ghouri
- Department of Medicine, University of Missouri, Columbia, Missouri, United States,
| | - Ghassan Hammoud
- Department of Medicine, University of Missouri, Columbia, Missouri, United States,
| | - Ryan Davis
- Department of Radiology, University of Missouri, Columbia, Missouri, United States,
| | - Ambarish Bhat
- Department of Radiology, University of Missouri, Columbia, Missouri, United States,
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20
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Timing of endoscopy in patients with upper gastrointestinal bleeding. Sci Rep 2022; 12:6833. [PMID: 35477727 PMCID: PMC9046398 DOI: 10.1038/s41598-022-10897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/11/2022] [Indexed: 11/08/2022] Open
Abstract
The optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding (UGIB) remains controversial. In this study, we investigated the clinical outcomes of urgent endoscopy in patients with UGIB compared with elective endoscopy. From January 2016 to December 2018, consecutive patients who visited the emergency department and underwent endoscopy for clinical manifestations of acute UGIB, including variceal bleeding, were eligible. Urgent endoscopy (within 6 h) and elective endoscopy (after 6 h) were defined as the time taken to perform endoscopy after presentation to the emergency department. The primary outcome was mortality rate within 30 days. A total of 572 patients were included in the analysis. Urgent endoscopy was performed in 490 patients (85.7%). The 30-day mortality rate did not differ between the urgent and elective endoscopy groups (5.3% and 6.1%, p = 0.791). There was no difference regarding the recurrent bleeding rate, total amount of transfusion, or length of hospital between the groups. In multivariate analysis, age and the amount of transfusion were associated with mortality. Urgent endoscopy was not associated with a lower 30-day mortality rate compared with elective endoscopy in patients with acute UGIB.
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21
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Ito N, Funasaka K, Furukawa K, Kakushima N, Hirose T, Muroi K, Suzuki T, Suzuki T, Hida E, Ishikawa T, Yamamura T, Ohno E, Nakamura M, Kawashima H, Miyahara R, Fujishiro M. A novel scoring system to predict therapeutic intervention for non-variceal upper gastrointestinal bleeding. Intern Emerg Med 2022; 17:423-430. [PMID: 34363550 DOI: 10.1007/s11739-021-02822-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022]
Abstract
Various scoring systems have been developed to predict the need for endoscopic treatment in patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, they have rarely been applied in clinical practice because the processes are complicated. The aim of this study was to establish a simple scoring system that predicts the need for endoscopic intervention in patients with NVUGIB. We retrospectively enrolled 509 consecutive patients with suspected NVUGIB who underwent emergency endoscopy. In the development cohort (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from 349 patients' data by multivariate logistic regression analysis. This led to the development of a novel scoring system named the Nagoya University score (N score). In the validation cohort (from January 2019 to September 2020), we evaluated the diagnostic value of the N score, the Hirosaki score, and the Glasgow-Blatchford scores (GBS) by receiver operating characteristic (ROC) curves using another 160 patients' data. Multivariate logistic regression analysis revealed syncope, hematemesis, blood urea nitrogen (BUN), and BUN/Cr as significant predictive factors for endoscopic intervention. In the validation study, the N score was superior to the GBS and equal to the Hirosaki score in predicting the endoscopic intervention (AUC, N score 0.776 [95% CI 0.702-0.851] vs. GBS 0.615 [0.523-0.708], Hirosaki 0.719 [0.636-0.803]). The N score revealed a sensitivity of 84.5% and a specificity of 61.8%. Our N score, which is consisted of only four factors, would select patients who require endoscopic intervention with high probability.
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Affiliation(s)
- Nobuhito Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Hirose
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koichi Muroi
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiko Suzuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Suzuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Emiko Hida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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22
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Freitas M, Macedo Silva V, Cúrdia Gonçalves T, Marinho C, Cotter J. How Can Patient's Risk Dictate the Timing of Endoscopy in Upper Gastrointestinal Bleeding? GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2022; 29:96-105. [PMID: 35497665 PMCID: PMC8995629 DOI: 10.1159/000516945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/29/2021] [Indexed: 01/04/2024]
Abstract
INTRODUCTION Although upper gastrointestinal bleeding (UGIB) management has improved substantially in the last decades, there is still much controversy regarding the optimal timing for performance of endoscopy. Recent guidelines suggest performing an early endoscopy within 24 h of nonvariceal UGIB (NVUGIB) presentation, although its impact on patients with different bleeding risks remains unclear. AIM To evaluate the impact of performing endoscopy within 24 h on NVUGIB outcomes and to compare it in patients with lower-risk vs. higher-risk bleeding. METHODS This is a retrospective cohort study including consecutive patients undergoing upper endoscopy for suspected NVUGIB over 4 years. Demographic, clinical, biochemical, endoscopic, and outcome data were collected. Lower-risk bleeding was defined as a Glasgow-Blatchford score (GBS) <12 and higher-risk bleeding was defined as a GBS ≥12. RESULTS A total of 298 patients with suspected NVUGIB were included, 55% of whom had higher-risk bleeding. Endoscopy was performed within 24 h in 62.1% of the patients. In lower-risk bleeding patients, performance of endoscopy within 24 h was associated with a higher need for endoscopic treatment (OR = 2.6; 95% CI 1.2-5.7; p = 0.004), a lower 30-day mortality (OR = 0.41; 95% CI 0.27-0.63; p = 0.03), and a lower need for transfusion (OR = 0.58; 95% CI 0.36-0.92; p = 0.02). In higher-risk bleeding patients, there were no statistically significant differences in NVUGIB outcomes in performing endoscopy within 24 h. CONCLUSION Endoscopy within 24 h of presentation was associated with a lower need for transfusion, a higher need for endoscopic treatment, and a lower 30-day mortality in lower-risk NVUGIB patients. Thus, performing endoscopy within the first 24 h of presentation can have a positive impact on NVUGIB outcomes even in lower-risk bleeding.
