Non-variceal upper GI bleeding in patients already hospitalized for another condition

Risk factors for massive gastrointestinal bleeding occurrence and mortality: A prospective single-center study

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.

Impact of COVID-19 infection on patients admitted with nonvariceal upper gastrointestinal bleeding: an analysis from the National Inpatient Sample

Background

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a medical emergency that has significant morbidity and mortality. The available data about the impact of COVID-19 infection on mortality in patients with NVUGIB is limited.

Methods

We identified all hospitalizations with a principal diagnosis of NVUGIB in 2020. The baseline characteristics and clinical outcomes of patients with COVID-19 infection were compared to those without COVID-19 infection.

Results

NVUGIB patients with COVID-19 infection had higher mortality (5% vs 2%, P < 0.0001), a longer mean length of stay (6.85 vs 4.48 days, P < 0.0001), and a lower rate of esophagogastroduodenoscopy utilization (40% vs 51%, P < 0.0001) than those without COVID-19 infection. Multivariate logistic regression analysis showed that COVID-19 infection was associated with a higher mortality rate (odds ratio 2.2, 95% confidence interval, 1.4-3.4).

Conclusions

COVID-19 infection is an independent predictor of mortality in adults hospitalized with NVUGIB.

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.

Upper gastrointestinal bleeding in patients 80 years old and over. A comparison with younger patients and risk factors analysis for in-hospital and delayed mortality

INTRODUCTION

Outcomes in old patients with upper gastrointestinal bleeding (UGIB) have been scarcely studied. Our aim was to compare very old individuals (>80 years old) with younger patients with UGIB, and to identify risk factors for the main outcomes.

METHODS

A single-centre prospectively collected database was analysed. Descriptive, inferential and multivariate logistic regression models were performed. Main clinical outcomes were in-hospital and delayed 6-month mortality.

RESULTS

698 patients were included, 143 very old and 555 aged <80. Old patients differed from younger ones in comorbidities (85.9% vs. 62%, P < .0001), oral anticoagulants (32.3% vs. 12.7%; P < .0001), and antiplatelets intake (32.3% vs. 21.2%; P < .007). No differences were found in the need for endoscopic interventions, blood unit transfusions, hospital stay, in-hospital rebleeding and mortality. Among very old patients, creatinine levels were higher in those who died compared with the ones who survived (1.92 ± 1.46 vs. 1.25 ± 0.59 mg/dL; P = .002), they had lower haemoglobin levels (8.1 ± 1.4 vs. 9.1 ± 2.4 g/dL; P = .04) and longer hospital stays (17.75 ± 15.5 vs. 8.1 ± 8.4 days; P < .0001). Logistic regression showed creatinine levels (OR: 2.42; 95% CI: 1.24-4.74; P = .01), cirrhosis (OR: 2.88, 95% CI: 1.88-17.34; P = .04) and being an impatient (OR: 3.90; 95% CI: 1.11-20; P = .035) were independent risk factors for mortality in older patients. They had an increased delayed 6-month mortality compared with younger patients (17.5% vs. 8%, P = .001).

CONCLUSIONS

Creatinine levels, cirrhosis or the onset of UGIB while being an inpatient were independent risk factors for mortality in very old patients. Delayed mortality was higher among them, mostly caused by cardiovascular events and neoplasms, but not in-hospital mortality.

Increasing the low-risk threshold for patients with upper gastrointestinal bleeding during the COVID-19 pandemic: a prospective, multicentre feasibility study

Objective

During the COVID-19 pandemic, we extended the low-risk threshold for patients not requiring inpatient endoscopy for upper gastrointestinal bleeding (UGIB) from Glasgow Blatchford Score (GBS) 0-1 to GBS 0-3. We studied the safety and efficacy of this change.

Methods

Between 1 April 2020 and 30 June 2020 we prospectively collected data on consecutive unselected patients with UGIB at five large Scottish hospitals. Primary outcomes were length of stay, 30-day mortality and rebleeding. We compared the results with prospective prepandemic descriptive data.

Results

397 patients were included, and 284 index endoscopies were performed. 26.4% of patients had endoscopic intervention at index endoscopy. 30-day all-cause mortality was 13.1% (53/397), and 33.3% (23/69) for pre-existing inpatients. Bleeding-related mortality was 5% (20/397). 30-day rebleeding rate was 6.3% (25/397). 84 patients had GBS 0-3, of whom 19 underwent inpatient endoscopy, 0 had rebleeding and 2 died. Compared with prepandemic data in three centres, there was a fall in mean number of UGIB presentations per week (19 vs 27.8; p=0.004), higher mean GBS (8.3 vs 6.5; p<0.001) with fewer GBS 0-3 presentations (21.5% vs 33.3%; p=0.003) and higher all-cause mortality (12.2% vs 6.8%; p=0.02). Predictors of mortality were cirrhosis, pre-existing inpatient status, age >70 and confirmed COVID-19. 14 patients were COVID-19 positive, 5 died but none from UGIB.

Conclusion

During the pandemic when services were under severe pressure, extending the low-risk threshold for UGIB inpatient endoscopy to GBS 0-3 appears safe. The higher mortality of patients with UGIB during the pandemic is likely due to presentation of a fewer low-risk patients.

