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Redondo-Cerezo E, Tendero-Peinado C, López-Tobaruela JM, Fernandez-García R, Lancho A, Ortega-Suazo EJ, López-Vico M, Martínez-Cara JG, Jiménez-Rosales R. Risk factors for massive gastrointestinal bleeding occurrence and mortality: A prospective single-center study. Am J Med Sci 2024; 367:259-267. [PMID: 38278359 DOI: 10.1016/j.amjms.2024.01.012] [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: 06/05/2023] [Revised: 11/15/2023] [Accepted: 01/19/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Massive gastrointestinal bleeding is a life-threatening condition without a well-established definition. We aimed to analyze the characteristics, risk factors, and outcomes of patients with massive upper gastrointestinal bleeding. METHODS Our study analyzed a prospective registry of patients admitted between 2013 and 2020 with variceal and non-variceal causes. Severe bleeding was defined as ongoing bleeding requiring transfusion of more than 2 units of packed red blood cells within 24 hours, accompanied by signs of shock. The main outcomes were 30-day and 6-month mortality, rebleeding within 7 days, persistent bleeding, and severe complications during admission. RESULTS Out of 1213 patients, 171 had massive gastrointestinal bleeding, with a predominance of males. The massive bleeding group had higher rates of chronic kidney disease, cirrhosis, in-patient status, disseminated malignancy, alcoholism, and ASA score ≥3. All major outcomes, including 30-day mortality, 6-month mortality, rebleeding, persistent bleeding, and severe complications, were more common in the massive bleeding group. Multivariate logistic regression identified inpatient status, systemic diseases, malignancy, active bleeding in endoscopy, and severe complications as risk factors for massive bleeding and mortality. CONCLUSIONS Inpatient status and comorbidities, especially systemic diseases, and malignancies, were associated with a higher risk of massive bleeding. Mortality was linked to chronic kidney disease, cirrhosis, severe comorbidities, and alcohol consumption. We observed increased 6-months mortality, probably related to a health status in which gastrointestinal bleeding heralded poor outcomes, some of them potentially preventable. Innovative healthcare interventions, such as Emergency Department-based intermediate care areas or Intensive Care Units, and multidisciplinary follow-up, could potentially improve survival.
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Affiliation(s)
- Eduardo Redondo-Cerezo
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain; Department of Medicine The University of Granada School of Medicine Granada Spain; Instituto de Investigación Biosanitaria de Granada (ibs.Granada) Granada Spain.
| | | | | | - Raúl Fernandez-García
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain
| | - Ana Lancho
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain
| | | | - Manuel López-Vico
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain
| | - Juan Gabriel Martínez-Cara
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain; Instituto de Investigación Biosanitaria de Granada (ibs.Granada) Granada Spain
| | - Rita Jiménez-Rosales
- Department of Gastroenterology Hospital Universitario Virgen de las Nieves Granada Spain; Instituto de Investigación Biosanitaria de Granada (ibs.Granada) Granada Spain
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Toro Tole D, Maurel A, Hedger J, Kwan S, Weber D. A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2024; 28:309-315. [PMID: 38446116 DOI: 10.1016/j.gassur.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.
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Affiliation(s)
- David Toro Tole
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia.
| | - Amelie Maurel
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Joe Hedger
- School of Medicine, Flinders University, Darwin, Australia.
| | - Sherman Kwan
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| | - Dieter Weber
- Department of Surgery, Royal Perth Hospital, Perth, Australia
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3
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Schuster KF, Thompson CC, Ryou M. Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding. Clin Endosc 2024; 57:73-81. [PMID: 37253640 PMCID: PMC10834283 DOI: 10.5946/ce.2022.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/14/2023] [Accepted: 03/06/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND/AIMS Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model. METHODS A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated. RESULTS All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract. CONCLUSION This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.
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Affiliation(s)
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Kubota Y, Yamauchi H, Nakatani K, Iwai T, Ishido K, Masuda T, Maruhashi T, Tanabe S. Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding. Scand J Gastroenterol 2021; 56:1396-1405. [PMID: 34455892 DOI: 10.1080/00365521.2021.1969593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. MATERIALS AND METHODS Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. RESULTS There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. CONCLUSIONS When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.