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Affiliation(s)
- Marta Freitas
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Vítor Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Carla Marinho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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23
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El-Dallal M, Walradt TJ, Stein DJ, Khrucharoen U, Feuerstein JD. Pros and Cons of Performing Early Endoscopy in Geriatric Patients Admitted with Non-variceal Upper Gastrointestinal Bleeding: Analysis of the US National Inpatient Database. Dig Dis Sci 2022; 67:826-833. [PMID: 33710436 DOI: 10.1007/s10620-021-06924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/23/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Age greater than 65 years is a well-defined risk factor for increased mortality in patients with non-variceal upper gastrointestinal bleeding (NVGIB). Endoscopy is indicated in most patients at any age but presents unique risks in the elderly cohort, and ideal timing is unclear. This study examined the association between outcomes and early (within 24 h) esophagogastroduodenoscopy (EGD) among elderly patients with NVGIB. METHODS All patients over age 65 admitted primarily for NVGIB who underwent EGD were included from the National Inpatient Sample 2016-2017. Clinical outcomes stratified by early EGD versus late EGD were compared after adjustment for comorbidities and bleeding severity using inverse probability of treatment weighting with survey-adjusted linear and logistic regression. RESULTS Out of estimated 625,530 admissions with a primary diagnosis of NVGIB, 120,835 met eligibility criteria; 24,830 underwent early EGD. Mean length of stay and total charges decreased by 1.17 days (95%CI 1.04-1.30, P < 0.001) and $5717.24 (95%CI 4034.57-7399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95%CI 1.06-1.64, P 0.01) and transfer to other hospitals 1.48 (95%CI 1.22-1.81, P < 0.001). No change was seen in the requirement for surgery or angiography. Rates of discharge to a nursing facility or home health were similar. CONCLUSION In a comprehensive cohort of geriatric patients with NVGIB, early EGD is associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer. Further research is needed to determine the optimal management of this vulnerable population.
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Affiliation(s)
- Mohammed El-Dallal
- Division of Hospital Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA. .,Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA.
| | - Trent J Walradt
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel J Stein
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Usah Khrucharoen
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA
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24
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Liu F, Liu X, Yin C, Wang H. Nursing Value Analysis and Risk Assessment of Acute Gastrointestinal Bleeding Using Multiagent Reinforcement Learning Algorithm. Gastroenterol Res Pract 2022; 2022:7874751. [PMID: 35035476 PMCID: PMC8758331 DOI: 10.1155/2022/7874751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Gastrointestinal bleeding (GIB) indicates an issue in the digestive system. Blood can be found in feces or vomiting; however, it is not always visible, even if it makes the stool appear darkish or muddy. The bleeding can range in harshness from light to severe and can be dangerous. It is advised that nursing value analysis and risk assessment of patients with GIB is essential, but existing risk assessment techniques function inconsistently. Machine learning (ML) has the potential to increase risk evaluation. For evaluating risk in patients with GIB, scoring techniques are ineffective; a machine learning method would help. As a result, we present а unique machine learning-based nursing value analysis and risk assessment framework in this research to construct a model to evaluate the risk of hospital-based interventions or mortality in individuals with GIB and make a comparison to that of other rating systems. Initially, the dataset is collected, and preprocessing is done. Feature extraction is done using local binary patterns (LBP). Classification is performed using a fuzzy support vector machine (FSVM) classifier. For risk assessment and nursing value analysis, machine learning-based prediction using a multiagent reinforcement algorithm is employed. For improving the performance of the proposed system, we use spider monkey optimization (SMO) algorithm. The performance metrics like classification accuracy, area under the receiver-operating characteristic curve (AUROC), area under the curve (AUC), sensitivity, specificity, and precision are analyzed and compared with the traditional approaches. In individuals with GIB, the suggested technique had a good-excellent prognostic efficacy, and it outperformed other traditional models.