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.

Predictors of endoscopic intervention in upper gastrointestinal bleeding patients hospitalized for another illness: a multi-center retrospective study

BACKGROUND

To characterize variables that may predict the need for endoscopic intervention in inpatients admitted for several causes who during the hospitalization developed acute non-variceal upper gastrointestinal bleeding (NVUGIB).

METHODS

A retrospective analysis of inpatients who underwent upper gastro-intestinal endoscopy for acute NVUGIB while hospitalized for other causes from 1 January 2016 to 1 December 2017, was performed. In the primary outcome analysis, patients (N.=14) who underwent endoscopic intervention (group A) were compared to those (N.=87) who did not need for endoscopic intervention (group B). Secondary outcome analysis included patients who had significant endoscopic findings compared to those who did not have them.

RESULTS

Multivariate regression analysis showed that in the primary outcome analysis, two parameters were significant: the number of packed red blood cells (PRBC) units transfused (odds ratio [OR]: 1.5, P=0.01) and Rockall Score (RS) (OR: 1.4, P=0.06) with receiver operator characteristic (ROC) curve of 0.7844. In the secondary outcome analysis, only the use of proton pump inhibitor drugs at admission was associated with protective effect for the development of significant endoscopic findings (odds ratio [OR]: 0.42, P=0.05) with ROC curve of 0.7342.

CONCLUSIONS

In hospitalized patients, in case of de novo NVUGIB, the number of PRBC units transfused and RS are predictive of significant endoscopic findings.

Predictors of mortality and endoscopic intervention in patients with upper gastrointestinal bleeding in the intensive care unit

Background

The outcomes of patients undergoing esophagogastroduodenoscopy (EGD) in the intensive care unit (ICU) for upper gastrointestinal bleeding (UGIB) are not well described. Our aims were to determine predictors of 30-day mortality and endoscopic intervention, and assess the utility of existing clinical-prediction tools for UGIB in this population.

Methods

Patients hospitalized in an ICU between 2008 and 2015 who underwent EGD were identified using a validated, machine-learning algorithm. Logistic regression was used to determine factors associated with 30-day mortality and endoscopic intervention. Area under receiver-operating characteristics (AUROC) analysis was used to evaluate established UGIB scoring systems in predicting mortality and endoscopic intervention in patients who presented to the hospital with UGIB.

Results

A total of 606 patients underwent EGD for UGIB while admitted to an ICU. The median age of the cohort was 62 years and 55.9% were male. Multivariate analysis revealed that predictors associated with 30-day mortality included American Society of Anesthesiologists (ASA) class (odds ratio [OR] 4.1, 95% confidence interval [CI] 2.2-7.9), Charlson score (OR 1.2, 95% CI 1.0-1.3), and duration from hospital admission to EGD (OR 1.04, 95% CI 1.01-1.07). Rockall, Glasgow-Blatchford, and AIMS65 scores were poorly predictive of endoscopic intervention (AUROC: 0.521, 0.514, and 0.540, respectively) and in-hospital mortality (AUROC: 0.510, 0.568, and 0.506, respectively).

Conclusions

Predictors associated with 30-day mortality include ASA classification, Charlson score, and duration in the hospital prior to EGD. Existing risk tools are poorly predictive of clinical outcomes, which highlights the need for a more accurate risk-stratification tool to predict the benefit of intervention within the ICU population.

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.

Prognostic factors in patients with active non-variceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Acute upper gastrointestinal bleeding is one of the main causes of hospitalisation. The purpose of this study was to determine the prognostic factors in non-variceal upper gastrointestinal bleeding.

PATIENTS AND METHODS

Clinical outcomes, demographic and laboratory variables of the subjects were collected from the HIS software and national code with the SQL format from three hospitals in Qazvin. The data were linked to the database software designed by the author. Clinical and upper endoscopic findings of patients' records were collected through a questionnaire form in the designed software database.

RESULTS

In this study, 29.2% of patients with favourable outcome and 64.2% of patients with unfavourable clinical outcomes had a history of anticoagulant drug use before hospitalisation (p < 0.001). The prevalence of chronic cardiovascular disease, chronic liver disease, chronic lung disease, diabetes and dialysis was higher in subjects with poor clinical outcomes than those with a favourable clinical outcome. 53.1% of subjects with favourable clinical outcome and 90.5% of subjects with undesirable clinical outcomes received packed red blood cell transfusion (p < 0.001). 16.1% of subjects with desirable clinical outcome and 86.3% of subjects with undesirable clinical outcomes received endoscopic haemostatic treatment which was statistically significant (p < 0.001).

CONCLUSION

Undesirable clinical outcome in patients with acute non-variceal upper gastrointestinal bleeding has a significant statistical association with longer hospitalisation, chronic underlying disease, anticoagulant administration, packed red blood cell infusion, higher Forrest stage, low systolic blood pressure, higher age, low haemoglobin, low platelet count, high INR and high BUN at the onset of diagnosis.