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Affiliation(s)
- Yo Kubota
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kento Nakatani
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomonari Masuda
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Satoshi Tanabe
- Department of Research and Development Center for New Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
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5
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Nozewski J, Grzesk G, Klopocka M, Wicinski M, Nicpon-Nozewska K, Konieczny J, Wlodarczyk A. Management of Patient with Simultaneous Overt Gastrointestinal Bleeding and Myocardial Infarction with ST-Segment Elevation - Priority Endoscopy. Vasc Health Risk Manag 2021; 17:123-133. [PMID: 33833517 PMCID: PMC8020127 DOI: 10.2147/vhrm.s292253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/15/2021] [Indexed: 01/28/2023] Open
Abstract
Background The current ERC guidelines are the source of many positive changes, reduction of mortality, length of hospitalization and improvement of prognosis of STEMI patients. However, there is a small group of patients whose slight modification in guidelines would further reduce in-hospital mortality and hospitalization costs. These are patients with concomitant STEMI infarction and gastrointestinal bleeding. Methods Two separate methods of treatment were compared in patients with concomitant gastrointestinal bleeding and ST-segment elevation myocardial infarction. The first – traditional approach, in the line with the ESC guidelines, the second innovative, with priority for endoscopy. Results Despite the innovative approach, the patient with endoscopy before PCI was discharged without complication. A patient who has undergone coronary intervention and who has been started on typical antiplatelet therapy prior to gastroenterological diagnosis has died due to massive bleeding. Conclusion For ethical reasons and in connection with the cardiological guidelines of the management of ACS, a study of patients with ASC a high risk of intestinal bleeding, in which endoscopy will have priority, and only later PCI, will probably never be performed. Although, as the described case shows, despite exceeding the 90 minutes time to implement PCI (<120 minutes) in logistic terms such behavior is completely feasible.
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Affiliation(s)
- Jakub Nozewski
- Faculty of Health Sciences, Emergency Department, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Grzegorz Grzesk
- Faculty of Health Sciences, Department of Cardiology and Clinical Pharmacology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maria Klopocka
- Faculty of Health Science, Department of Gastroenterology, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michal Wicinski
- Faculty of Medicine, Department of Pharmacology and Therapy, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Klara Nicpon-Nozewska
- Faculty of Health Sciences, Department and Clinic of Geriatrics, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Adam Wlodarczyk
- Faculty of Medicine, Department of Psychiatry, Medical University of Gdansk, Gdansk, Poland
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7
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Gaiani F, De'Angelis N, Kayali S, Manfredi M, Di Mario F, Leandro G, Ghiselli A, Fornaroli F, De'Angelis GL. Clinical approach to the patient with acute gastrointestinal bleeding. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:12-19. [PMID: 30561412 PMCID: PMC6502216 DOI: 10.23750/abm.v89i8-s.7861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 12/03/2022]
Abstract
Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery. (www.actabiomedica.it)
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Affiliation(s)
- Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Fujishiro M, Iguchi M, Kakushima N, Kato M, Sakata Y, Hoteya S, Kataoka M, Shimaoka S, Yahagi N, Fujimoto K. Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding. Dig Endosc 2016; 28:363-378. [PMID: 26900095 DOI: 10.1111/den.12639] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 01/10/2023]
Abstract
Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.
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Affiliation(s)
| | | | | | - Motohiko Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shu Hoteya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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9
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Nemiroski A, Ryou M, Thompson CC, Westervelt RM. Swallowable fluorometric capsule for wireless triage of gastrointestinal bleeding. LAB ON A CHIP 2015; 15:4479-4487. [PMID: 26490455 DOI: 10.1039/c5lc00770d] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Real-time detection of gastrointestinal bleeding remains a major challenge because there does not yet exist a minimally invasive technology that can both i) monitor for blood from an active hemorrhage and ii) uniquely distinguish it from blood left over from an inactive hemorrhage. Such a device would be an important tool for clinical triage. One promising solution, which we have proposed previously, is to inject a fluorescent dye into the blood stream and to use it as a distinctive marker of active bleeding by monitoring leakage into the gastrointestinal tract with a wireless fluorometer. This paper reports, for the first time to our knowledge, the development of a swallowable, wireless capsule with a built-in fluorometer capable of detecting fluorescein in blood, and intended for monitoring gastrointestinal bleeding in the stomach. The embedded, compact fluorometer uses pinholes to define a microliter sensing volume and to eliminate bulky optical components. The proof-of-concept capsule integrates optics, low-noise analog sensing electronics, a microcontroller, battery, and low power Zigbee radio, all into a cylindrical package measuring 11 mm × 27 mm and weighing 10 g. Bench-top experiments demonstrate wireless fluorometry with a limit-of-detection of 20 nM aqueous fluorescein. This device represents a major step towards a technology that would enable simple, rapid detection of active gastrointestinal bleeding, a capability that would save precious time and resources and, ultimately, reduce complications in patients.
