Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study

Meta-analysis: Over-the-scope clips in patients at high risk of re-bleeding following upper gastrointestinal tract bleeding

BACKGROUND

Acute non-variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re-bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over-the-scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain.

AIMS

To confirm the role of OTSC in patients with UGIB at high risk of re-bleeding.

METHODS

We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non-variceal UGIB with high re-bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity.

RESULTS

We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08-1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re-bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30-0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30-day mortality, or length of hospital or ICU stay.

CONCLUSIONS

Moderate certainty evidence supports OTSC as a superior initial treatment for acute non-variceal UGIB with high re-bleeding risk. Further large-scale studies are needed to confirm OTSCs' role by exploring other prognostic outcomes and assessing cost-effectiveness and potential complications.

Early nutrition is safe and does not increase complications after upper gastrointestinal bleeding-a systematic review and meta-analysis of randomized controlled trials

Despite a lack of evidence, patients are often not fed for 48-96 h after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB. The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27th of April 2024 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model. A total of 10 trials with 1051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR 1.20, CI 0.85-1.71, I2 = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR 0.61, CI 0.35-1.06, I2 = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR 1.04, CI 0.66-1.63, I2 = 0% and RR 1.16, CI 0.63-2.13, I2 = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD -1.22 days, CI: -2.43 to -0.01, I2 = 94%). In conclusion, compared with DN, EN (within 24 h) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.

At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis

Background

Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI).

Objectives

We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB.

Design

A systematic search was conducted in three medical databases in October 2021.

Data sources and methods

Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias.

Results

A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies.

Conclusion

Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI.

Registration

PROSPERO registration number: CRD42021285727.

Efficacy of endoscopic therapy and long-term outcomes of upper gastrointestinal tumor bleeding in patients with esophageal cancer

BACKGROUND

Upper gastrointestinal bleeding (UGIB) from malignancies is associated with a poor outcome. Only a small number of studies on gastrointestinal tumor bleeding have been published so far, focusing mainly on bleeding from gastric cancer. Since the information on patients with UGIB from esophageal cancer appears insufficient, this study aimed to present clinical and endoscopic findings, treatment options as well as clinical outcomes such as rebleeding and survival of those patients.

METHODS

This retrospective analysis included all patients admitted with UGIB from esophageal cancer at our university hospital during a 10-year period.

RESULTS

45 patients were analyzed of whom 26 (57.8%) already had cancer stage IV at index bleeding. 22 (48.9%) patients presented with hemodynamic instability and 30 (66.7%) patients received blood transfusions. Active bleeding was present in 24 (53.3%) patients, of whom 20 (83.3%) received endoscopic therapy. Successful hemostasis was achieved in 18 (90%) of 20 patients with Argon plasma coagulation used most frequently (52.4%). Early and delayed rebleeding occurred in 5 (12.5%) and 11 (27.5%) of all inoperable patients, respectively. Intake of anticoagulation or anti-platelet drugs were risk factors for delayed rebleeding and the median overall survival after index bleeding was 1.2 months.

CONCLUSION

UGIB from esophageal cancer occurred most frequently in advanced tumor stages and was associated with significant blood loss. Even though initial endoscopic therapy was effective, rebleeding occurred in a significant number of patients. Those taking anticoagulants or anti-platelet drugs should be closely monitored for rebleeding. The overall survival after index bleeding was poor.

Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding

The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.

The global epidemiology of upper and lower gastrointestinal bleeding in general population: A systematic review

BACKGROUND

Gastrointestinal bleeding (GIB) is a common and potentially life-threatening clinical event. To date, the literature on the long-term global epidemiology of GIB has not been systematically reviewed.

AIM

To systematically review the published literature on the worldwide epidemiology of upper and lower GIB.

METHODS

EMBASE^® and MEDLINE were queried from 01 January 1965 to September 17, 2019 to identify population-based studies reporting incidence, mortality, or case-fatality rates of upper GIB (UGIB) or lower GIB (LGIB) in the general adult population, worldwide. Relevant outcome data were extracted and summarized (including data on rebleeding following initial occurrence of GIB when available). All included studies were assessed for risk of bias based upon reporting guidelines.

RESULTS

Of 4203 retrieved database hits, 41 studies were included, comprising a total of around 4.1 million patients with GIB worldwide from 1980–2012. Thirty-three studies reported rates for UGIB, four for LGIB, and four presented data on both. Incidence rates ranged from 15.0 to 172.0/100000 person-years for UGIB, and from 20.5 to 87.0/100000 person-years for LGIB. Thirteen studies reported on temporal trends, generally showing an overall decline in UGIB incidence over time, although a slight increase between 2003 and 2005 followed by a decline was shown in 5/13 studies. GIB-related mortality data were available from six studies for UGIB, with rates ranging from 0.9 to 9.8/100000 person-years, and from three studies for LGIB, with rates ranging from 0.8 to 3.5/100000 person-years. Case-fatality rate ranged from 0.7% to 4.8% for UGIB and 0.5% to 8.0% for LGIB. Rates of rebleeding ranged from 7.3% to 32.5% for UGIB and from 6.7% to 13.5% for LGIB. Two main areas of potential bias were the differences in the operational GIB definition used and inadequate information on how missing data were handled.

CONCLUSION

Wide variation was seen in estimates of GIB epidemiology, likely due to high heterogeneity between studies however, UGIB showed a decreasing trend over the years. Epidemiological data were more widely available for UGIB than for LGIB.

Use of over-the-scope clip (OTSC) versus standard therapy for the prevention of rebleeding in large peptic ulcers (size ≥1.5 cm): an open-labelled, multicentre international randomised controlled trial

INTRODUCTION

Over-the-scope clip (OTSC) has been used recently for primary haemostasis of peptic ulcers. This study aimed to compare the efficacy of OTSC to standard endoscopic therapy in primary treatment of patients with peptic ulcer bleeding that are of size ≥1.5 cm. The target population accounts for only 2.5% of all upper GI bleeders.