The Use of Higher Dose Steroids Increases the Risk of Rebleeding After Endoscopic Hemostasis for Peptic Ulcer Bleeding

BACKGROUND

Previous studies have shown that several factors such as hemodynamic instability at admission are risk factors for rebleeding of peptic ulcer bleeding. However, whether steroid use increases the risk of rebleeding remains elusive.

AIMS

This study aimed to clarify the risk factors for rebleeding after endoscopic hemostasis for peptic ulcer bleeding.

METHODS

A total of 185 patients who underwent endoscopic hemostasis for peptic ulcer bleeding at our institution between 2005 and 2017 were retrospectively analyzed. We evaluated factors, including comorbid conditions, in-hospital onset, and steroid use, associated with rebleeding by logistic regression analysis. In addition, we investigated the association between the dose of steroids and rebleeding.

RESULTS

The rebleeding rate after endoscopic hemostasis for peptic ulcer bleeding was 14.6%. In the multivariate analysis, the independent risk factors for rebleeding were steroid use (odds ratio 4.56, p = 0.015), multiple ulcers (4.43, p = 0.005), number of comorbidities ≥ 3 3.18, p = 0.026), hemodynamic instability (3.06, p = 0.039), and number of comorbidities ≥ 3 (2.93, p = 0.047). Furthermore, the use of higher dose steroids (≥ 20 mg per day in prednisolone; 10.55, p = 0.002), but not lower dose (< 20 mg per day in prednisolone), was an independent risk factor for rebleeding in the multivariate analysis. The relationship between steroid use and rebleeding was observed in a dose-dependent manner (p for trend = 0.002).

CONCLUSIONS

This study first revealed that using higher dose steroids was an independent risk factor for rebleeding after endoscopic hemostasis for peptic ulcer bleeding, with a dose-response relation.

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.

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.

Poor outcomes in hospitalized patients with gastrointestinal bleeding: impact of baseline risk, bleeding severity, and process of care

OBJECTIVES

Previous studies have found higher mortality rates among inpatients (IPs) compared with new admissions (outpatients, OPs) with acute upper gastrointestinal bleeding (AUGIB), but no studies have investigated the cause for this. The objective of this study was to determine whether the difference in outcomes between IPs and OPs with AUGIB can be explained by differences in baseline characteristics, bleeding severity, or processes of care.

METHODS

Data were collected from 6,657 presentations with all-cause AUGIB from 212 UK hospitals as part of a nationwide audit.

RESULTS

IPs were older (77 vs. 65 years, P<0.001), had greater comorbidity, and presented with more severe bleeding. There was no difference in median time to endoscopy (24 vs. 24 h, P=0.67) or receipt of endotherapy (19% vs. 17%, P=0.29). IPs had an odds of mortality 4.8 times that of OPs (26% vs. 7%; odds ratio (OR) 4.8, 95% confidence interval (CI) 3.9-5.8); after adjusting for baseline characteristics, this fell by 24% to 3.3 (95% CI 3.2-4.9) and after adjusting for bleeding severity alone to 4.0 (95% CI 3.2-4.9); adjusting for care processes had minimal effect. IPs had more than a twofold increased odds of rebleeding (20% vs. 12%; OR 2.1, 95% CI 1.7-2.5); adjusting for both baseline characteristics and severity of bleeding reduced this by 50% (OR 1.4, 95% CI 1.3-2.4), but process of care had no additional impact.

CONCLUSIONS

IPs present with both higher baseline risks and more severe bleeding. These differences in baseline characteristics explain some but not all of the greater mortality of IPs with AUGIB.

Adherence to guidelines: a national audit of the management of acute upper gastrointestinal bleeding. The REASON registry

OBJECTIVES

To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to 'best practice' standards.

METHODS

Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with 'best practice' using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.

RESULTS

Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g⁄L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]).

CONCLUSION

There was variability between the process of care and 'best practice' in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.

Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding

CONTEXT

Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs.

OBJECTIVES

The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding.

METHODS

From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake.

RESULTS

From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy.

CONCLUSIONS

Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.

Etiology, endoscopic management and mortality of upper gastrointestinal bleeding in patients with cancer

BACKGROUND

The source and outcomes of upper gastrointestinal bleeding (UGIB) in oncologic patients are poorly investigated.

OBJECTIVE

The study aimed to investigate these issues in a tertiary academic referral center specialized in cancer treatment.

METHODS

This was a retrospective study including all patients with cancer referred to endoscopy due to UGIB in 2010.

RESULTS

UGIB was confirmed in 147 (of 324 patients) referred to endoscopy for a suspected episode of GI bleeding. Tumor was the most common cause of bleeding (N = 35, 23.8%), followed by varices (N = 30, 19.7%), peptic ulcer (N = 29, 16.3%) and gastroduodenal erosions (N = 16, 10.9%). Among the 32 patients with cancer of the upper GI tract, the main causes of bleeding were cancer (N = 27, 84.4%) and peptic ulcer (N = 5, 6.3%). Forty-one patients (27.9%) presented with bleeding from the primary tumor or from a metastatic lesion, and seven received endoscopic therapy, with successful initial hemostasis in six (85.7%). Rebleeding and mortality rates were not different between endoscopically treated (N = 7) and non-treated (N = 34) patients (28.6% vs. 14.7%, p = 0.342; 43.9% vs. 44.1%, p = 0.677). Median survival was 20 days, and the overall 30-day mortality rate was 44.9%. There was no predictive factor of mortality or rebleeding.