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Affiliation(s)
- Fang Liu
- Neurosurgery Department, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, China
| | - Xiaoli Liu
- Department of Infection Management, Dongying People's Hospital, China
| | - Changyou Yin
- Neurosurgery Department, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, China
| | - Hongrong Wang
- Emergency Department, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, China
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25
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Lau JYW. Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy. Dig Endosc 2022; 34:260-264. [PMID: 34551156 DOI: 10.1111/den.14144] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 02/08/2023]
Abstract
For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes. The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.
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Affiliation(s)
- James Yun Wong Lau
- Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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26
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Horibe M, Iwasaki E, Matsuzaki J, Bazerbachi F, Kaneko T, Minami K, Fukuhara S, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Kanai T. Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata. Gastroenterol Rep (Oxf) 2021; 9:543-551. [PMID: 34925851 PMCID: PMC8677506 DOI: 10.1093/gastro/goab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/26/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS). Methods Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed. Results HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0–4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5–19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09–0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16–0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001). Conclusions A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, MN, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare, St Cloud Hospital, MN, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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27
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Falcão D, Alves da Silva J, Pereira Guedes T, Garrido M, Novo I, Pedroto I. The Current Portrayal of Non-Variceal Upper Gastrointestinal Bleeding in a Portuguese Tertiary Center. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 28:392-397. [PMID: 34901445 PMCID: PMC8630385 DOI: 10.1159/000516139] [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: 01/08/2021] [Accepted: 03/14/2021] [Indexed: 11/21/2022]
Abstract
Introduction Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important healthcare problem whose epidemiology and outcomes have been changing throughout the years. The main goal of this study was to characterize the current demographics, etiologies, and risk factors of NVUGIB. Methods Analysis of clinical, endoscopic, and outcome data from patients who were admitted for NVUGIB between January 2016 and January 2019 in an emergency department of a tertiary hospital center. Results A total of 522 patients were included, with a median age of 71 years, mainly men, with multiple comorbidities. Most patients were directly admitted, while the others were transferred from other hospitals. Peptic ulcer disease was the most common cause of NVUGIB and it was followed by tumor bleeding. Esophagogastroduodenoscopy was performed within <12 h after hospital admission in 51.9%. In-hospital rebleeding occurred in 6.9% and overall mortality was 4.2%. Transferred patients had superior Glasgow-Blatchford score (GBS), required more blood transfusion, endoscopic and surgical interventions, and presented higher rebleeding rate, with similar mortality. Complete Rockall score (CRS) and GBS were predictors of endoscopic therapy. Surgery need was only related to CRS. Patients who rebled had superior pre-endoscopic Rockall score (RS), CRS, and GBS. Mortality was increased in patients with higher RS and CRS. Discussion/Conclusion Ageing and increasing comorbidities have not been related to worse outcomes in NVUGIB. These findings seem to be the consequence of the correct use of both diagnostic and therapeutic tools in an organized and widely accessible healthcare system.
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Affiliation(s)
- Daniela Falcão
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Joana Alves da Silva
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Tiago Pereira Guedes
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mónica Garrido
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Inês Novo
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Isabel Pedroto
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Impact of time to esophagogastroduodenoscopy in patients with nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 87:320-329. [PMID: 34862146 DOI: 10.1016/j.rgmxen.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION There is conflicting evidence regarding the benefit of urgent esophagogastroduodenoscopy (EGD) for reducing mortality and rebleeding, in the context of nonvariceal upper gastrointestinal bleeding. AIM To describe the decrease in the risk for mortality, rebleeding, and red blood cell transfusion, with the performance of urgent EGD, in patients with nonvariceal upper gastrointestinal bleeding. MATERIALS AND METHODS We carried out a search for cohort studies or controlled clinical trials, published from December 1966 to May 2020, that compared urgent EGD versus elective EGD in the management of adults with nonvariceal upper gastrointestinal bleeding, utilizing the MEDLINE, Embase, LILACS, and Cochrane Central Register of Controlled Trials databases. Our primary outcome was the hospital mortality comparison. The incidence of rebleeding and the mean number of red blood cell units transfused were also compared. A random effects model was utilized for the meta-analysis. RESULTS Twenty-one studies that met the eligibility criteria were included, involving 489,622 patients. We found no differences in the mortality of subjects exposed to urgent EGD versus elective EGD (RR 1.12 [0.72-1.72]). There was a significant increase in the risk for rebleeding (RR 1.30 [1.05-1.60]) in the subjects exposed to urgent EGD, and fewer red blood cell units were transfused in those patients (RR 0.52 [0.05-0.99]). CONCLUSIONS Urgent EGD in subjects with nonvariceal upper gastrointestinal bleeding does not appear to have a significant impact on short-term mortality.