METHODS

This was a multicentre international randomised controlled trial from July 2017 to October 2020. All patients with Forest IIa or above peptic ulcers of ≥1.5 cm were included. Primary outcome was 30-day clinical rebleeding. Secondary endpoints include 3-day all-cause mortality, transfusion requirement, hospital stay, technical and clinical success, and further interventions. 100 patients are needed to yield a power of 80% to detect a difference of -0.15 at the 0.05 significance level (alpha) using a two-sided Z-test (pooled).

RESULTS

100 patients were recruited. Success in achieving primary haemostasis was achieved in 46/50 (92%) and 48/50 (96%) in the OTSC and conventional arm, respectively. Among patients who had success in primary haemostasis, 2/46 (4.35%) patients in the OTSC arm and 9/48 (18.75%) patients in the conventional arm developed 30-day rebleeding (p=0.03). However, in an intention-to-treat analysis, there was no difference in rebleeding within 30 days (5/50 (10%) OTSC vs 9/50 (18%) standard, p=0.23) or all-cause mortality (2/50 (4%) OTSC vs 4/50 (8%) standard, p=0.68; OR=2.09, 95% CI 0.37 to 11.95). There was also no difference in transfusion requirement, hospital stay, intensive care unit admission and further interventions.

CONCLUSION

The routine use of OTSC as primary haemostasis in large bleeding peptic ulcers was not associated with a significant decrease in 30-day rebleeding.

TRIAL REGISTRATION NUMBER

NCT03160911.

Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding

Background & Aims: Several risk scores have been proposed for risk-stratification of patients with upper gastrointestinal bleeding. ABC score was found more accurate predicting mortality than AIMS65. MAP(ASH) is a simple, pre-endoscopy score with a great ability to predict intervention and mortality. The aim of this study was to compare ABC and MAP(ASH) discriminative ability for the prediction of mortality and intervention in UGIB. As a secondary aim we compared both scores with Glasgow-Blatchford score and AIMS65. Methods: Our study included patients admitted to the emergency room of Virgen de las Nieves University Hospital with UGIB (2017-2020). Information regarding clinical, biochemical tests and procedures was collected. Main outcomes were in-hospital mortality and a composite endpoint for intervention. Results: MAP(ASH) and ABC had similar AUROCs for mortality (0.79 vs. 0.80). For intervention, MAP(ASH) (AUROC = 0.75) and ABC (AUROC = 0.72) were also similar. Regarding rebleeding, AUROCs of MAP(ASH) and ABC were 0.67 and 0.61 respectively. No statistically differences were found in these outcomes. With a low threshold for MAP(ASH) ≤ 2, ABC and MAP(ASH) classified a similar proportion of patients as being at low risk of death (42% vs. 45.2%), with virtually no mortality under these thresholds. Conclusions: MAP(ASH) and ABC were similar for the prediction of relevant outcomes for UGIB, such as intervention, rebleeding and in-hospital mortality, with an accurate selection of low-risk patients. MAP(ASH) has the advantage of being easier to calculate even without the aid of electronic tools.

A multicenter prospective study of the treatment and outcome of patients with gastroduodenal peptic ulcer bleeding in Japan

Gastroduodenal peptic ulcers are the main cause of nonvariceal upper gastrointestinal bleeding (UGIB). We believe that recent advances in endoscopic techniques and devices for diagnosing upper gastrointestinal tract tumors have advanced hemostasis for UGIB. However, few prospective multicenter studies have examined how these changes affect the prognosis. This prospective study included 246 patients with gastroduodenal peptic ulcers treated at 14 participating facilities. The primary endpoint was in-hospital mortality within 4 weeks, and the secondary endpoints required intervention and refractory bleeding. Subsequently, risk factors affecting these outcomes were examined using various clinical items. Furthermore, the usefulness of the risk stratification using the Glasgow-Blatchford score, rockall score and AIMS65 based on data from the day of the first urgent endoscopy were examined in 205 cases in which all items were complete there are two periods. Thirteen (5%) patients died within 4 weeks; and only 2 died from bleeding. Significant risk factors for poor outcomes were older age and severe comorbidities. Hemostasis was required in 177 (72%) cases, with 20 cases of refractory bleeding (2 due to unsuccessful endoscopic treatment and 18 due to rebleeding). Soft coagulation was the first choice for endoscopic hemostasis in 57% of the cases and was selected in more than 70% of the cases where combined use was required. Rockall score and AIMS65 predicted mortality equally, and Glasgow-Blatchford score was the most useful in predicting the requirement for intervention. All scores predicted refractory bleeding similarly. Although endoscopic hemostasis for UGIB due to peptic ulcer had a favorable outcome, old age and severe comorbidities were risk factors for poor prognosis. We recommend that patients with UGIB should undergo early risk stratification using a risk scoring system.

Characteristics, Outcomes, and Risk Factors for Upper Gastrointestinal Bleeding in Inpatients - A Comparison with Outpatients

Objective The study objectives were to clarify the clinical findings and the causes of intractability and mortality of upper gastrointestinal (UGI) bleeding in inpatients. Methods The patients were divided into Inpatient (Ip) and Outpatient (Op) onset groups, and their characteristics, clinical and bleeding data, and outcomes were compared. Patients or Materials Our study included 375 patients who developed UGI bleeding during hospitalization or were admitted after being diagnosed with UGI bleeding in an outpatient setting from January 1, 2015, to June 30, 2020. Results The Ip group had worse general condition; increased percentages of comorbidities; and more common use of proton pump inhibitor, anti-coagulant, and steroid than the Op group. Compared with the Op group, the Ip group had lower serum albumin levels and platelet counts at the onset of bleeding, whereas rebleeding, mortality, and bleeding-related death rates were higher. Multivariate analysis of the Ip group revealed that the risks of rebleeding included endoscopic high-risk stigmata, maintenance dialysis, and duodenal bleeding, whereas the risks of mortality were gastric ulcer and a Charlson Comorbidity Index update score of ≥3. Conclusion UGI bleeding in the Ip group was associated with higher rebleeding and mortality rates. Because of their poor general health condition, the pathology of UGI bleeding in these patients may differ from that of patients with common UGI bleeding. A different approach for the care and prevention of UGI bleeding in inpatients is required.