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Affiliation(s)
- A Nemiroski
- Department of Chemistry and Chemical Biology, Harvard University, 12 Oxford St., Cambridge, MA 02138, USA.
| | - M Ryou
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - C C Thompson
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - R M Westervelt
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA and Department of Physics, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA.
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Chen YI, Dorreen AP, Warshawsky PJ, Wyse JM. Sengstaken-Blakemore tube for non-variceal distal esophageal bleeding refractory to endoscopic treatment: a case report & review of the literature. Gastroenterol Rep (Oxf) 2014; 2:313-5. [PMID: 24787390 PMCID: PMC4219138 DOI: 10.1093/gastro/gou023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Non-variceal upper-gastrointestinal bleeding (NVUGIB) refractory to therapeutic endoscopy is a challenging situation. The following details a novel use for the Sengstaken-Blakemore tube in a case of severe ulcerative esophagitis after failure of conventional medical and endoscopic treatment. A 77-year-old man with a history of peptic ulcer disease developed massive hematemesis during a hospital admission. Initial gastroscopy revealed an adherent blood clot occupying the distal esophagus, extending to the gastric cardia and proximal fundus. Epinephrine was injected into and surrounding the clot; however, following the endoscopy the patient was hemodynamically unstable, requiring aggressive resuscitation. Repeat gastroscopy, following saline lavage, revealed active bleeding within severely ulcerated esophageal mucosa, immediately proximal to the gastro-esophageal (GE) junction. Despite apparent hemostasis following injection of epinephrine and electrocautery, the patient displayed clinical signs of continued bleeding. Furthermore, surgical and radiological interventions were precluded by the patient's hemodynamic instability. In an attempt to tamponade blood supply to the GE junction, a Sengstaken-Blakemore tube was inserted and placed under tension. Successful hemostasis was subsequently achieved and the patient remained stable. This is the first case to describe use of a Sengstaken-Blakemore tube in severe ulcerative esophagitis refractory to standard endoscopic management.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology, McGill University, Jewish General Hospital, Montreal, Canada, Internal Medicine, McGill University, Jewish General Hospital, Montreal, Canada and Critical Care Medicine, McGill University, Jewish General Hospital, Montreal, Canada
| | - Alastair P Dorreen
- Division of Gastroenterology, McGill University, Jewish General Hospital, Montreal, Canada, Internal Medicine, McGill University, Jewish General Hospital, Montreal, Canada and Critical Care Medicine, McGill University, Jewish General Hospital, Montreal, Canada
| | - Paul J Warshawsky
- Division of Gastroenterology, McGill University, Jewish General Hospital, Montreal, Canada, Internal Medicine, McGill University, Jewish General Hospital, Montreal, Canada and Critical Care Medicine, McGill University, Jewish General Hospital, Montreal, Canada
| | - Jonathan M Wyse
- Division of Gastroenterology, McGill University, Jewish General Hospital, Montreal, Canada, Internal Medicine, McGill University, Jewish General Hospital, Montreal, Canada and Critical Care Medicine, McGill University, Jewish General Hospital, Montreal, Canada
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Holley A, Marks DC, Johnson L, Reade MC, Badloe JF, Noorman F. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013; 41:10-9. [PMID: 23362885 DOI: 10.1177/0310057x1304100104] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
The development of effective cryopreservation techniques for both red blood cells and platelets, which maintain ex vivo biological activity, in combination with frozen plasma, provides for a unique blood banking strategy. This technology greatly enhances the storage life of these products. The rationale and potential advantages of using cryopreservation techniques for the provision of blood products to remote and military environments have been effectively demonstrated in several conflicts over the last decade. Current haemostatic resuscitation doctrine for the exsanguinating patient supports the use of red blood cells, platelets and frozen plasma early in the resuscitation. We believe an integrated fresh-frozen blood bank inventory could facilitate provision of blood products, not only in the military setting but also in regional Australia, by overcoming many logistic and geographical challenges. The processes involved in production and point of care thawing are sufficiently well developed and achievable to make this technology a viable option. The potential limitations of cryopreservation and subsequent product thawing need to be considered if such a strategy is to be developed. A substantial body of international experience using cryopreserved products in remote settings has already been accrued. This experience provides a template for the possible creation of an Australian integrated fresh-frozen blood bank inventory that could conceivably enhance the care of patients in both regional Australia and in the military setting.