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Analysis of the Effect of Intelligent Red Blood Cell Distribution Diagnosis Model on the Diagnosis and Treatment of Gastrointestinal Bleeding. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:5216979. [PMID: 34804453 PMCID: PMC8604600 DOI: 10.1155/2021/5216979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/06/2021] [Accepted: 10/23/2021] [Indexed: 02/08/2023]
Abstract
In order to explore the role of red blood cell distribution width in the diagnosis and treatment of gastrointestinal bleeding, this paper applies map feature recognition technology to red blood cell distribution broadband and constructs an intelligent red blood cell distribution width diagnosis model. To extract the content-level features of the image safely and effectively, this paper introduces the mechanism of jitter quantization to extract the content-level features at the lowest frequency of the image. In addition, this article employs an experimental approach to investigate the function of red blood cell distribution width in the diagnosis and management of gastrointestinal bleeding in the elderly. Finally, this article establishes an experimental group and a control group and then performs a research study using real-life hospital case studies. According to the statistical findings, the red blood cell distribution width index may play a significant role in the diagnosis and management of gastrointestinal bleeding, particularly in the case of severe bleeding.
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Park JK. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Evaluating the impact of frailty on periprocedural adverse events and mortality among patients with GI bleeding. Gastrointest Endosc 2021; 94:517-525.e11. [PMID: 33753111 DOI: 10.1016/j.gie.2021.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Frailty is a known predictor of mortality and adverse events in the inpatient setting; however, it has not been studied as a modality to assess risk among patients undergoing endoscopy for GI bleeding (GIB). We aimed to determine the association between frailty status and risk of adverse events in hospitalized patients with GIB who underwent endoscopy. METHODS We performed a cohort study using the 2016 and 2017 National Inpatient Sample database, using International Classification of Diseases diagnostic codes to identify adult patients with GIB who underwent endoscopic procedures within 2 days of admission and the Hospital Frailty Risk Score to classify patients as frail or nonfrail. Univariable and multivariable logistic regression models were constructed to assess the predictors of periprocedural adverse events, and marginal standardization analysis was performed to assess for possible interaction between age and frailty. RESULTS A total of 757,920 patients met inclusion criteria, of which 44.4% (336,895) were identified as frail and 55.6% (421,025) as nonfrail; 49.2% of frail patients had composite periprocedural adverse events compared with 25.5% of nonfrail patients (P < .001). Frail patients notably had more cardiovascular (32.1% vs 17.1%, P < .001), pulmonary (18.5% vs 4.3%, P < .001), GI (10.1% vs 6.1%, P < .001), and infectious (9.9% vs .7%, P < .001) adverse events compared with nonfrail patients. Frail patients also had higher all-cause inpatient mortality rates (4.8% vs .5%, P < .001). On multivariable analysis, positive frailty status was associated with a 2.13 times increased likelihood of having composite periprocedural adverse events. CONCLUSIONS In hospitalized patients undergoing endoscopy for GIB, frailty status is associated with increased periprocedural adverse events including all-cause mortality. The use of frailty assessments can thus further guide clinical decision-making when considering endoscopy and risk of adverse events in adult patients with GI hemorrhage.
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Kwack WG. Clinical outcomes of esophagogastroduodenoscopy in critically ill patients using high-dose proton pump inhibitor for suspected bleeding: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e27028. [PMID: 34449479 PMCID: PMC8389866 DOI: 10.1097/md.0000000000027028] [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: 02/21/2021] [Accepted: 08/07/2021] [Indexed: 01/04/2023] Open
Abstract
Esophagogastroduodenoscopy (EGD) is a useful procedure performed for gastrointestinal (GI) bleeding. No definite clinical guidelines recommend EGD implementation in intensive care unit (ICU) patients with suspected GI bleeding. The objective of this study was to compare the clinical effectiveness of EGD in critically ill patients who are using high-dose proton pump inhibitor (PPI) for suspected GI bleeding.We retrospectively analyzed ICU patients using high-dose PPI for suspected GI bleeding from January 2012 to September 2020. Major cases of GI bleeding, such as those with hematemesis and hematochezia, were excluded, and 1:1 propensity score matching was performed. The change in hemoglobin level, requirement of red blood cell transfusion, re-suspected bleeding event, length of ICU stay, and ICU mortality were compared between the EGD and non-EGD groups.Of the 174 subjects included, 52 patients underwent EGD within 24 hours of PPI administration. In the EGD group, 22 (42.3%) patients showed normal findings, while esophagitis and gastritis were most common abnormal finding (n = 11, 21.2%), and 14 patients (26.9%) underwent a hemostatic procedure. While comparing the 2 groups, the EGD group required a higher amount of red blood cell transfusion (packs) than the non-EGD group for a week (3.04 ± 0.44 vs 2.07 ± 0.25, P = .01). There was no significant difference in the change in hemoglobin level after 1 week (P = .15). After propensity score matching, the EGD group showed similar the requirement of red blood cell transfusion and change in hemoglobin level for a week (P = .52, P = .97, respectively). In analyses for all patients and propensity score matched patients, there was no statistically significant difference in term of re-suspected bleeding event rate, duration of ICU stay, and ICU mortality. However, re-suspected bleeding event rate and ICU mortality were lower trend in the EGD group than the non-EGD group.This study showed that EGD had no definite clinical benefit in ICU patients using high-dose PPI for suspected GI bleeding and aggressive EGD is not necessarily recommended. However, it is necessary to consider EGD in patients who are tolerant.