CONCLUSION

Tumor bleeding is the most common cause of UGIB in cancer patients. UGIB in cancer patients correlates with a high mortality rate regardless of the bleeding source. Current endoscopic treatments may not be effective in preventing rebleeding or improving survival.

Upper gastrointestinal bleeding in patients with CKD

BACKGROUND AND OBJECTIVES

Patients with CKD receiving maintenance dialysis are at risk for upper gastrointestinal bleeding. However, the risk of upper gastrointestinal bleeding in patients with early CKD who are not receiving dialysis is unknown. The hypothesis was that their risk of upper gastrointestinal bleeding is negatively linked to renal function. To test this hypothesis, the association between eGFR and risk of upper gastrointestinal bleeding in patients with stages 3-5 CKD who were not receiving dialysis was analyzed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with stages 3-5 CKD in the CKD program from 2003 to 2009 were enrolled and prospectively followed until December of 2012 to monitor the development of upper gastrointestinal bleeding. The risk of upper gastrointestinal bleeding was analyzed using competing-risks regression with time-varying covariates.

RESULTS

In total, 2968 patients with stages 3-5 CKD who were not receiving dialysis were followed for a median of 1.9 years. The incidence of upper gastrointestinal bleeding per 100 patient-years was 3.7 (95% confidence interval, 3.5 to 3.9) in patients with stage 3 CKD, 5.0 (95% confidence interval, 4.8 to 5.3) in patients with stage 4 CKD, and 13.9 (95% confidence interval, 13.1 to 14.8) in patients with stage 5 CKD. Higher eGFR was associated with a lower risk of upper gastrointestinal bleeding (P=0.03), with a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.87 to 0.99) for every 5 ml/min per 1.73 m(2) higher eGFR. A history of upper gastrointestinal bleeding (P<0.001) and lower serum albumin (P=0.004) were independently associated with higher upper gastrointestinal bleeding risk.

CONCLUSIONS

In patients with CKD who are not receiving dialysis, lower renal function is associated with higher risk for upper gastrointestinal bleeding. The risk is higher in patients with previous upper gastrointestinal bleeding history and low serum albumin.

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

BACKGROUND

Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified.

OBJECTIVE

To assess clinical outcomes of NVUGIB and identify predictors of mortality from NVUGIB in patients with in-hospital bleeding compared with outpatients.

DESIGN

Secondary analysis of prospectively collected data from 2 nationwide multicenter databases. Descriptive, inferential, and multivariate logistic regression models were carried out in 338 inpatients (68.6 ± 16.4 years of age, 68% male patients) and 1979 outpatients (67.8 ± 17 years of age, 66% male patients). A predictive model was constructed using the risk factors identified at multivariate analysis, weighted according to the contribution of each factor.

SETTINGS

A total of 23 Italian community and tertiary care centers.

PATIENTS

Consecutive patients admitted for acute NVUGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Recurrent bleeding, surgery, and 30-day mortality.

RESULTS

The mortality rate in patients with in-hospital bleeding was significantly higher than that in outpatients (8.9% vs 3.8%; odds ratio [OR] 2.44; 95% confidence interval [CI], 1.57-3.79; P < .0001). Hemodynamic instability on presentation (OR 7.31; 95% CI, 2.71-19.65) and the presence of severe comorbidity (OR 6.72; 95% CI, 1.87-24.0) were the strongest predictors of death for in-hospital bleeders. Other independent predictors of mortality were a history of peptic ulcer disease and failed endoscopic treatment. Rebleeding was a strong predictor of death only for outpatients (OR 5.22; 95% CI, 2.45-11.10). Risk factors had a different prognostic impact on the 2 populations, resulting in a significantly different prognostic accuracy of the model (area under the receiver-operating characteristic curve = 0.83; 95% CI, 0.77-0-93 vs 0.74; 95% CI, 0.68-0.80; P < .02).

LIMITATIONS

Study design not experimental, no data on ward specialty, potential referral bias.

CONCLUSIONS

In-hospital bleeders have a significantly higher risk of death because they are sicker and more often hemodynamically unstable than outpatients. Predictors of death have a different impact in the 2 populations.

Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: implications for early discharge?

BACKGROUND

There is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding.

AIMS

Identify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death).

METHODS

Secondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis.

RESULTS

Out of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoy's lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome.

CONCLUSIONS

The "good luck score" may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.

Peptic ulcer disease risk in chronic kidney disease: ten-year incidence, ulcer location, and ulcerogenic effect of medications

Objectives

We aimed at determining peptic ulcer disease (PUD) incidence among chronic kidney disease (CKD) patients during 1998–2008, compared to patients without CKD, and at examining associations between CKD and PUD.

Methods

Data for 1998–2008 were extracted from the National Health Insurance Research Database in Taiwan. The annual PUD incidence (cases per thousand persons per year) was calculated separately for patients with and without CKD. Characteristics of patients with newly diagnosed PUD (n = 16322) were compared to those of a control group without PUD (n = 32644). The 2 groups were matched for age, sex, and index year. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression.