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Affiliation(s)
- A Holley
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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12
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Wang YL, Cheng YS, Liu LZ, He ZH, Ding KH. Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage. World J Gastroenterol 2012; 18:4765-70. [PMID: 23002347 PMCID: PMC3442216 DOI: 10.3748/wjg.v18.i34.4765] [Citation(s) in RCA: 12] [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: 09/19/2011] [Revised: 02/02/2012] [Accepted: 05/06/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive duodenal ulcer hemorrhage.
METHODS: Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer were admitted to our hospital from 2006 to 2011. Superselective angiography of the celiac and gastroduodenal arteries was performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via a 5 French angiographic catheter or 3 French microcatheter. After ETAE, further superior mesenteric arteriography was undertaken in case collateral circulation supplied areas of the duodenal ulcer. Technical and clinical success rates were analyzed. Changes in the mucous membrane were observed using endoscopy following ETAE.
RESULTS: Angiography showed active bleeding with extravasation of contrast medium in seven cases with a 24% positive rate of celiac artery bleeding, and in 19 cases with a 65.5% rate of gastroduodenal artery bleeding. There were no angiographic signs of bleeding in three patients who underwent endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technical success rate reached 90%. No hemostasis was observed in 27 patients within 30 d after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in two patients who drank a lot of wine who were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized.
CONCLUSION: ETAE is an effective and safe measure to control acute massive bleeding of duodenal ulcer.
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Vashist YK, Yekebas EF, Gebauer F, Tachezy M, Bachmann K, König A, Kutup A, Izbicki JR. Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh). Langenbecks Arch Surg 2012; 397:1243-9. [PMID: 22903877 DOI: 10.1007/s00423-012-0990-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 07/31/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. "Classical" technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study. METHODS Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion. RESULTS Overall perioperative mortality was 10.5%. However, DJ significantly reduced the mortality rate (4.8%) associated with penetrating duodenal ulcer compared to CC (16.1%, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5%) and CC (29%) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95% confidence interval 0.005-0.42) and CC patients (odds ratio 0.2, 95% confidence interval 0.05-0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect. CONCLUSION Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.
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Affiliation(s)
- Yogesh K Vashist
- Department of Surgery, University Hospital Hamburg-Eppendorf, Martinistrasse52, 20246, Hamburg, Germany
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Anil G, Tan A, Cheong HW, Ng KS, Teoh WC. Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers. Clin Radiol 2012; 67:468-75. [DOI: 10.1016/j.crad.2011.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 09/24/2011] [Accepted: 10/03/2011] [Indexed: 12/17/2022]
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Seo N, Shin JH, Ko GY, Yoon HK, Gwon DI, Kim JH, Sung KB. Incidence and management of bleeding complications following percutaneous radiologic gastrostomy. Korean J Radiol 2012; 13:174-81. [PMID: 22438684 PMCID: PMC3303900 DOI: 10.3348/kjr.2012.13.2.174] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 09/20/2011] [Indexed: 12/31/2022] Open
Abstract
Objective Upper gastrointestinal (GI) bleeding is a serious complication that sometimes occurs after percutaneous radiologic gastrostomy (PRG). We evaluated the incidence of bleeding complications after a PRG and its management including transcatheter arterial embolization (TAE). Materials and Methods We retrospectively reviewed 574 patients who underwent PRG in our institution between 2000 and 2010. Eight patients (1.4%) had symptoms or signs of upper GI bleeding after PRG. Results The initial presentation was hematemesis (n = 3), melena (n = 2), hematochezia (n = 2) and bloody drainage through the gastrostomy tube (n = 1). The time interval between PRG placement and detection of bleeding ranged from immediately after to 3 days later (mean: 28 hours). The mean decrease in hemoglobin concentration was 3.69 g/dL (range, 0.9 to 6.8 g/dL). In three patients, bleeding was controlled by transfusion (n = 2) or compression of the gastrostomy site (n = 1). The remaining five patients underwent an angiography because bleeding could not be controlled by transfusion only. In one patient, the bleeding focus was not evident on angiography or endoscopy, and wedge resection including the tube insertion site was performed for hemostasis. The other four patients underwent prophylactic (n = 1) or therapeutic (n = 3) TAEs. In three patients, successful hemostasis was achieved by TAE, whereas the remaining one patient underwent exploration due to persistent bleeding despite TAE. Conclusion We observed an incidence of upper GI bleeding complicating the PRG of 1.4%. TAE following conservative management appears to be safe and effective for hemostasis.