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Does timing of endoscopy affect outcomes in patients with upper gastrointestinal bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2021; 33:1055-1062. [PMID: 33177382 DOI: 10.1097/meg.0000000000001975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The timing of esophagogastroduodenoscopy (EGD) for the management of upper gastrointestinal bleeding (UGIB) remains controversial. Early EGD (E-EGD) (within 24 h of presentation) has been compared to late EGD (L-EGD) (after 24 h) in numerous studies with conflicting results. The previous systematic review included three randomized controlled trials (RCTs); however, the cutoff time for performing EGD was arbitrary. We performed an updated systematic review and meta-analysis of the studies comparing the outcomes of E-EGD and L-EGD group. METHODS A comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was undertaken to include both RCTs and cohort studies. Primary outcomes including overall mortality and secondary outcomes (recurrent bleeding, need for transfusion, and length of stay) were compared. Risk ratios and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated. RESULTS A total of 13 observational studies (with over 1.8 million patients) were included in the final analysis. No significant difference in overall mortality (risk ratio: 0.97; CI, 0.74-1.27), recurrent bleeding (risk ratio: 1.12; CI, 0.62-2.00), and length of stay (SMD: -0.07, CI, -0.31 to 0.18) was observed for E-EGD group compared to L-EGD group. The possibility of endoscopic intervention was higher in E-EGD group (risk ratio: 1.70, CI, 1.28-2.27). Consistent results were obtained for subgroup analysis of studies with 100% nonvariceal bleed (NVB) patient (risk ratio: 1.12; CI, 0.84-1.50). CONCLUSION Given the outcomes and limitations, our meta-analysis did not demonstrate clear benefit of performing EGD within 24 h of presentation for UGIB (particularly NVB).
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Haas NL, Medlin RP, Cranford JA, Boyd C, Havey RA, Losman ED, Rice MD, Bassin BS. An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding. Am J Emerg Med 2021; 50:173-177. [PMID: 34371325 DOI: 10.1016/j.ajem.2021.07.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/28/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. METHODS A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. RESULTS We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. CONCLUSION For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA.
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caryn Boyd
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Renee A Havey
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Eve D Losman
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Rice
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
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Li Y, Cai BS, Li X, Ju S, Yang XY, Qiang JW. Treatment of Upper Gastrointestinal Bleeding by Percutaneous Transsplenic Varices Embolization in Chronic Hepatic Schistosomiasis Japonicum Patients. Am J Trop Med Hyg 2021; 105:1109-1113. [PMID: 34280135 DOI: 10.4269/ajtmh.21-0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/13/2021] [Indexed: 11/07/2022] Open
Abstract
To evaluate percutaneous transsplenic varices embolization (PTSVE) in the treatment of upper gastrointestinal bleeding (UGIB) in patients with chronic hepatic schistosomiasis japonicum (CHS), 29 CHS patients (20 males and 9 females) complicated with UGIB were selected as the investigation subjects. The patients were treated by PTSVE under the guidance of X-ray fluoroscopy. The success rate of PTSVE and the rate of complications were observed. In addition, the degrees of varices before and after PTSVE were evaluated by abdominal computed tomography (CT). Results showed that 26 CHS patients (89.6%) were successfully treated with PTSVE. Three cases (10.3%) failed, and two experienced intraperitoneal bleeding within 1 week after PTSVE. The abdominal CT showed a significant decrease of the varices stage in coronary (P < 0.001), esophageal (P = 0.006), and paraesophageal (P = 0.013) varices, but slightly increased perisplenic varices within 1 month of the intervention (P = 0.014). PTSVE may be a safe and effective procedure for the treatment of UGIB in CHS patients, particularly suitable for those with a widened hepatic fissure and exposed hepatic portal vein trunk and an enlarged spleen.