Results

Over the 10-year period, the PUD incidence was ∼10–12 times higher in CKD patients than in those without CKD. Its incidence in elderly CKD patients increased rapidly over time. For CKD patients, most PUD events (>95%) were managed during hospitalization. Peptic ulcer risk, adjusted for all potential confounders, was much higher in CKD patients undergoing hemodialysis (adjusted OR, 9.74; 95% CI, 7.11–13.31). Maintenance hemodialysis patients were 2 times more likely to have gastric ulcers than duodenal ulcers, while CKD patients not on dialysis had similar risks for both. There were no significant interactions between medications and CKD status on the peptic ulcer risk. Unlike CKD patients on nonsteroidal anti-inflammatory drugs and clopidogrel, those on aspirin did not have a higher peptic ulcer risk (adjusted OR, 0.88; 95% CI, 0.44–1.77).

Conclusions

CKD patients have a substantially increased PUD risk, and the majority of CKD patients with PUD require hospital management. Further, peptic ulcer risk is affected by hemodialysis therapy, patient status (inpatient vs. outpatient), and ulcerogenic medications.

Characteristics of nonvariceal upper gastrointestinal hemorrhage in patients with chronic kidney disease

AIM: To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage (NGIH) in patients with chronic kidney disease (CKD).

METHODS: From 2003 to 2010, a total of 72 CKD patients (male n = 52, 72.2%; female n = 20, 27.8%) who had undergone endoscopic treatments for NGIH were retrospectively identified. Clinical findings, endoscopic features, prognosis, rebleeding risk factors, and mortality-related factors were evaluated. The characteristics of the patients and rebleeding-related data were recorded for the following variables: gender, age, alcohol use and smoking history, past hemorrhage history, endoscopic findings (the cause, location, and size of the hemorrhage and the hemorrhagic state), therapeutic options for endoscopy, endoscopist experience, clinical outcomes, and mortality.

RESULTS: The average size of the hemorrhagic site was 13.7 ± 10.2 mm, and the most common hemorrhagic site in the stomach was the antrum (n = 21, 43.8%). The most frequent method of hemostasis was combination therapy (n = 32, 44.4%). The incidence of rebleeding was 37.5% (n = 27), and 16.7% (n = 12) of patients expired due to hemorrhage. In a multivariate analysis of the risk factors for rebleeding, alcoholism (OR = 11.19, P = 0.02), the experience of endoscopists (OR = 0.56, P = 0.03), and combination endoscopic therapy (OR = 0.06, P = 0.01) compared with monotherapy were significantly related to rebleeding after endoscopic therapy. In a risk analysis of mortality after endoscopic therapy, only rebleeding was related to mortality (OR = 7.1, P = 0.02).

CONCLUSION: Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD, especially when a patient is an alcoholic.

Acute nonvariceal upper gastrointestinal bleeding--experience of a tertiary care center in southern India

BACKGROUND AND AIM

Over the last few decades, epidemiologic studies from the West have shown changing trends in etiology and clinical outcomes in patients with nonvariceal upper gastrointestinal bleed (NVUGIB). There are limited data from India on the current status of NVUGIB. The aim of this study therefore was to assess the etiological profile and outcomes of patients with NVUGIB at our center.

METHODS

We prospectively studied all patients (≥15 years) who presented with NVUGIB over a period of 1 year. The clinical and laboratory data, details of endoscopy, and course in hospital were systematically recorded. Outcome measures assessed were rebleeding rate, surgery, and mortality.

RESULTS

Two hundred and fourteen patients (age, ≥15 years) presented to us with NVUGIB during the study period. The mean age was 49.9 ± 16.8 years and 73.8 % were males. Peptic ulcer was the commonest cause (32.2 %) of NVUGIB. About one third of patients required endoscopic therapy. Rebleeding occurred in 8.9 % patients, surgery was required in 3.7 %, and mortality rate was 5.1 %. Rebleeding and mortality were significantly higher among inpatients developing acute NVUGIB compared to those presenting directly to the emergency room.

CONCLUSIONS

Peptic ulcer was the most common cause of NVUGIB. Outcomes (rebleed, surgery, and mortality) at our center appear similar to those currently being reported from the West.

Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding

BACKGROUND

There exists considerable practice variation and little evidence to guide red blood cell (RBC) transfusion in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). Studies in other critically ill cohorts suggest associations between transfusions and adverse patient outcomes.

AIM

To characterise any possible clinically-relevant association between RBC transfusion following NVUGIB with rebleeding and mortality.

METHODS

Observational study utilising the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE). Multivariable logistic regression models were used to examine and quantify independent associations between RBC transfusion and clinical outcomes.

