Pathogenesis, risk factors, and incidence of upper gastrointestinal bleeding after cardiac surgery: Is specific prophylaxis in routine bypass procedures needed?

Prophylactic use of proton pump inhibitors post-cardiac surgery

AIMS/BACKGROUND

Gastrointestinal bleeding significantly increases morbidity and mortality rates postoperatively in patients undergoing cardiac surgery. The prophylactic prescribing of proton pump inhibitors post-cardiac surgery is currently a class IIa recommendation of the European Association of Cardio-Thoracic Surgery.

METHOD

A retrospective review of patients who underwent cardiac surgery between July and December 2019 in the authors' hospital was carried out, using discharge summaries. New treatment charts were introduced with a pre-printed proton pump inhibitor included in the 'regular medication' section of the treatment chart and two reaudits were performed using the same methodology.

RESULTS

Before the intervention, 47% were prescribed omeprazole postoperatively, compared to 74% (P<0.001) and 66% (P=0.008) in the first and second reaudits respectively. Gastrointestinal bleeding was more common pre-intervention (4% vs 1% respectively; P=0.10).

CONCLUSIONS

This intervention resulted in a statistically significant improvement in the prescription of postoperative omeprazole and a decrease in gastrointestinal bleeds. However, other risk factors such as diabetes mellitus, arteriosclerosis and procedure urgency may have contributed to the absence of statistical significance in the latter.

Use of proton pump inhibitors for the provision of stress ulcer prophylaxis: clinical and economic consequences

The provision of stress ulcer prophylaxis (SUP) for the prevention of clinically significant bleeding is widely recognized as a crucial component of care in critically ill patients. Nevertheless, SUP is often provided to non-critically ill patients despite a risk for clinically significant bleeding of roughly 0.1 %. The overuse of SUP therefore introduces added risks for adverse drug events and cost, with minimal expected benefit in clinical outcome. Historically, histamine-2-receptor antagonists (H2RAs) have been the preferred agent for SUP; however, recent data have revealed proton pump inhibitors (PPIs) as the most common modality (76 %). There are no high quality randomized controlled trials demonstrating superiority with PPIs compared with H2RAs for the prevention of clinically significant bleeding associated with stress ulcers. In contrast, PPIs have recently been linked to several adverse effects including Clostridium difficile diarrhea and pneumonia. These complications have substantial economic consequences and have a marked impact on the overall cost effectiveness of PPI therapy. Nevertheless, PPI use remains widespread in patients who are at both high and low risk for clinically significant bleeding. This article will describe the utilization of PPIs for SUP and present the clinical and economic consequences linked to their use/overuse.

Serum levels of gastric-acid-stimulating factors in children undergoing open heart surgery

PURPOSE

Upper gastrointestinal (GI) bleeding is a feared consequence of open heart surgery in children. Increased gastric acid secretion is a known key factor in the pathogenesis of gastritis and upper intestinal ulcerations. The aim of this study is to evaluate the serum kinetics of acid-stimulating factors and associated perioperative parameters after heart surgery in children.

METHODS

Fifteen pediatric patients after open heart surgery and 15 children with cardiac catheterization were included in this study. Serum levels of gastrin, histidine, alanine, and tryptophan were analyzed before and up to 26 h after surgery.

RESULTS

In the postoperative period there was a significant elevation of gastrin with a peak at 4 h after surgery. Serum histidine was increased significantly immediately after surgery only in patients undergoing heart surgery with cardioplegia. No association of gastrin and histidine elevation with ischemia, perfusion time or lactate was observed.

CONCLUSION

Factors that are responsible for postoperative gastrin elevation still have to be determined. Circumstances of extracorporeal circulation (ECC) in low-risk patients most likely do not lead to relevant elevation of amino acids with acid-stimulatory effect in our study population.