Cost-effectiveness of check of medication appropriateness: methodological approach

Background Adverse drug events following inappropriate prescribing in the hospital cause a substantial and avoidable medical and economic burden to hospitals, payers and patients alike. A clinical rule-based, pharmacist-led medication-review service, the 'Check of Medication Appropriateness' (CMA) was implemented in the University Hospitals Leuven. The CMA is shown to be effective in reducing potentially inappropriate prescriptions. Aim This study investigated whether this centralised clinical pharmacy service is cost-effective. Method We performed a cost-effectiveness analysis of three clinical rules of the CMA, targeting adverse drug events at three levels of severity: A) persistent opioid-induced constipation, B) ketorolac-induced gastrointestinal bleeding and C) drug-induced Torsade de Pointes. A decision tree was developed for each clinical rule. Both intervention costs as well as total costs associated with the occurrence of an adverse drug event were considered. The outcomes were reported in the form of an incremental cost-effectiveness ratio, expressed as an incremental cost per adverse drug event avoided. Results Applying clinical rules to avoid persistent opioid-induced constipation and ketorolac-induced gastrointestinal bleeding were cost-saving. Implementation of a medication check to avoid drug-induced Torsade de Pointes costed €8,846 per Torsade de Pointes avoided. Conclusion Our study provides strong indications that the CMA is worth its investment for clinical rules targeting (very) common adverse drug events, that can be avoided with limited expenses. Further research is required to assess the full CMA. The proposed model may be useful to perform cost-effectiveness analyses of other centralised clinical pharmacy services targeting inappropriate prescribing, at the level of individual adverse drug events.

Hemostasis Techniques for Non-variceal Upper GI Hemorrhage: Beyond Injection and Cautery

B. Nulsen D. M. Jensen.

Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis

OBJECTIVES

Endoscopy is the mainstay treatment option for acute variceal bleeding (AVB) in liver cirrhosis. However, the optimal timing of endoscopy in such patients remains unclear.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched. We compared the mortality, incidence of rebleeding, length of stay, endoscopic hemostasis, need for salvage and units of transfusion between cirrhotic patients with AVB who underwent early and delayed endoscopy. Meta-analyses were performed by using a random-effect model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analysis was performed in studies where early endoscopy was defined as <12 h.

RESULTS

Nine retrospective studies involving 2824 patients were included. The early endoscopy group had a significantly lower overall mortality than the delayed endoscopy group in overall analysis (OR = 0.56, 95% CI, 0.33-0.95, P = 0.03), but the difference between them was NS in subgroup analysis (OR = 0.72, 95% CI, 0.38-1.38, P = 0.33). In-hospital (OR = 0.77, 95% CI, 0.26-2.32, P = 0.65) and 6-week (OR = 0.78, 95% CI, 0.42-1.47, P = 0.45) mortality were not significantly different between them. Overall rebleeding was not significantly different between early and delayed endoscopy groups in both overall (OR = 0.88, 95% CI, 0.51-1.51, P = 0.63) and subgroup (OR = 1.04, 95% CI, 0.55-1.95, P = 0.90) analyses. In-hospital (OR = 1.41, 95% CI, 0.67-2.96, P = 0.37) and 6-week (OR = 0.93, 95% CI, 0.40-2.17, P = 0.86) rebleeding remained not significantly different between them. Additionally, the length of stay, endoscopic hemostasis, need for salvage and units of transfusion were not significantly different between them.

CONCLUSIONS

Early endoscopy may improve the survival of cirrhotic patients with AVB, but has no remarkable benefit on the prevention of rebleeding. These findings should be further validated by high-quality studies.

Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND AND AIMS

No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim.

METHODS

Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician.

RESULTS

53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH.

CONCLUSION

1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465).

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study

BACKGROUND & AIM

Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management.

METHODS

Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded.

RESULTS

Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients.

CONCLUSION

Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412].

A simple prediction score for in-hospital mortality in patients with nonvariceal upper gastrointestinal bleeding

BACKGROUND

No prediction scores for the mortality of both inpatients and outpatients who developed nonvariceal upper gastrointestinal bleeding (UGIB) without endoscopic findings have been established. We aimed to derive and validate a novel prediction score for in-hospital mortality.

METHODS

We conducted a three-stage, multicenter retrospective study. In the derivation stage, patients with nonvariceal UGIB at six institutions were enrolled to derive the prediction score by logistic regression analysis. External validation of the score was performed to analyze discrimination by patients at six other institutions. Then the performance of this score was compared with that of four existing scores.

RESULTS

We enrolled 1380 and 825 patients in the derivation and validation cohorts, respectively. A prediction score (CHAMPS-R Score) comprising seven variables (Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroids, and rebleeding) with equal-weight scores was established, with high discriminative ability in both derivation and validation cohorts (c statistic, 0.91 and 0.80, respectively). When rebeeding was excluded from the score (an onset model; CHAMPS Score), this score also achieved high discriminative ability (c statistic, 0.90 and 0.81, respectively). The prediction scores had significantly higher discriminative ability than the Glasgow Blatchford Score, AIMS65, ABC Score, and clinical Rockall Score in both cohorts (all, p < 0.05).

CONCLUSIONS

We derived and externally validated prediction scores for in-hospital mortality in patients with nonvariceal UGIB. The CHAMPS Score might be optimal for managing such patients. Its mobile application is freely available ( https://apps.apple.com/app/id1565716902 for iOS and https://play.google.com/store/apps/details?id=hatta.CHAMPS for Android).

Prognosis of variceal and non-variceal upper gastrointestinal bleeding in already hospitalised patients: Results from a French prospective cohort

OBJECTIVES

Patients who develop upper gastrointestinal bleeding (UGIB) while in hospital appear to have a poor prognosis. Our study aims at analysing the difference in outcome between in-patients (IPs) and out-patients presenting with variceal and non-variceal UGIB.

METHODS

We conducted a multicentre prospective study by collecting data about variceal and non-variceal UGIB cases through 46 hospitals in France between November 2017 and October 2018. We then compared baseline demographic features, endoscopic findings and outcome between patients who developed variceal and non-variceal UGIB on admission (OPs) and those at least 24 h after hospitalisation (IPs). Our primary end-point was mortality and re-bleeding rates at 6 weeks of bleeding onset.