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Affiliation(s)
- Ying Li
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Ban Sheng Cai
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Department of Intervention Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Xiu Ying Yang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jin Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
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Tarar ZI, Zafar MU, Farooq U, Ghous G, Shoukat HMH, Kuwajima V. Does Performing Endoscopy Sooner Have an Impact on Outcomes in Patients With Acute Nonvariceal Upper Gastrointestinal Hemorrhage? A Systematic Review. Cureus 2021; 13:e16092. [PMID: 34367748 PMCID: PMC8330500 DOI: 10.7759/cureus.16092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Endoscopy is the cornerstone for the diagnosis and treatment of nonvariceal upper gastrointestinal bleeding. Regarding the management of nonvariceal bleeding, the administration of crystalloid solution and proton pump inhibitors before endoscopy is well established, but the optimal timing of endoscopy has been a matter of debate and a subject of many investigational studies. The need for urgent endoscopy arises to provide prompt redress to acute bleeding, decrease the length of stay, and lower mortality from ongoing bleeding. Objective This study aimed to determine if endoscopy performed within 24 hours of presentation improves outcomes in terms of mortality, hospital length of stay, and rebleeding in individuals presenting with nonvariceal upper gastrointestinal bleed with any risk. Methodology We performed a systematic review of two large databases (PubMed and Google Scholar) to incorporate all studies published after 2000. We included studies with nonvariceal upper gastrointestinal bleeding and excluded those reporting variceal gastrointestinal hemorrhage. Results We reviewed eight studies that qualified after meeting our inclusion and exclusion criteria. We divided these studies into three separate groups based on the timing of endoscopy. Only two studies found a difference in mortality that was statistically significant in patients who underwent endoscopy within 24 hours of presentation. One study showed lower mortality in a patient who underwent urgent endoscopy, but it did not reach statistical significance. Other studies did not show any statistical difference in mortality, hospital length of stay, and rebleeding rates. The studies showed conflicting evidence on the amount of blood transfusion, though urgent endoscopy was found to be difficult in few studies due to blood obscuring the lesion. Conclusions While data suggest that there is a potential benefit in performing endoscopy sooner, there is no concrete evidence to point to a particular time range. Before performing endoscopy, the American Society for Gastrointestinal Endoscopy (2012) recommends adequate resuscitation with crystalloid solutions, blood transfusions, and antisecretory and prokinetic agent therapy. More investigational studies are needed to formulate a time-sensitive flow sheet to approach endoscopy in patients with nonvariceal upper gastrointestinal bleeding. A strict criterion is also needed to delineate patients into low-risk and high-risk groups. Doing so would provide a systematic approach to help with mortality, rebleeding, and healthcare resource utilization.
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Affiliation(s)
| | | | - Umer Farooq
- Internal Medicine, Loyola Medicine, MacNeal Hospital, Berwyn, USA
| | - Ghulam Ghous
- Hematology/Oncology, University of Missouri, Columbia, USA
| | | | - Vanessa Kuwajima
- Gastroenterology and Hepatology, University of Missouri, Columbia, USA
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. [Guidelines for Non-variceal Upper Gastrointestinal Bleeding]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 75:322-332. [PMID: 32581203 DOI: 10.4166/kjg.2020.75.6.322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Zhao Q, Chi T. Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study. BMC Gastroenterol 2021; 21:250. [PMID: 34092231 PMCID: PMC8183090 DOI: 10.1186/s12876-021-01836-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few studies have reported whether a biopsy in emergency gastroscopy (EG) increased the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) combined with suspected malignant gastric ulcer (SMGU). This study aims to conduct a multicenter retrospective cohort study using propensity score matching to verify whether a biopsy in EG increases the risk of rebleeding in patients diagnosed with Forrest I ANVUGIB combined with SMGU. METHODS Using the data for propensity-matched patients, logistic regression models were fitted using rebleeding as the dependent variable. Survival time was defined as the length of time the patient experienced from visiting the emergency department to rebleeding. We used the Kaplan-Meier (KM) method to analyze the 30-day survival of the patients with and without a biopsy after matching, and the log-rank test was performed to examine the differences in survival. RESULTS With the use of propensity score matching, 308 patients who underwent a biopsy in EG were matched with 308 patients who did not. In the five logistic regression models, there were no significant group differences in the risk of rebleeding in patients with Forrest I ANVUGIB combined with SMGU between the biopsy and no-biopsy groups. The probability of survival was not significantly different between the no-biopsy and biopsy groups. CONCLUSIONS In this multicenter, retrospective propensity score matching cohort study, compared with patients without a biopsy, patients with a biopsy during EG had no increased risk of rebleeding, and there was no significant difference in the rate of rebleeding.
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Affiliation(s)
- Quchuan Zhao
- Department of Gastroenterology, Xuanwu Hospital of Capital Medical University, 45 Chang-chun Street, Beijing, 100053, China
| | - Tianyu Chi
- Department of Gastroenterology, Xuanwu Hospital of Capital Medical University, 45 Chang-chun Street, Beijing, 100053, China.