Upper endoscopy in patients with acute myocardial infarction and upper gastrointestinal bleeding: results of a decision analysis

BACKGROUND

The management of patients with acute myocardial infarction (AMI) and upper gastrointestinal bleeding (UGIB) can present a challenge. The utility of upper endoscopy (esophagogastroduodenoscopy, EGD) and endoscopic therapy must be weighed against safety considerations.

AIM

To assess the utility and safety of EGD in patients with UGIB and AMI.

METHODS

Using decision analysis, patients with UGIB and AMI were assigned to one of two strategies: (1) EGD prior to cardiac catheterization (EGD strategy) and (2) cardiac catheterization without EGD (CATH strategy).

RESULTS

In patients with overt UGIB, the EGD strategy resulted in 97 deaths per 10,000 patients, compared with 600 deaths in the CATH strategy. The EGD strategy resulted in fewer non-fatal complications (1,271 vs. 6,000 per 10,000 patients). In patients with occult blood loss, the EGD strategy resulted in more deaths (59 vs. 16 per 10,000) and more non-fatal complications (888 vs. 160 per 10,000) than the CATH strategy.

CONCLUSIONS

Our analysis supports EGD prior to cardiac catheterization in patients with AMI and overt UGIB. This strategy results in fewer deaths and complications compared with a strategy of proceeding directly to catheterization. Our analysis does not support routine EGD prior to cardiac catheterization in patients with fecal occult blood.

[Upper digestive bleedings after cardiac surgery]

INTRODUCTION

Upper gastrointestinal haemorrhage (UGH) following cardiac surgery is infrequent with high mortality. The aim of this study is to compare the frequency and outcome of UGH in patients who had undergone open heart surgery at our institution.

PATIENTS AND METHODS

From January 1994 to December 2005, 1278 cardiac operations were performed. A systematic prophylaxis antiacid was used by antagonists of histaminic receptor (anti-H2, ranitidine 150 mg/12 h) in all patients. The diagnosis was based on clinical symptoms (haematemesis and/or melaena) in the postoperative period and confirmed by fibroscopy. We conducted a retrospective study of these patients.

RESULTS

Only 8 of the 1278 (0,6%) cardiac operations were complicated by UGH. Demographic data were reported in Table 1. The mean interval between surgery and UGH was 10+/-3,7 days (range 5,15 days). Gastro-duodenal ulcer was the most common cause of UGH in 5 patients (62%), ulcero-hemorrhagic eosophagitis was developed in one patient (12,5%), candidosic eosophagitis in one and multiple gastric ulcer in one patient (12,5%). Medical treatment was applied in 6 patients (72%) with successful result. Surgical intervention was necessary in 2 patients (25%). 2 patients had repeat gastrointestinal bleeding. One patient was died; he was recorded as having severe sepsis and multiple organ failure in addition to UGH.

CONCLUSION

UGH in patients undergoing heart operation is rare but associated with poor prognosis despite antiacid prophylaxis. These complications occurred in patients who had in postoperative bad hemodynamic conditions.

Early postoperative anticoagulation after mechanical valve replacement: a systematic review

The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of thrombus formation and the different strategies for early postoperative anticoagulation. The most commonly reported anticoagulation regimens had the after estimates of early postoperative thromboembolism and hemorrhage: oral anticoagulation alone (0.9%, 3.3%); oral anticoagulation with intravenous unfractionated heparin (1.1%, 7.2%); and oral anticoagulation with low molecular weight heparin (0.6%, 4.8%). Although intravenous heparin may be associated with a higher incidence of hemorrhage, a randomized trial is needed to provide the best evidence regarding early postoperative anticoagulation after mechanical valve implantation. Nearly four decades have passed since the first mechanical prosthetic valves were implanted. Frequent thromboembolic complications with the first mechanical valves led to recommendations of universal anticoagulation for these patients. Since then, several design changes and modifications have been made to improve the longevity, hemodynamics, and thrombogenicity of newer generation mechanical valves. With improved blood flow, less stasis, and less thrombogenic materials, lower rates of thromboembolism have been reported. Despite these advances however, thromboembolism and anticoagulant-related bleeding continue to account for 75% of all complications after mechanical valve replacement. Occurring most commonly within six months after implantation, these complications can adversely affect mortality and quality of life. Furthermore, the threat of their occurrence creates a psychological burden for each patient with a mechanical valve. The need for life-long anticoagulation in patients with mechanical valves is not in dispute, and the perioperative management of anticoagulation during non-cardiac surgery has been reviewed extensively. However, the approach to early postoperative anticoagulation after mechanical valve implantation is still a matter of debate. The optimal intensity and timing of anticoagulation to prevent early thromboembolism after valve replacement surgery without postoperative bleeding complications is unknown. Hence, many anticoagulation protocols have been proposed, but a lack of consensus remains. The objectives of this study were (1) to reexamine the pathogenesis of thrombus formation and the need for anticoagulation; (2) to critically review the literature on early postoperative anticoagulation strategies; and (3) provide an estimate of the incidence of bleeding and thromboembolism for each approach to early postoperative anticoagulation.