RESULTS

A total of 2498 UGIB cases were identified, of whom 634 (25.4%) occurred in IPs. IPs were older than OPs (72.5 vs. 67.2 years old, p < 0.001) and had a higher rate of comorbidities (38.9% vs. 26.6%, p < 0.0001). Their bleeding was more severe with a Rockall score of >5 present in 40.9% (vs. 30.3% in OPs, p < 0.0001). The 6-week mortality rate was significantly higher in IPs when compared to OPs (21.7% vs. 8%, p < 0.0001). Prothrombin time <50% and rebleeding were the only independent predictors of mortality (p = 0.001 and 0.003, respectively). Six-week rebleeding occurred more frequently among IPs (18.6% vs. 14.4%, p = 0.015) and predictors included female sex, active bleeding upon endoscopy and a Blatchford score >11 (p = 0.017, 0.011 and 0.008, respectively).

CONCLUSION

IPs who develop variceal and non-variceal UGIB are more likely to be elderly with more comorbidities. They have a higher rate of mortality and rebleeding. Independent predictors of mortality were underlying coagulopathy and bleeding recurrence. An optimal bleeding management and efficient rebleeding prevention may improve outcome in these patients.

C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis

In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.

Outcomes in patients with acute upper gastrointestinal bleeding following changes to management protocols at an Australian hospital

Background and Aim

Upper gastrointestinal bleeding (UGIB) has a high mortality rate and requires efficient and directed acute management. This project aimed to assess patient outcomes following changes to UGIB management protocols at Northern Hospital, Victoria, Australia. Changes involved streamlining management under a single inpatient unit, earlier endoscopy, blood transfusion thresholds, and risk stratification.

Methods

This was a cohort study of 400 patients aged ≥18 years admitted to Northern Hospital who underwent endoscopy for acute UGIB. Data of preprotocol changes (Group 1) and prospectively postprotocol changes (Group 2) were collected retrospectively. Primary outcomes were inpatient mortality, rebleeding, radiologic or surgical intervention, and endoscopic reintervention. Secondary outcomes included length of stay (LOS) ≥4 days and blood units transfused. Univariate analyses were conducted comparing groups and associations between variables and outcomes, followed by multivariate analyses for each outcome.

Results

There was no difference in mortality on multivariate analysis (P = 0.95). Rebleeding reduced by 4% (adjusted odds ratio [AOR] 0.48; P = 0.03), LOS ≥4 days reduced by 15.1% (AOR 0.46; P < 0.00) and median blood units transfused decreased with adjusted incidence rate ratio of 0.81 (P = 0.00). Early endoscopy (i.e. ≤12 h) for all patients increased by 15% (P < 0.00) and there were 12% more high‐risk patients (i.e. Glasgow–Blatchford score ≥ 12) in Group 2 (P = 0.01).

Conclusion

Following changes to UGIB protocols at this Australian hospital, endoscopic times decreased with reductions in rebleeding, LOS ≥4 days, and blood transfusion rates. These findings demonstrate improved outcomes after the implementation of new treatment targets focusing on streamlined care of patients presenting with UGIB.

Second urgent endoscopy within 48-hour benefits cirrhosis patients with acute esophageal variceal bleeding

Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.

Clipping Over the Scope for Recurrent Peptic Ulcer Bleeding is Cost-Effective as Compared to Standard Therapy: An Initial Assessment

Clipping over the scope (C-OTS) is a novel closure technique used for the treatment of nonvariceal gastrointestinal bleeding, especially for high-risk lesions. C-OTS devices cost more than clipping through the scope and thermal devices. The high upfront cost of C-OTS may pose a barrier to its use and the cost-effectiveness of C-OTS for peptic ulcer disease bleeding is unknown. Cost-effectiveness studies of C-OTS for peptic ulcer bleeding as both first-line and second-line therapy can provide the current estimate of the conditions in which the use of C-OTS is cost-effective and give insights of the determinants to the cost-effectiveness of C-OTS.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated.

AIM

To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB.

METHODS

This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups.

RESULTS

A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.

CONCLUSION

In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding

BACKGROUND

Nonvariceal upper digestive bleeding (NVUDB) represents a severe emergency condition and is associated with significant morbidity and mortality. Despite a decrease in the incidence due to the widespread use of potent therapy with proton pump inhibitors as well as the implementation of modern endoscopic techniques, the mortality rate associated with NVUDB is still high.

AIM

To identify the clinical, biological, and endoscopic parameters associated with a poor outcome in patients with NVUDB to allow the stratification of risk, which will lead to the implementation of the most accurate management.

METHODS

We performed a retrospective study including patients who were admitted to the Gastroenterology Department of Clinical Emergency County Hospital Timisoara, Romania, with a diagnosis of NVUDB between 1 January 2008 and 31 December 2016. All the data were collected from the patient’s records, including demographic data, medication history, hemodynamic status, paraclinical tests, and endoscopic features as well as the methods of hemostasis, rate of rebleeding, need for surgery and death; we also assessed the Rockall score of the patients, length of hospitalization and associated comorbidities. All these parameters were evaluated as potential risk factors associated with rebleeding and death in patients with NVUDB.

RESULTS

We included a batch of 1581 patients with NVUDB, including 523 (33%) females and 1058 (67%) males with a median age of 66 years. The main cause of NVUDB was peptic ulcer (73% of patients). More than one-third of the patients needed endoscopic treatment. Rebleeding rate was 7.72%; surgery due to failure of endoscopic hemostasis was needed in 3.22% of cases; the in-hospital mortality rate was 8.09%, and the bleeding-episode-related mortality rate was 2.97%. Although our predictive models for rebleeding and death had a low sensitivity, the specificity was very high, suggesting a better discriminative capacity for identifying patients with better outcomes. Our results showed that the Rockall score was associated with both rebleeding and death; comorbidities such as respiratory conditions, liver cirrhosis and sepsis increased significantly the risk of in-hospital mortality (OR of 3.29, 2.91 and 8.03).

CONCLUSION

Our study revealed that the Rockall score, need for endoscopic therapy, necessity of transfusion and sepsis were risk factors for rebleeding. Moreover, an increased Rockall score and the presence of comorbidities were predictive factors for in-hospital mortality.