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Affiliation(s)
- Nieun Seo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea
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16
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Abstract
Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.
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Affiliation(s)
- Wadie I Najm
- Department of Family Medicine & Geriatrics, Susan Samueli Center of Integrative Medicine, University of California, Irvine, 101 The City Drive, Building 200, #512, Orange, CA 92868, USA.
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Loffroy R, Lin M, Thompson C, Harsha A, Rao P. A comparison of the results of arterial embolization for bleeding and non-bleeding gastroduodenal ulcers. Acta Radiol 2011; 52:1076-82. [PMID: 22006986 DOI: 10.1258/ar.2011.110344] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although some authors have advocated the practice of arterial embolization for angiographically negative acute hemorrhage from gastroduodenal ulcers, this technique remains controversial. PURPOSE To compare the results of arterial embolization for bleeding (BU) and non-bleeding (NBU) gastroduodenal ulcers. MATERIAL AND METHODS Transcatheter embolization was performed in 57 patients (39 men, 18 women, mean age 69.8 years) who experienced acute bleeding from gastroduodenal ulcers. At the time of embolization active contrast extravasation was seen in 36 of 57 patients, while in the remaining 21 patients embolization was based on endoscopic findings. Patient demographics, clinical success, need for re-intervention secondary to re-bleeding, and 30-day complication and mortality rates were reviewed and compared between the two groups by using statistical analyses. RESULTS In the BU group, the gastroduodenal artery (GDA) was embolized in 31 patients (86.1%), the left gastric artery (LGA) in three patients (8.3%), and the left gastroepiploic artery (LGEA) in two patients (5.6%). In the NBU group, the GDA was embolized in 18 patients (85.7%), and the LGA in three patients (14.3%). Clinical success (61.9 vs. 75.0%, P = 0.30), need for re-intervention (38.1 vs. 27.8%, P = 0.42), and 30-day complication (9.5 vs. 5.6%, P = 0.57), and mortality (28.6 vs. 25%, P = 0.77) rates were not statistically different between the two groups. Embolization in patients in NBU group did not have impact on clinical success (OR, 0.54; 95%CI, 0.17-1.72; P = 0.30). CONCLUSION Arterial embolization in patients with angiographically NBU is as safe and effective as embolization in patients with BU.
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Affiliation(s)
- Romaric Loffroy
- Russell H Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - MingDe Lin
- Clinical Informatics, Interventional, and Translational Solutions (CIITS), Philips Research North America, Briarcliff Manor, New York
| | - Carol Thompson
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amith Harsha
- Department of Neuroradiology and Biomedical Engineering, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Pramod Rao
- Russell H Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, Johns Hopkins Hospital, Baltimore, Maryland
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Ryou M, Nemiroski A, Azagury D, Shaikh SN, Ryan MB, Westervelt RM, Thompson CC. An implantable wireless biosensor for the immediate detection of upper GI bleeding: a new fluorescein-based tool for diagnosis and surveillance (with video). Gastrointest Endosc 2011; 74:189-194.e1. [PMID: 21704817 DOI: 10.1016/j.gie.2011.03.1182] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 03/17/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Early recurrent hemorrhage after endoscopic intervention for acute upper GI bleeding (UGIB) can approach 20% and leads to increased morbidity and mortality. Little has changed over the past several decades regarding immediate posthemorrhage surveillance, and there has likewise been no significant improvement in outcomes. OBJECTIVE To develop and test an endoscopically implantable wireless biosensor for real-time detection of fluorescein-labeled blood in ex vivo and in vivo porcine models of UGIB. SETTING Animal laboratory. DESIGN Benchtop and acute animal studies. SUBJECTS Five pigs. INTERVENTIONS UGIB models were surgically created in living pigs. Biosensors were endoscopically deployed in the stomach using standard endoscopic clips. The ability to detect acute UGIB and estimated blood loss leading to biosensor activation were recorded. Feasibility of wireless data transmission out of the body to an external computer and cell phone was assessed. MAIN OUTCOME MEASUREMENTS Technical feasibility and immediate complications. RESULTS A porcine UGIB model was successfully created. Biosensors were able to detect all acute bleeding events and wirelessly transmit out of the body, and successfully sent an emergency text message to the intended cell phone in all cases. Average estimated blood loss leading to biosensor activation was 30 mL (10-75 mL). LIMITATIONS Animal study; small numbers. CONCLUSIONS An endoscopically implantable wireless biosensor successfully detected acute hemorrhage in a porcine UGIB model and sent an emergency cell-phone alert in real time.