Efficacy of a proton pump inhibitor given in the early postoperative period to relieve symptoms of hiatal hernia after open heart surgery

PURPOSE

To evaluate the efficacy of a proton pump inhibitor, we retrospectively reviewed patients who underwent gastric fiberscopy (GFS) in the early phase after cardiac surgery.

METHODS

The subjects were 103 patients who underwent GFS for poor appetite, gastric pain, heartburn, or hematemesis after cardiac surgery. We divided the patients into two groups: group I consisted of 49 patients who received an H2-receptor antagonist (ranitidine hydrochloride 300 mg/day), and group II consisted of 54 patients who received a proton pump inhibitor (PPI; sodium rabeprazole 10 mg/day) as prophylactic treatment. The incidence of upper gastrointestinal (GI) disease was compared in the two groups.

RESULTS

Gastric fiberscopy confirmed that 82.5% of the patients had type I hiatal hernia. The incidences of gastric pain and heartburn were significantly higher in group I (12.2% and 83.7%) than in group II (0% and 37.0%). Moreover, gastric bleeding occurred in two patients from group I, one [corrected] of whom died of coagulopathy. The incidences of hemorrhagic gastritis, active ulcer, and reflux esophagitis were significantly higher in group I than in group II, at 22.4%, 22.4%, and 24.5% vs 1.9%, 0%, and 7.4%.

CONCLUSIONS

Early postcardiotomy GFS confirmed a high incidence of type I hiatal hernia. However, the proton pump inhibitor given in the early postoperative period proved more effective than the H2-receptor antagonist for relieving GI symptoms and preventing upper GI disorders after cardiac surgery.

An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit?

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection.

DESIGN

A prospective observational study followed by a case-control study.

SETTING

Seven ICUs in the Paris area, five of them located in teaching hospitals.

PATIENTS

All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04).

CONCLUSIONS

Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.

Prospective randomized trial for optimal prophylactic treatment of the upper gastrointestinal complications after open heart surgery

BACKGROUND

Upper gastrointestinal bleeding is a lethal complication after open heart surgery. We designed a prospective randomized trial to test the efficacy of different antisecretory agents to prevent upper gastrointestinal disease after operation.

METHODS AND RESULTS

A total of 210 patients were divided into 3 groups: group I had 70 patients who had mucosal protection (teprenone 150 mg/day), group II had 70 patients who had histamine2-receptor antagonist (ranitidine 300 mg/day), and group III included 70 patients who had a proton pump inhibitor (rabeprazole 10 mg/day). Gastric fiberscopy was used in all patients postoperatively during days 5 to 7. We compared the 3 groups in terms of endoscopic findings. Four patients (5.7%) had gastric bleeding complications in each of groups I and II; 2 died of coagulopathy. In group III no patients had gastric bleeding. The incidence of hemorrhagic gastritis was significantly higher in groups I (22.9%) and II (15.7%) than in III (2.9%) (p=0.0003). The incidence of active ulcers was also significantly higher in groups I (28.6%) and II (21.4%) than in III (4.3%) (p=0.0001).