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ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021; 116:899-917. [PMID: 33929377 DOI: 10.14309/ajg.0000000000001245] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Ryan K, Malacova E, Appleyard M, Brown AF, Song L, Grimpen F. Clinical utility of the Glasgow Blatchford Score in patients presenting to the emergency department with upper gastrointestinal bleeding: A retrospective cohort study. Emerg Med Australas 2021; 33:817-825. [PMID: 33543572 DOI: 10.1111/1742-6723.13737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) is a common presentation to EDs. Limited Australian data are available. Study aims were to assess mortality and re-bleeding rates in patients presenting with UGIB as risk-stratified by the Glasgow Blatchford Score (GBS). METHODS We conducted a retrospective medical chart review of all patients presenting with UGIB to a Brisbane tertiary hospital ED over a 12-month period. This descriptive study summarised the medical characteristics related to UGIB as risk-stratified by the GBS. Non-variceal bleeding was categorised as low-risk (GBS 0-2) or high-risk (GBS 3+). Variceal bleeding was not risk stratified. RESULTS A total of 211 patients presented with UGIB to the ED. The median age was 57 years, 67% were male. Mortality rates at 30 days were: 0% for GBS 0-2, 3% (95% confidence interval [CI] 0-6) for GBS 3+ and 10% (95% CI 0-21) for variceal groups. The overall 30-day re-bleeding rate was 4.3% (95% CI 2-7). High-risk patients accessed endoscopy according to international best practice of less than 24 h (GBS 3+, 23.7 h; variceal bleeding, 7.3 h). CONCLUSIONS Mortality and re-bleeding outcomes are similar to other international UGIB cohorts. Patients with a low-risk bleed were appropriately identified and discharged home. Those at higher risk were correctly identified and accessed timely endoscopy. The GBS demonstrated clinical utility in an Australian ED cohort of UGIB bleeding patients.
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Affiliation(s)
- Kimberley Ryan
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Eva Malacova
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Mark Appleyard
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anthony Ft Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Song
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Florian Grimpen
- Department of Gastroenterology and Hepatology/Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
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Surek A, Gemici E, Bozkurt MA, Karabulut M. UPPER GASTROINTESTINAL BLEEDING:IS ONLY AN INJECTION OF EPINEPHRINE SUFFICIENT? SUCCES RATES BY FORREST CLASSIFICATION. SANAMED 2020. [DOI: 10.24125/sanamed.v15i3.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Lee MW, Katz PO. Nonsteroidal Antiinflammatory Drugs, Anticoagulation, and Upper Gastrointestinal Bleeding. Clin Geriatr Med 2020; 37:31-42. [PMID: 33213773 DOI: 10.1016/j.cger.2020.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Advanced age, history of peptic ulcer disease, Helicobacter pylori, coadministration of nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, anticoagulation, and antiplatelets are risk factors for gastrointestinal bleeding in the elderly. Awareness of these risks and appropriate use of NSAIDs, particularly in those needing antiplatelet or anticoagulant therapy, is critical to optimal management. Careful selection of elderly patients requiring antiplatelet, anticoagulation, or chronic NSAID therapy for cotherapy with proton pump inhibitors can significantly reduce morbidity and mortality from gastrointestinal bleeding.
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Affiliation(s)
- Mindy Winghin Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA
| | - Philip O Katz
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA.
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Schembre DB, Ely RE, Connolly JM, Padhya KT, Sharda R, Brandabur JJ. Semiautomated Glasgow-Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding. BMJ Open Gastroenterol 2020; 7:bmjgast-2020-000479. [PMID: 33214231 PMCID: PMC7681917 DOI: 10.1136/bmjgast-2020-000479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/13/2020] [Accepted: 10/23/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The Glasgow-Blatchford Bleeding Score (GBS) was designed to identify patients with upper gastrointestinal bleeding (UGIB) who do not require hospitalisation. It may also help stratify patients unlikely to benefit from intensive care. DESIGN We reviewed patients assigned a GBS in the emergency room (ER) via a semiautomated calculator. Patients with a score ≤7 (low risk) were directed to an unmonitored bed (UMB), while those with a score of ≥8 (high risk) were considered for MB placement. Conformity with guidelines and subsequent transfers to MB were reviewed, along with transfusion requirement, rebleeding, length of stay, need for intervention and death. RESULTS Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients had a GBS ≤7. 29 (12%) low-risk patients were admitted to MBs. Four low-risk patients admitted to UMB required transfer to MB within the first 48 hours. Low-risk patients admitted to UMBs were no more likely to die, rebleed, need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low-risk patient died from GIB. Patients with GBS ≥8 were more likely to rebleed, require transfusion and interventions to control bleeding but not to die. CONCLUSION A semiautomated GBS calculator can be incorporated into an ER workflow. Patients with a GBS ≤7 are unlikely to need MB care for UGIB. Further studies are warranted to determine an ideal scoring system for MB admission.