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Affiliation(s)
- Marvin Ryou
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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19
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Climate of confrontation. Health groups urge Congress: let EPA oversee greenhouse gases. Presse Med 2010; 40:123-5. [PMID: 21033003 DOI: 10.1016/j.lpm.2010.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 08/26/2010] [Accepted: 09/06/2010] [Indexed: 12/16/2022] Open
Abstract
Health organizations have a new cause after helping push through the reform law: climate change. They see it as a public health issue since rising temperatures can create health hazards. "Any action that interferes with or dilutes EPA's efforts will have a very negative effect on our public health," says Nancy Hughes, left, of the American Nurses Association.
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Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55:3436-41. [PMID: 20848205 DOI: 10.1007/s10620-010-1385-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 08/02/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Dieulafoy lesions are a rare cause of gastrointestinal hemorrhage with a striking presentation because of rapid blood loss. Endoscopic therapy is usually successful at achieving primary hemostasis, but the best mode of endoscopic intervention is not clear, and outcomes relating to variables such as gender, medication, alcohol, and smoking are not known. We reviewed the clinical experience with Dieulafoy lesions at our institution, focusing on clinico-epidemiological features, management practices, and also survival. METHODS A retrospective and prospective cohort of patients with Dieulafoy lesions who underwent endoscopy from January 2004 through April 2009 were studied and detailed clinical data were abstracted and collected. RESULTS We identified 63 patients with a Dieulafoy lesion. The majority were male with an average age 58 years. Hematemesis and melena were the most common presenting symptoms. Almost half the patients were on anticoagulation medication. Most of the Dieulafoy lesions occurred in the upper GI tract, and mostly in the stomach. Single-modality endoscopic therapy was used as frequently as combination therapy, and both were effective, as primary hemostasis was achieved in 92% of cases. There were 11 deaths overall; death due to Dieulafoy lesion exsanguination was attributed to three patients. CONCLUSIONS Dieulafoy lesions occurred in younger patients than previously reported, and were more frequently diagnosed in males. Most DL lesions occurred in the upper GI tract. Primary hemostasis with endoscopic therapy was highly successful. Overall mortality was 17%, and associated with co-morbidities, and not with medical history, gender, age, or medication.
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Abe N, Takeuchi H, Yanagida O, Sugiyama M, Atomi Y. Surgical indications and procedures for bleeding peptic ulcer. Dig Endosc 2010; 22 Suppl 1:S35-7. [PMID: 20590769 DOI: 10.1111/j.1443-1661.2010.00966.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recent important insights into the surgical treatment of bleeding peptic ulcer are reviewed in this article. Although the widespread use of endoscopic treatment and interventional radiology has reduced the number of surgical cases, surgery still plays a pivotal role in managing bleeding peptic ulcer. Failure to stop the bleeding by endoscopy and/or interventional radiology is the most important indication for emergency surgery. An early elective/planned surgery after the initial endoscopic control to prevent life-threatening rebleeding seems justified in patients who have risk factors for rebleeding, although its true efficacy still remains controversial. The surgical procedures in emergency situations should be limited to safe hemostasis. The addition of acid-reduction surgery may be unnecessary as a result of the increasing utilization of proton pump inhibitors. Angiographic embolization may be a less invasive alternative to surgery, and may further enhance endoscopic hemostasis.
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Affiliation(s)
- Nobutsugu Abe
- The Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan.
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Embolization of Acute Nonvariceal Upper Gastrointestinal Hemorrhage Resistant to Endoscopic Treatment: Results and Predictors of Recurrent Bleeding. Cardiovasc Intervent Radiol 2010; 33:1088-100. [DOI: 10.1007/s00270-010-9829-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 02/18/2010] [Indexed: 01/16/2023]
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