CONCLUSIONS

Early medication postoperative by a proton pump inhibitor was shown to be the most effective treatment and indeed might be described as mandatory to prevent upper gastrointestinal diseases after open heart surgery.

Gastrointestinal complications after cardiac surgery

BACKGROUND

Gastrointestinal complications after cardiac surgery are often difficult to diagnose, and are associated with high morbidity and mortality rates. The aim of this study was to determine risk factors for these complications.

METHOD

Between 1996 and 2001 data were collected prospectively from 6119 patients who underwent 6186 cardiac surgical procedures. Data from patients who experienced major gastrointestinal complications were analysed retrospectively by univariate and multivariate analysis.

RESULTS

Fifty major gastrointestinal complications were identified in 47 patients (incidence 0.8 per cent). Thirteen of these patients died within 30 days. The most common complication was upper gastrointestinal bleeding (16 patients). Intestinal ischaemia was the most lethal complication (eight of ten patients died). Abdominal surgical operations were performed in 12 patients. Multivariate analysis identified nine variables that independently predicted major gastrointestinal complications: age over 80 years, active smoker, need for preoperative inotropic support, New York Heart Association class III-IV, cardiopulmonary bypass time more than 150 min, postoperative atrial fibrillation, postoperative heart failure, reoperation for bleeding and postoperative vascular complications.

CONCLUSION

Nine risk factors for the development of major gastrointestinal complications after cardiac surgery were identified. Gastrointestinal complications were often lethal but did not independently predict death within 30 days.

Abdominal organ injury after cardiac surgery

Gastrointestinal complications occur in about 2.5% of patients undergoing cardiac surgery, are associated with a high mortality (about 33%), and account for nearly 15% (and perhaps increasing) of all postoperative deaths. The various complications and risk factors are reviewed. Splanchnic ischemia prior to, during, and especially postoperatively appears to be an important cause of these complications. In addition, splanchnic ischemia is hypothesized to be one cause of the systemic inflammatory response syndrome and multiorgan failure that may follow cardiac surgery. The physiology of splanchic perfusion and the effects of cardiac surgery, including cardiopulmonary bypass, on it are reviewed. Finally, possible methods to minimize splanchnic ischemia and reduce the incidence of abdominal complications are discussed.

Use of enteral nutrition for stress ulcer prophylaxis

OBJECTIVE

To review the controversies involving the use of enteral nutrition support for stress ulcer prophylaxis and formulate recommendations.

DATA SOURCES

A MEDLINE search (1966-December 2000) was conducted using the MeSH of nutrition, ulcer, critical care, and acid to identify relevant articles. References of selected articles were reviewed, and relevant abstracts from critical care or gastrointestinal journals identified.

DATA EXTRACTION

Animal and human data from prospective studies, retrospective studies, and case series were evaluated for the effects of enteral nutrition on gastric pH, intramucosal pH, gastrointestinal blood flow, development of macroscopic mucosal erosions, and hemorrhage.

DATA SYNTHESIS

Intragastric administration of enteral nutrition has variable effects on gastric pH, enhances regional distribution of gastrointestinal blood flow, and may lower intramucosal pH. All substrates (carbohydrate, lipid, amino acid), when administered into the stomach, reduce the occurrence of mucosal erosions but do not entirely prevent their development. Few studies of stress ulcer prophylaxis regimens have reported use of enteral nutrition. Limited retrospective data suggest enteral nutrition support may be effective for preventing gastrointestinal hemorrhage, but the results of prospective studies are confounded by poor study design.

CONCLUSIONS

Definitive recommendations regarding the role of enteral nutrition for stress ulcer prophylaxis are not possible due to the lack of prospective, randomized studies. Therefore, the use of enteral nutrition as the only therapeutic agent for stress ulcer prophylaxis should be discouraged until definitive data are available. Initiation and discontinuation of pharmacologic stress ulcer prophylaxis should be independent of enteral nutrition.