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Affiliation(s)
- Drew B Schembre
- Digestive Health, John Muir Health, Walnut Creek, California, USA
| | - Robson E Ely
- Clinical Transformation, Swedish Medical Center, Seattle, Washington, USA
| | | | - Kunjali T Padhya
- Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
| | - Rohit Sharda
- Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
| | - John J Brandabur
- Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. Guidelines for Nonvariceal Upper Gastrointestinal Bleeding. Gut Liver 2020; 14:560-570. [PMID: 32581203 PMCID: PMC7492499 DOI: 10.5009/gnl20154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Hafezi-Nejad N, Bailey CR, Arun A, Weiss CR. Transcatheter and Endoscopic Treatment of Gastric and Duodenal Bleeding: Population-Based Analysis of National Inpatient Trends and Outcomes in the United States. J Am Coll Radiol 2020; 18:361-374. [PMID: 32890494 DOI: 10.1016/j.jacr.2020.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding is a common cause of hospital admission in the United States and is frequently treated by endoscopy. Recent studies have shown an increasing role for treatment using transcatheter embolization. METHODS Data from the national inpatient sample (1993-2015) were used for trend analysis and to compare patient characteristics, comorbidities, and outcomes for endoscopic and transcatheter treatments of gastric and duodenal bleeding. RESULTS Despite the continued decline in the rate of hospitalization for upper GI bleeding (-43% since 1993, P < .01), admissions for embolization (21.1% per year since 2005, P < .01) and endoscopic treatments (1.2%-6.1% per year since 1993, P < .01) have increased in the past decade. Patients with multiple comorbidities that include coagulopathy (25.6% versus 11.9%, P < .05), liver disease (16.0% versus 10.7%, P < .05), fluid and electrolyte disorder (51.0% versus 35.4%, P < .05), and metastatic cancer (6.9% versus 2.4%, P < .05) were more likely to receive embolization. Embolization was associated with higher crude risk of death (9.2% versus 2.1%, P < .01), lengthier hospital stays (9.1 days versus 5.1 days, P < .01), and greater average total hospital charges (US$135,000 versus US$46,000). The association between embolization (versus endoscopy) and mortality and length of stay diminished after controlling for disease severity and other procedures in propensity score-matched groups and by covariate adjustment. DISCUSSION Though endoscopy remains the main treatment of upper GI bleeding, embolization is associated with comparable mortality and length of stay after accounting for disease severity and the need for additional procedures.
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Affiliation(s)
- Nima Hafezi-Nejad
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher R Bailey
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anirudh Arun
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford R Weiss
- Associate Professor of Radiology, Surgery and Biomedical Engineering, Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Medical Director, Johns Hopkins Center for Bioengineering, Innovation and Design; Director, Johns Hopkins Interventional Radiology Research; Director, Johns Hopkins HHT Center of Excellence; Director, Johns Hopkins Vascular Anomalies Center, Baltimore, Maryland.
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Horibe M, Iwasaki E, Bazerbachi F, Kaneko T, Matsuzaki J, Minami K, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Chan AT, Kanai T. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020; 92:578-588.e4. [PMID: 32240682 DOI: 10.1016/j.gie.2020.03.3846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although upper GI bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3-variable score (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure] ≥1, and blood urea nitrogen/creatinine ≥30 [urea/creatinine≥140]), the Horibe gAstRointestinal BleedING scoRe (HARBINGER), with the 8-variable Glasgow-Blatchford Score (GBS) and 5-variable AIMS65 to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy. METHODS Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. On presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata. RESULTS Of 1486 enrolled patients, 637 (43%) harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver operating characteristic curve (AUC) for the HARBINGER was .76 (95% confidence interval [CI], .72-.79), which was significantly superior to both the GBS (AUC, .68; 95% CI, .64-.71; P < .001) and the AIMS65 (AUC, .54; 95% CI, .50-.58; P < .001). When the HARBINGER cutoff value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively. CONCLUSIONS The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and AIMS65.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Andrew T Chan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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49
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Affiliation(s)
- Loren Laine
- From Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven - both in Connecticut
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50
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Lau JYW, Yu Y, Tang RSY, Chan HCH, Yip HC, Chan SM, Luk SWY, Wong SH, Lau LHS, Lui RN, Chan TT, Mak JWY, Chan FKL, Sung JJY. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020; 382:1299-1308. [PMID: 32242355 DOI: 10.1056/nejmoa1912484] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined. METHODS To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization. RESULTS A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group. CONCLUSIONS In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).
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Affiliation(s)
- James Y W Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yuanyuan Yu
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Raymond S Y Tang
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Heyson C H Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hon-Chi Yip
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shannon M Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sally W Y Luk
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sunny H Wong
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Louis H S Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rashid N Lui
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ting T Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joyce W Y Mak
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francis K L Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joseph J Y Sung
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| |
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