Clinical experience with ferric carboxymaltose in the management of anemia in acute gastrointestinal bleeding

OBJECTIVE

The aim of this study was to assess the efficacy and safety of intravenous ferric carboxymaltose (FCM) following hospitalization for acute gastrointestinal bleeding (AGIB) in the context of a restrictive transfusion strategy.

PATIENTS AND METHODS

A retrospective single-center study analyzed patients with AGIB (excluding AGIB secondary to portal hypertension) administered a single FCM dose with or without blood transfusion.

RESULTS

Eighty-six episodes in 84 patients were analyzed. Seventy-nine patients had upper AGIB. Nineteen episodes were associated with hemodynamic instability. FCM was administered during hospitalization as a single dose of 1000 mg iron in 84/86 episodes and as a single dose of 500 mg iron in two episodes, with blood transfusion in 60/86 (69.8%) episodes. The mean hemoglobin (Hb) was 9.0 g/dl at admission, 7.6 g/dl at the lowest in-hospital value, 9.4 g/dl at discharge, and 12.7 g/dl at follow-up (mean: 55 days postdischarge) (P<0.001 for follow-up vs. all other timepoints). The lowest mean in-hospital Hb value was 7.2 and 8.8 g/dl, respectively, in patients with transfusion+FCM versus FCM alone; the mean Hb was 12.4 versus 13.7 g/dl at follow-up. In patients administered FCM alone, the mean Hb at follow-up in the subpopulations aged older than or equal to 75 years (n=33), Charlson comorbidity index of at least 3 (n=48), and Hb of up to 10 g/dl at admission (n=47) were 12.6, 13.1, and 13.3 g/dl, respectively. No adverse effects were detected.

CONCLUSION

Treatment with FCM for AGIB is associated with a good erythropoietic response and anemia correction after hospitalization, even in severe episodes or when transfusion is needed. FCM is safe and well tolerated, and may support a restrictive transfusion policy.

Over-the-scope-clips as primary and rescue therapy for non-variceal gastrointestinal bleeding: a systematic review and meta-analysis

INTRODUCTION

Endoscopic hemostasis in patients with non-variceal bleeding (NVGIB) with standard therapy has improved outcomes. However, persistent bleeding and re-bleeding continues to drive morbidity and mortality. Use of over-the-scope clips (OTSC) is an emerging treatment modality for managing gastrointestinal (GI) bleeding. We performed a systematic review and meta-analysis to evaluate the ability of OTSC to achieve primary hemostasis and re-bleeding rates as primary therapy and rescue endoscopic interventions in patients with NVGIB.

EVIDENCE ACQUISITION

We searched articles in PubMed, Ovid Medline In- Process & Other Non-Indexed Citations, Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from inception to July 2017 using keywords such as "OTSC" and "NVGIB."

EVIDENCE SYNTHESIS

A total of 16 studies which involved 475 patients met the inclusion criteria. 288 patients were treated with OTSC as primary therapy while 187 patients were treated with OTSC as rescue therapy. Primary hemostasis rate achieved with primary endoscopic therapy with OTSC was 0.93 (95% CI: 0.89-0.96). Similarly, primary hemostasis rate achieved with rescue endoscopic therapy with OTSC was 0.91 (95% CI: 0.84-0.95). Re-bleeding rates after primary endoscopic therapy with OTSC was 0.21 (95% CI:0.08-0.43) and 0.25 (95% CI:0.17-0.34) with rescue therapy. There was a decreased risk of re-bleeding in patients treated with OTSC as primary therapy versus rescue therapy. RR=0.52 (95% CI: 0.31-0.89).

CONCLUSIONS

This meta-analysis demonstrates success on the use of OTSC as primary and rescue therapy in the management of NVGIB. Further trials should clarify the ideal setting for the use of OTSC and assess the cost of these devices as compared to standard therapy.

Outcomes of Patients Undergoing Endoscopic Hemostasis for the Upper Gastrointestinal Bleeding Were Not Influenced by the Timing of Hospital Emergency Visits: A Situation Prevailing in Japan

BACKGROUND

The aim of the present study was to determine differences in the prognosis of patients in Japan who underwent emergency endoscopic hemostasis (i) during regular hours versus off hours and (ii) as outpatients versus hospitalized patients.

METHODS

The present retrospective study included 443 patients who underwent emergency endoscopic hemostasis for non-variceal upper gastrointestinal bleeding from January 2008 to December 2014. These patients were classified into 2 groups: hospitalized patients and outpatients. The outpatients were further subclassified into those who visited the hospital during regular hours and those who visited during off hours.

RESULTS

The outcomes of outpatients who underwent emergency hemostasis during off hours did not differ from patients treated during regular hours. Multivariate analysis revealed that outcomes of hospitalized patients, including mortality, need for blood transfusion and length of hospitalization, were worse than those of outpatients; it also revealed that patient age, malnutrition rate and prevalence of diabetes and neoplasms were higher among hospitalized patients than those in outpatients.

CONCLUSIONS

The clinical outcomes of patients who underwent emergency endoscopic hemostasis for upper gastrointestinal bleeding during off hours did not differ from those of patients treated during regular hours. Outcomes were worse among hospitalized patients, mainly because of their bad general condition.

Inhospital and delayed mortality after upper gastrointestinal bleeding: an analysis of risk factors in a prospective series

BACKGROUND

Detailed analyses of mortality after upper gastrointestinal (GI) bleeding are lacking. Follow-up rarely extends beyond 30 days.

AIMS

Our aim was to analyze in-hospital and delayed 6-months mortality, identifying risk factors.

METHODS

This was a prospective study on patients with upper GI bleeding over 36 months. Clinical outcomes were in-hospital and delayed-6 month-mortality.

RESULTS

Four hundred and forty-none patients were included. Overall inpatient mortality was 9.8% but mortality directly related to bleeding was 5.1%. Patients who died presented lower systolic blood pressures, platelet recounts, prothrombin times and lower levels of hemoglobin, calcium, albumin, urea, creatinine and total proteins. Cirrhosis and neoplasms determined a higher in-hospital mortality. Albumin levels were protective, whereas creatinine and an active bleeding were risk factors for in-hospital death in multivariate analysis. Up to 12.6% of patients discharged died in the first 6 months. Neoplasms, chronic kidney disease, coronary disease and esophageal varices were related to delayed mortality. Coronary disease and neoplasms were independent risk factors for mortality, but albumin levels were protective in multivariate analysis.