RESULTS

Overall, 1677 patients were included (66.2 ± 16.8 years, 61.7% male, 2.5 ± 1.7 comorbid conditions, initial haemoglobin, 96.8 ± 27.2 g/L); 53.7% received RBC transfusions (2.9 ± 1.6 units of blood), 31.6% had haemodynamic instability, 5.1% fresh blood on rectal examination and 8.6% in the nasogastric tube aspirate. Endoscopic haemostasis was performed in 35.2%. Overall rebleeding (defined as continuous bleeding, rebleeding or surgery) and mortality rates were 17.9% and 5.4%, respectively. After adjusting for potential confounders, transfusion of RBC within 24 h of presentation was significantly and independently associated with an increased risk of rebleeding (OR: 1.0, 95% CI: 0.6-1.8), but not death (OR: 1.5, 95% CI: 0.94-2.23).

CONCLUSIONS

This study suggests an association between RBC transfusion following NVUGIB and subsequent rebleeding, after appropriate and extensive adjustment for confounding. Prospective randomised trial evidence is needed to identify the most efficacious and cost-effective transfusional strategies in these patients.

Variability in the management of nonvariceal upper gastrointestinal bleeding in Europe: an observational study

INTRODUCTION

Despite recent advances in endoscopic and pharmacological management, nonvariceal upper gastrointestinal bleeding (NVUGIB) is still associated with considerable mortality and morbidity that vary between countries. The European Survey of Nonvariceal Upper Gastrointestinal Bleeding (ENERGiB) reported clinical outcomes across Europe (Belgium, Greece, Italy, Norway, Portugal, Spain, and Turkey) and evaluated management strategies in a "real-world" European setting. This article presents the differences in clinical management strategies among countries participating in ENERGiB.

METHODS

Adult patients consecutively presenting with overt NVUGIB at 123 participating hospitals over a 2-month period were included. Data relevant to the initial NVUGIB episode and for up to 30 days afterwards were collected retrospectively from patient medical records.

RESULTS

The number of evaluable patients was 2,660; patient demographics and clinical characteristics were similar across countries. There was wide between-country variability in the area and speciality of the NVUGIB management team and unit transfer rates after the initial hospital assessment. The mean time from admission to endoscopy was <1 day only in Italy and Spain. Wide variation in the use of preendoscopy (35.0-88.7%) and relatively consistent (86.5-96.0%) postendoscopic pharmacological therapy rates were observed. There was substantial by-country variability in the rate of therapeutic procedures performed during endoscopy (24.9-47.6%). NVUGIB-related healthcare resource consumption was high and variable (days hospitalized, mean 5.4-8.7 days; number of endoscopies during hospitalization, mean 1.1-1.7).

CONCLUSIONS

ENERGiB demonstrates that there are substantial differences in the management of patients with acute NVUGIB episodes across Europe, and that in many cases the guideline recommendations for the management of NVUGIB are not being followed.

Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies

BACKGROUND

Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB).

OBJECTIVE

To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them.

METHODS

The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected.

RESULTS

Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices.

CONCLUSIONS

Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.

Urgent endoscopy in severe non-variceal upper gastrointestinal hemorrhage: does the Glasgow-Blatchford score help endoscopists?

OBJECTIVE

The Glasgow-Blatchford score (GBS) has been validated to select severe patients with non-variceal upper gastrointestinal hemorrhage (UGIH). The aim was to compare the yield of the triage based on the GBS with an endoscopist' decision to perform an urgent upper gastrointestinal endoscopy (UGIE) in newly admitted patients and inpatients with UGIH in the setting of an endoscopy on-duty service in 13 tertiary care centers.

MATERIAL AND METHODS

During a 6-month period, GBS and patient data were collected for all patients with non-variceal UGIH for whom an UGIE was requested in emergency. If patients experienced severe endoscopic lesion, surgery or death, they were categorized as patients who had been at need for urgent UGIE.

RESULTS

The 102 UGIH patients included (mean age 62, men 73%) had a median GBS of 12 (range 0-21), significantly lower for new patients compared with inpatients (11, range 0-21 vs. 14, range 2-21, respectively, p = 0.001). If triage for urgent UGIE had followed the GBS, no more patients would have had an urgent UGIE compared with what endoscopists performed (99/102 (97%) vs. 92/102 (90%), respectively, p = 0.09). Sensitivity for the detection of patients who needed an UGIE was no different with the GBS than endoscopists (98% vs. 98%, respectively, p = 0.10) and both showed insufficient specificity (4% and 19%, respectively).

CONCLUSIONS

The GBS does not detect more patients at need for urgent UGIE than on-duty endoscopists. Both methods lead to numerous unjustified UGIEs. A score that would equally help endoscopists in their decision to intervene urgently is still warranted.