CONCLUSION

Comorbidities were risk factors for delayed mortality, whereas albumin levels were a protective factor for in-hospital and delayed deaths. Six months mortality is proportionately as important as in-hospital mortality. Half of the delayed deaths might be preventable.

Outcomes and Role of Urgent Endoscopy in High-Risk Patients With Acute Nonvariceal Gastrointestinal Bleeding

BACKGROUND & AIMS

We investigated clinical outcomes in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), and determined if urgent endoscopy is effective.

METHODS

Consecutive patients with a Glasgow-Blatchford score greater than 7 who underwent endoscopy for acute nonvariceal UGIB at the emergency department from January 1, 2005, to December 31, 2014, were included. Urgent (<6 h) and elective (6-48 h) endoscopies were defined according to the time to endoscopy after the initial presentation. The primary outcomes were mortality and rebleeding within 28 days of admission.

RESULTS

Among 961 patients, 571 patients underwent urgent endoscopy. The 28-day mortality rate was 2.5%, and the rebleeding rate was 10.4%. There were significant differences in mortality rate (1.6% vs 3.8%), the number of transfused packed red blood cells (2.6 ± 2.5 vs 2.3 ± 2.1 packs), need for intervention (69.5% vs 53.5%), and embolization (2.8% vs 0.5%), but no differences in rebleeding, intensive care unit admission, vasopressor use, and length of stay between the urgent and elective endoscopy groups. Mortality was associated with malignancy (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.33-9.62), cirrhosis (OR, 4.67; 95% CI, 1.85-11.76), urgent endoscopy (OR, 0.36; 95% CI, 0.14-0.95), failed primary endoscopic treatment (OR, 15.03; 95% CI, 4.63-48.82), and rebleeding (OR, 2.77; 95% CI, 1.03-7.45). Rebleeding was associated with Forrest I ulcers (OR, 7.67; 95% CI, 2.71-21.69), Forrest II ulcers (OR, 2.34; 95% CI, 1.51-3.60), and coagulopathy (OR, 2.34; 95% CI, 1.51-3.60).

CONCLUSIONS

Urgent endoscopy was an independent predictor of lower mortality rate but was not associated with rebleeding in high-risk patients with acute nonvariceal UGIB.

Association between patient characteristics and magnetically controlled capsule endoscopy findings

BACKGROUND/AIM

Magnetically-controlled capsule endoscopy (MCE) is a potential option for the evaluation of gastric diseases in cases that are unsuited for conventional endoscopy, avoiding discomfort, sedation, and related complications. This retrospective study investigated associations between MCE findings and patient gender, age, and inpatient/outpatient status.

PATIENTS AND METHODS

The data of 580 consecutive patients who underwent MCE from 2015 to 2016 were analyzed. Data included age, gender, indication for MCE, inpatient/outpatient status, overall coverage of gastric anatomical landmarks, and comorbid conditions.

RESULTS

Compared with outpatients, inpatients had a higher rate of overall significant MCE findings (P = 0.014), polyp (P = 0.03), and ulceration (P = 0.003). MCE findings of the inpatient men and women were similar. Considering all patients, the percentage with ulceration was significantly higher in men than in women (P = 0.004), and men were younger (P < 0.001). Compared with younger patients, those aged ≥60 years had significantly higher rates of overall significant findings, mainly polyp and angiodysplasia.

CONCLUSIONS

Compared with outpatients, the inpatients showed higher overall significant findings. Men undergoing MCE were younger than the women, and more likely to have ulcerations. Older patients, whether outpatient or inpatient, had higher rates of significant findings, mainly polyp and angiodysplasia.

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital

BACKGROUND

Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities.

METHODS

A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients.

RESULTS

Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities.

CONCLUSIONS

The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65.

Risk of Rebleeding and Mortality in Cirrhotic Patients with Peptic Ulcer Bleeding: A 12-Year Nationwide Cohort Study

Although a few studies have investigated the risks of peptic ulcer bleeding (PUB) in cirrhotic patients, large population-based studies on in-hospital and long-term reports on recurrent PUB in a cohort of cirrhotic patients are lacking. This 12-year nationwide cohort study aimed to investigate the risks of in-hospital and long-term rebleeding and mortality in cirrhotic patients and to identify possible risk factors. Patient data from 1997 to 2008 were extracted from the National Health Insurance Research Database in Taiwan. A total of 15,575 patients who were discharged with a diagnosis of PUB were identified after strict exclusions (n = 2889). Among them, patients with cirrhosis (n = 737) and those with chronic hepatitis (n = 1044) were compared to propensity-score matched normal controls at a ratio of 1:1. Accumulated in-hospital and long-term follow-up PUB-free survival rates were analyzed in patients with cirrhosis, patients with chronic hepatitis, and matched controls. Cox proportional hazards regression was used to identify each independent risk factor. Compared with matched controls, patients with cirrhosis exhibited a 2.62-fold (95% CI: 1.74–3.92) higher risk of developing in-hospital rebleeding, but the risk of long-term rebleeding was comparable between cirrhotic patients and matched controls (hazard ratio: 1.29, 95% CI: 0.8–2.09). On the other hand, no significant difference was observed in in-hospital and long-term rebleeding between chronic hepatitis patients and matched controls. We compared the survival rates of cirrhotic and chronic hepatitis patients to that of matched controls. After propensity score matching, both cirrhotic and chronic hepatitis patients showed significantly lower survival than the matched controls (P < 0.0001 and 0.033, respectively) during the 12-year follow-up period. However, in-hospital and long-term rebleeding rates were not significantly different between chronic hepatitis patients and matched controls (P = 0.251 and 0.474, respectively). In conclusion, liver cirrhosis increased health care expenses in patients with PUB and these patients exhibited higher recurrent bleeding rate than non-cirrhotic patients during hospitalization. Cirrhosis and chronic hepatitis are independently associated with an increased long-term mortality when compared with patients without liver disease.

Chronic obstructive pulmonary disease is associated with increased recurrent peptic ulcer bleeding risk

BACKGROUND

The association between chronic obstructive pulmonary disease (COPD) and the risk of recurrent peptic ulcer bleeding (PUB) remains unclear. In this study, we compared the risk of recurrent PUB between patients with and those without COPD.

METHODS

Using the Taiwan National Health Insurance Research Database, we first selected patients newly diagnosed with PUB in 2002-2009. Two groups comprising 13,732 COPD cases and 13,732 non-COPD matched controls were created using propensity score matching, thereby making the differences in basic demographics, medication use, and disease conditions between the two groups negligible. Cox proportional hazard regression was used to evaluate the risk of recurrent PUB during the follow-up period.

RESULTS

The cumulative recurrence rate of PUB was significantly higher in the patients with COPD than in the non-COPD matched controls (2years: 10.8% vs 9.3%; 6years: 18.3% vs 15.7%, P all <0.05), with an adjusted hazard ratio (HR) of 1.17 (95% confidence interval [CI], 1.08-1.26, P<0.001) and 1.19 (95% CI, 1.12-1.26, P<0.001) within 2-year and 6-year follow-ups, respectively. Patients with COPD using steroids were at a marginally higher risk of recurrent PUB than those who did not use steroids. Multivariate stratified analysis revealed similar results in many subgroups.

CONCLUSIONS

The risk of recurrent PUB is higher in patients with COPD than in patients without COPD.

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

Validity of peptic ulcer disease and upper gastrointestinal bleeding diagnoses in administrative databases: a systematic review protocol

INTRODUCTION

Administrative healthcare databases are useful to investigate the epidemiology, health outcomes, quality indicators and healthcare utilisation concerning peptic ulcers and gastrointestinal bleeding, but the databases need to be validated in order to be a reliable source for research. The aim of this protocol is to perform the first systematic review of studies reporting the validation of International Classification of Diseases, 9th Revision and 10th version (ICD-9 and ICD-10) codes for peptic ulcer and upper gastrointestinal bleeding diagnoses.

METHODS AND ANALYSIS

MEDLINE, EMBASE, Web of Science and the Cochrane Library databases will be searched, using appropriate search strategies. We will include validation studies that used administrative data to identify peptic ulcer disease and upper gastrointestinal bleeding diagnoses or studies that evaluated the validity of peptic ulcer and upper gastrointestinal bleeding codes in administrative data. The following inclusion criteria will be used: (a) the presence of a reference standard case definition for the diseases of interest; (b) the presence of at least one test measure (eg, sensitivity, etc) and (c) the use of an administrative database as a source of data. Pairs of reviewers will independently abstract data using standardised forms and will evaluate quality using the checklist of the Standards for Reporting of Diagnostic Accuracy (STARD) criteria. This systematic review protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) 2015 statement.

ETHICS AND DISSEMINATION

Ethics approval is not required given that this is a protocol for a systematic review. We will submit results of this study to a peer-reviewed journal for publication. The results will serve as a guide for researchers validating administrative healthcare databases to determine appropriate case definitions for peptic ulcer disease and upper gastrointestinal bleeding, as well as to perform outcome research using administrative healthcare databases of these conditions.

TRIAL REGISTRATION NUMBER

CRD42015029216.

Successful Endoscopic Hemostasis Is a Protective Factor for Rebleeding and Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

Rebleeding and mortality rates remain high in patients with nonvariceal upper gastrointestinal bleeding.

AIM

To identify clinical and endoscopic risk factors for rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

METHODS

This study was performed in patients with nonvariceal upper gastrointestinal bleeding who underwent upper endoscopic procedures between July 2006 and February 2013. Clinical and endoscopic characteristics were compared among patients with and without rebleeding and mortality. Logistic regression analysis was performed to determine independent risk factors for rebleeding and mortality.

RESULTS

After excluding 64 patients, data for 689 patients with nonvariceal upper gastrointestinal bleeding were analyzed. Peptic ulcer (62.6 %) was by far the most common source of bleeding. Endoscopic intervention was performed within 24 h in 99.0 % of patients, and successful endoscopic hemostasis was possible in 80.7 % of patients. The 30-day rebleeding rate was 13.1 % (n = 93). Unsuccessful endoscopic hemostasis was found to be the only independent risk factor for rebleeding (odds ratio 79.6; 95 % confidence interval 37.8-167.6; p = 0.000). The overall 30-day mortality rate was 3.2 % (n = 23). Unsuccessful endoscopic hemostasis (odds ratio 4.9; 95 % confidence interval 1.7-13.9; p = 0.003) was also associated with increased 30-day mortality in patients with nonvariceal upper gastrointestinal bleeding.

CONCLUSIONS

Successful endoscopic hemostasis is an independent protective factor for both rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

Management of anticoagulation in patients with acute gastrointestinal bleeding

Acute gastrointestinal bleeding represents the most common adverse event associated with the use of oral anticoagulant therapy. Due to increasing prescription of anticoagulants worldwide, gastroenterologists are more and more called to deal with bleeding patients taking these medications. Their management is challenging because several issues have to be taken into account, such as the severity of bleeding, the intensity of anticoagulation, the patient's thrombotic risk and endoscopy findings. The recent introduction into the marketplace of new direct oral anticoagulants, for whom specific reversal agents are still lacking, further contributes to make the decision-making process even more demanding. Available evidence on this topic is limited and practice guidelines by gastroenterology societies only marginally address key issues for clinicians, including when and how to reverse coagulopathy, the optimal timing of endoscopy and when and how to resume anticoagulation thereafter. The present paper reviews the evidence in the literature and provides practical algorithms to support clinicians in the management of patients on anticoagulants who present with acute gastrointestinal bleeding.

Risk Factors for Adverse Outcomes in Patients Hospitalized With Lower Gastrointestinal Bleeding

OBJECTIVE

To determine which risk factors and subtypes of lower gastrointestinal bleeding (LGIB) are associated with adverse outcomes after hospital discharge (30-day readmissions, recurrent LGIB, and death).

PATIENTS AND METHODS

We conducted a prospective observational study of consecutive patients admitted with LGIB to Beth Israel Deaconess Medical Center from April 1, 2013, through March 30, 2014. Patients were contacted 30 days after discharge to determine hospital readmissions, recurrent LGIB, and death. Multivariable Cox proportional hazards regression models were used to describe associations of variables with 30-day readmissions or recurrent LGIB. Logistic regression was used to determine association with mortality.