In-Hospital Nonvariceal Upper Gastrointestinal Bleeding following Cardiac Surgery: Patient Characteristics, Endoscopic Lesions and Prognosis

Background. Nonvariceal upper gastrointestinal bleeding (NVUGIB) can occur following cardiac surgery, with sparse contemporary data on patient characteristics and predictors of outcome in this setting. Aim. To describe the clinical and endoscopic characteristics of patients with NVUGIB following cardiac surgery and characterize predictors of outcome. Methods. Retrospective review of 131 consecutive patients with NVUGIB following cardiac surgery from 2002 to 2005. Demographic characteristics, therapeutic management, and predictors of outcomes were determined. Results. 69.5% were male, mean age: 68.8 ± 10.2 yrs, mean Parsonnet score: 24.6 ± 14.2. Commonest symptoms included melena (59.4%) or coffee ground emesis (25.8%). In-hospital medications included ASA (88.5%), heparin (95.4%, low molecular weight 6.9%), coumadin (48.1%), clopidogrel (22.9%), and NSAIDS (42%). Initial hemodynamic instability was noted in 47.1%. Associated laboratory results included hematocrit 26 ± 6, platelets 243 ± 133 109/L, INR 1.7 ± 1.6, and PTT 53.3 ± 35.6 s. Endoscopic evaluation (122 patients) yielded ulcers (85.5%) with high-risk lesions in 45.5%. Ulcers were located principally in the stomach (22.5%) or duodenum (45.9%). Many patients had more than one lesion, including esophagitis (28.7%) or erosions (26.8%). 48.8% received endoscopic therapy. Mean lengths of intensive care unit and overall stays were 10.4 ± 18.4 and 39.4 ± 46.9 days, respectively. Overall mortality was 19.1%. Only mechanical ventilation under 48 hours predicted mortality (O.R = 0.11; 95% CI = 0.04−0.34). Conclusions. This contemporary cohort of consecutive patients with NVUGIB following cardiac surgery bled most often from ulcers or esophagitis; many had multiple lesions. ICU and total hospital stays as well as mortality were significant. Mechanical ventilation for under 48 hours was associated with improved survival.

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]

BACKGROUND

Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain.

METHODS

The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables.

RESULTS

Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.

CONCLUSIONS

This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.

Proton pump inhibitors vs. histamine 2 receptor antagonists for stress-related mucosal bleeding prophylaxis in critically ill patients: a meta-analysis

OBJECTIVES

H2-receptor antagonists (H2RA) have been shown to reduce stress-related mucosal bleeding (SRMB), yet randomized controlled trials assessing proton pump inhibitors (PPIs) have yielded conflicting results. The objective of this study was to evaluate the efficacy of PPIs vs. H2RAs in the prophylaxis of SRMB in critically ill adults with risk factors for bleeding.

METHODS

Tailored literature searches of the past four decades were conducted. Outcomes measured were the decreases in rates of clinically significant bleeding (B, primary outcome of the meta-analysis), nosocomial pneumonia (P), and mortality (M) (secondary outcomes). Study heterogeneity was sought and quantified. Results are reported as odd ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eight fully published randomized controlled trials and five abstracts met the inclusion criteria. Prophylactic PPI administration significantly decreased the incidence of bleeding (N = 1,587 patients, OR = 0.30; 95% CI: 0.17-0.54), number needed to treat = 39; 95% CI: 21-303 with no observed statistical heterogeneity among the relevant comparisons (P = 0.93, I2 = 0.0%). No statistical differences were noted for the development of nosocomial pneumonia (n = 7, N = 1,017 patients, OR = 1.05; 95% CI: 0.69-1.62) or mortality (n = 8, N = 1,260 patients, OR = 1.19; 95% CI: 0.84-1.68) or (and no heterogeneity was found for either: P = 0.85, I2 = 0.0%, and P = 0.96, I2 = 0%, respectively).

CONCLUSIONS

In critically ill patients at risk for the development of SRMB, PPI prophylaxis significantly decreased rates of clinically significant bleeding compared with H2RA, without affecting the development of nosocomial pneumonia or mortality rates. The magnitude of the beneficial effect, and its clinical relevance, now requires further characterization using cost-effectiveness analysis considering the incidence of stress-related mucosal disease-related bleeding.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

BACKGROUND

Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality.

OBJECTIVE

To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB).

DESIGN

Secondary analysis of prospectively collected data from 3 national databases.

SETTINGS

Community and teaching hospitals.

PATIENTS

Consecutive patients admitted for acute nonvariceal UGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Thirty-day mortality, recurrent bleeding, and need for surgery.

RESULTS

A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001).

LIMITATIONS

No data on the American Society of Anesthesiologists class score in the Prometeo study.

CONCLUSIONS

Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Clinical outcomes and risk factors of rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage

Background/Aims

Rebleeding after endoscopic therapy for non-variceal upper gastrointestinal hemorrhage (NGIH) is the most important predictive factor of mortality. We evaluated the risk factors of rebleeding in patients undergoing endoscopic therapy for the NGIH.

Methods

Between January 2003 and January 2007, 554 bleeding events in 487 patients who underwent endoscopic therapy for NGIH were retrospectively enrolled. We reviewed the clinicoendoscopical characteristics of patients with rebleeding and compared them with those of patients without rebleeding.

Results

The incidence of rebleeding was 21.7% (n=120). In the multivariate analysis, initial hemoglobin level ≤9 g/dL (p=0.002; odds ratio [OR], 2.433), inexperienced endoscopist with less than 2 years of experience in therapeutic endoscopy (p=0.001; OR, 2.418), the need for more 15 cc of epinephrine (p=0.001; OR, 2.570), injection therapy compared to thermal and injection therapy (p=0.001; OR, 2.840), and comorbidity with chronic renal disease (p=0.004; OR, 2.908) or liver cirrhosis (p=0.010; OR, 2.870) were risk factors for rebleeding following endoscopic therapy.