RESULTS

There were 277 patients hospitalized with LGIB. Of the 271 patients surviving to discharge, 21% (n=57) were readmitted within 30 days, 21 of whom were admitted for recurrent LGIB. The following factors were associated with 30-day readmissions: developing in-hospital LGIB (hazard ratio [HR], 2.26; 95% CI, 1.08-4.28), anticoagulation (HR, 1.82; 95% CI, 1.05-3.10), and active malignancy (HR, 2.33; 95% CI, 1.11-4.42). Patients discharged while taking anticoagulants had higher rates of recurrent bleeding (HR, 2.93; 95% CI, 1.15-6.95). Patients with higher Charlson Comorbidity Index scores (odds ratio [OR], 1.57; 95% CI, 1.25-2.08), active malignancy (OR, 6.57; 95% CI, 1.28-28.7), and in-hospital LGIB (OR, 11.5; 95% CI, 2.56-52.0) had increased 30-day mortality risk.

CONCLUSION

In-hospital LGIB, anticoagulation, and active malignancy are risk factors for 30-day readmissions in patients hospitalized with LGIB. In-hospital LGIB, Charlson Comorbidity Index scores, and active malignancy are risk factors for 30-day mortality.

Clinical characteristics of Helicobacter pylori-negative drug-negative peptic ulcer bleeding

AIM: To investigate the clinical characteristics and outcomes of idiopathic Helicobacter pylori (H. pylori)-negative and drug-negative] peptic ulcer bleeding (PUB).

METHODS: A consecutive series of patients who experienced PUB between 2006 and 2012 was retrospectively analyzed. A total of 232 patients were enrolled in this study. The patients were divided into four groups according to the etiologies of PUB: idiopathic, H. pylori-associated, drug-induced and combined (H. pylori-associated and drug-induced) types. We compared the clinical characteristics and outcomes between the groups. When the silver stain or rapid urease tests were H. pylori-negative, we obtained an additional biopsy specimen by endoscopic re-examination and performed an H. pylori antibody test 6-8 wk after the initial endoscopic examination. For a diagnosis of idiopathic PUB, a negative result of an H. pylori antibody test was confirmed. In all cases, re-bleeding was confirmed by endoscopic examination. For the risk assessment, the Blatchford and the Rockall scores were calculated for all patients.

RESULTS: For PUB, the frequency of H. pylori infection was 59.5% (138/232), whereas the frequency of idiopathic cases was 8.6% (20/232). When idiopathic PUB was compared to H. pylori-associated PUB, the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis during the hospital stay (30% vs 7.4%, P = 0.02). When idiopathic PUB was compared to drug-induced PUB, the patients in the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis upon admission (30% vs 2.7%, P < 0.01). When drug-induced PUB was compared to H. pylori-associated PUB, the patients in the drug-induced PUB were older (68.49 ± 14.76 years vs 47.83 ± 15.15 years, P < 0.01) and showed a higher proportion of gastric ulcer (77% vs 49%, P < 0.01). However, the Blatchford and the Rockall scores were not significantly different between the two groups. Among the patients who experienced drug-induced PUB, no significant differences were found with respect to clinical characteristics, irrespective of H. pylori infection.

CONCLUSION: Idiopathic PUB has unique clinical characteristics such as re-bleeding after initial hemostasis upon admission. Therefore, these patients need to undergo close surveillance upon admission.

Prophylactic tracheal intubation for upper GI bleeding: A meta-analysis

AIM: To evaluate usefulness of prophylactically intubating upper gastrointestinal bleeding (UGIB) patients.

METHODS: UGIB results in a significant number of hospital admissions annually with endoscopy being the key intervention. In these patients, risks are associated with the bleeding and the procedure, including pulmonary aspiration. However, very little literature is available assessing the use of prophylactic endotracheal intubation on aspiration in these patients. A comprehensive search was performed in May 2014 in Scopus, CINAHL, Cochrane databases, PubMed/Medline, Embase, and published abstracts from national gastroenterology meetings in the United States (2004-2014). Included studies examined UGIB patients and compared prophylactic intubation to no intubation before endoscopy. Meta-analysis was conducted using RevMan 5.2 by Mantel-Haenszel and DerSimonian and Laird models with results presented as odds ratio for aspiration, pneumonia (within 48 h), and mortality. Funnel plots were utilized for publication bias and I² measure of inconsistency for heterogeneity assessments.

RESULTS: Initial search identified 571 articles. Of these articles, 10 relevant peer-reviewed articles in English and two relevant abstracts were selected to review by two independent authors (Almashhrawi AA and Bechtold ML). Of these studies, eight were excluded: Five did not have a control arm, one was a letter the editor, one was a survey study, and one was focused on prevention of UGIB. Therefore, four studies (N = 367) were included. Of the UGIB patients prophylactically intubated before endoscopy, pneumonia (within 48 h) was identified in 20 of 134 (14.9%) patients as compared to 5 of 95 (5.3%) patients that were not intubated prophylactically (P = 0.02). Despite observed trends, no significant differences were found for mortality (P = 0.18) or aspiration (P = 0.11).

CONCLUSION: Pneumonia within 48 h is more likely in UGIB patients who received prophylactic endotracheal intubation prior to endoscopy.

Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.

Endoscopy for nonvariceal upper gastrointestinal bleeding

Endoscopy for acute nonvariceal upper gastrointestinal bleeding plays an important role in primary diagnosis and management, particularly with respect to identification of high-risk stigmata lesions and to providing endoscopic hemostasis to reduce the risk of rebleeding and mortality. Early endoscopy, defined as endoscopy within the first 24 hours after presentation, improves patient outcome and reduces the length of hospitalization when compared with delayed endoscopy. Various endoscopic hemostatic methods are available, including injection therapy, mechanical therapy, and thermal coagulation. Either single treatment with mechanical or thermal therapy or a treatment that combines more than one type of therapy are effective and safe for peptic ulcer bleeding. Newly developed methods, such as Hemospray powder and over-the-scope clips, may provide additional options. Appropriate decisions and specific treatment are needed depending upon the conditions.