Conclusions

Together with patients with low hemoglobin level at presentation, chronic renal disease, liver cirrhosis, the need for more 15 cc of epinephrine, or therapy done by inexperienced endoscopist were risk factors for the development of rebleeding.

Clinical predictors of poor outcomes among patients with nonvariceal upper gastrointestinal bleeding in Europe

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency associated with substantial morbidity and mortality. Despite advances in endoscopic and pharmacological treatment during the past two decades, the incidence of mortality associated with NVUGIB has remained relatively constant.

AIM

To report outcomes and predictive factors for bleeding continuation/re-bleeding and mortality of NVUGIB in clinical practice in different European countries.

METHODS

This observational, retrospective cohort study (NCT00797641; ENERGIB) was conducted in Belgium, Greece, Italy, Norway, Portugal, Spain and Turkey. Eligible patients were hospitalised (new admissions or inpatients), presenting with overt NVUGIB with endoscopy from 1 October to 30 November, 2008. Patients were managed according to routine care, and data regarding bleeding continuation/re-bleeding, pharmacological treatment, surgery and mortality during 30-days after the initial bleed were collected. A multivariate analysis of clinical factors predictive of poor outcomes was conducted.

RESULTS

Overall, 2660 patients (64.7% men; mean age 67.7 years) were evaluable. Significant differences across countries in bleeding continuation/re-bleeding (range: 9-15.8%) or death (2.5-8%) at 30 days were explained by clinical factors (number of comorbidities, age > 65 years, history of bleeding ulcers, in-hospital bleeding, type of lesion or type of concomitant medication). Other factors (country, size of hospital, profile of team managing the event, or endoscopic/pharmacological therapy received) did not affect these outcomes. Similar predictors were observed in patients with high-risk stigmata.

CONCLUSION

Differences in the outcomes of nonvariceal upper gastrointestinal bleeding in clinical practice across some European countries are explained mainly by patient-related factors, and not by management factors.

Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding

BACKGROUND

The prognostic value of an elevated international normalised ratio (INR) as part of initial risk stratification in nonvariceal upper gastrointestinal bleeding (NVUGIB) remains poorly characterised.

AIM

To assess the usefulness of the initial INR in patients with NVUGIB.

METHOD

After a systematic review, we included the presenting INR and other validated prognosticators in multivariable models predicting rebleeding and mortality. Data are reported as odd ratios and 95% confidence intervals.

RESULTS

Only two of 769 candidate studies were useful, but reported disparate, highly selected NVUGIB patients with varying threshold initial INR values, yielding conflicting results on predictive ability. The RUGBE cohort included 1869 patients (mean age 66.3 ± 16.8, 38.1% female) with a mean presenting INR of 1.5 ± 1.7. 462 (24.7%) patients had an elevated INR (INR > 2.5 in 7.6%). INR did not add to the prediction of rebleeding. An INR >1.5, in contradistinction, significantly predicted mortality (OR: 1.96; 95% CI: 1.13-3.41).

CONCLUSIONS

An elevated INR at initial presentation does not predict rebleeding in NVUGIB. A value 1.5 or greater, however, is associated with increased patient mortality after adjustment for validated prognosticators. The INR appears most useful as proxy of co-morbid burden at the time of initial assessment in NVUGIB.

Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score

OBJECTIVES

We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death.

METHODS

We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the chi2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models.

RESULTS

Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54-5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72-0.90) vs. 0.66 (0.60-0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05.

CONCLUSIONS

The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.

Methodology for randomized trials of patients with nonvariceal upper gastrointestinal bleeding: recommendations from an international consensus conference

The aim of this document is to provide a methodological framework for the design, performance, analysis, interpretation, and communication of randomized trials that assess management of patients with nonvariceal upper gastrointestinal bleeding. Literature searches were performed and an iterative process with electronic and face-to-face meetings was used to achieve consensus among panel members as part of an International Consensus Conference on Nonvariceal Upper Gastrointestinal Bleeding. Recommendations of the panel include the following. Randomized trials must explicitly state their primary hypothesis. A nonmanipulable randomization schedule with concealed allocation should be used. Stratification (e.g., for age and stigmata of hemorrhage) may be considered, especially in smaller studies. The patient and personnel providing care or recording information should be blinded. Inclusion criteria should be overt bleeding with endoscopy performed within 24 h or less. One type of lesion (e.g., ulcer) should be studied with stigmata to be included predefined. Use of placebo/no therapy vs. active controls depends on current standard practice. Standardizing study and key non-study interventions should ensure uniform provision of interventions. Criteria for repeat endoscopy and subsequent interventions should be predefined. The primary end point should be further bleeding (persistent and recurrent bleeding) with primary assessment at 7 days; mortality, with primary assessment at 30 days, would be appropriate in very large trials. Sample size calculation based on assumptions regarding primary end point results with regard to study intervention and control must be provided, and all patients enrolled must be accounted for. In general, the primary population for analysis is all patients randomized, although a per-protocol population may be used if this is the more conservative approach (e.g., equivalence study).