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Lee AY, Cho JY. Advancements in hemostatic strategies for managing upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2024; 30:2087-2090. [PMID: 38681987 PMCID: PMC11045484 DOI: 10.3748/wjg.v30.i15.2087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/20/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
Upper gastrointestinal (GI) hemorrhage presents a substantial clinical challenge. Initial management typically involves resuscitation and endoscopy within 24 h, although the benefit of very early endoscopy (< 12 h) for high-risk patients is debated. Treatment goals include stopping acute bleeding, preventing rebleeding, and using a multimodal approach encompassing endoscopic, pharmacological, angiographic, and surgical methods. Pharmacological agents such as vasopressin, prostaglandins, and proton pump inhibitors are effective, but the increase in antithrombotic use has increased GI bleeding morbidity. Endoscopic hemostasis, particularly for nonvariceal bleeding, employs techniques such as electrocoagulation and heater probes, with concerns over tissue injury from monopolar electrocoagulation. Novel methods such as Hemospray and Endoclot show promise in creating mechanical tamponades but have limitations. Currently, the first-line therapy includes thermal probes and hemoclips, with over-the-scope clips emerging for larger ulcer bleeding. The gold probe, combining bipolar electrocoagulation and injection, offers targeted coagulation but has faced device-related issues. Future advancements involve combining techniques and improving endoscopic imaging, with studies exploring combined approaches showing promise. Ongoing research is crucial for developing standardized and effective hemorrhage management strategies.
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Affiliation(s)
- Ah Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, Korea
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2
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Hatchimonji JS, Mavroudis CL, Friedman A, Kaufman EJ, Syvyk S, Wirtalla CJ, Keele L, Reilly PM, Kelz RR. National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions. J Surg Res 2023; 290:310-318. [PMID: 37329626 PMCID: PMC10330654 DOI: 10.1016/j.jss.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/22/2023] [Accepted: 05/13/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Catherine L Mavroudis
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ari Friedman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Wirtalla
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Keele
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Tuerk E, Doss S, Polsley K. Peptic Ulcer Disease. Prim Care 2023; 50:351-362. [PMID: 37516507 DOI: 10.1016/j.pop.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Peptic ulcer disease is a common cause of epigastric pain typically related to Helicobacter pylori infection or NSAID use that can lead to serious consequences including upper GI bleed or perforation if undiagnosed. Diagnostic strategies vary depending on age and treatment is dependent on etiology.
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Affiliation(s)
- Emily Tuerk
- Loyola University Chicago Stritch School of Medicine, Primary Care, 2160 South First Avenue, Mulcahy 2525, Maywood, IL 60153, USA.
| | - Sara Doss
- Loyola University Chicago Stritch School of Medicine, Primary Care, 2160 South First Avenue, Mulcahy 2525, Maywood, IL 60153, USA
| | - Kevin Polsley
- Loyola University Chicago Stritch School of Medicine, Primary Care, 2160 South First Avenue, Mulcahy 2525, Maywood, IL 60153, USA
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Jo SY, Noh JH, Cha B, Ahn JY, Oh SP, Seo JY, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical outcomes of Dieulafoy's lesion compared with peptic ulcer in upper gastrointestinal bleeding. J Gastroenterol Hepatol 2023. [PMID: 36740948 DOI: 10.1111/jgh.16139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico-epidemiological outcomes due to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes. METHODS Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated. RESULTS Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range [IQR], 56-75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow-up period of 52 months (IQR, 34-70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518). CONCLUSIONS Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding.
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Affiliation(s)
- Sang Yong Jo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boram Cha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Pyo Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lim SG. Seeking a better risk-prediction model for upper gastrointestinal bleeding. Korean J Intern Med 2022; 37:1138-1139. [PMID: 36375486 PMCID: PMC9666246 DOI: 10.3904/kjim.2022.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Kang S, Kim Y, Choi KD. Gastric Ulcer Bleeding associated with a Left Gastric Artery Pseudoaneurysm. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A left gastric artery (LGA) pseudoaneurysm is known to occur as a complication of abdominal surgery, trauma, or pancreatitis. However, an LGA pseudoaneurysm presenting with gastrointestinal bleeding is rare. A 77-year-old man complained of dizziness and three episodes of melena in the last 24 hours. He did not have a history of surgery, trauma, or pancreatitis. He underwent primary coronary intervention for unstable angina and started dual antiplatelet therapy 1 month prior. Esophagogastroduodenoscopy (EGD) revealed a 3-cm ulcer in the lesser curvature of the gastric high body with a pulsating subepithelial tumor-like lesion in the ulcer. Hemostasis was achieved endoscopically. Three days after the endoscopic hemostasis, hematemesis and hypovolemic shock occurred. Emergent angiography of the superior mesenteric artery revealed an LGA pseudoaneurysm with extravasation. Coil embolization was successfully performed. Three days after the angiographic embolization, EGD revealed improvement of the gastric ulcer, which was covered with exudate, and disappearance of the subepithelial tumor-like lesion. At the 2-month follow-up, EGD showed that the ulcer was in the healing stage.
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Jeon HJ, Moon HS, Kwon IS, Kang SH, Sung JK, Jeong HY. Which scoring system should be used for non-variceal upper gastrointestinal bleeding? Old or new? J Gastroenterol Hepatol 2021; 36:2819-2827. [PMID: 34031928 DOI: 10.1111/jgh.15555] [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] [Received: 03/04/2021] [Revised: 05/01/2021] [Accepted: 05/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Several scoring systems for predicting outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB) have recently been devised, but not sufficiently validated. We compared the predictive accuracy of several scoring systems and assessed the usefulness of new scoring systems. METHODS The medical records of 1048 patients with NVUGIB were reviewed to collect demographic, clinical, laboratory, and endoscopic data. The areas under the receiver operating characteristic curve (AUROCs) were calculated for the ABC, new Japanese scoring system, Progetto Nazionale Emorrhagia Digestiva (PNED), and other scores to compare their predictive accuracy for 30-day mortality, therapeutic intervention, rebleeding, and prolonged hospital stay (≥ 10 days). Outcome predictors were identified by multivariate analysis. RESULTS The ABC, new Japanese scoring system, and PNED scores best predicted 30-day mortality (AUROC 0.907), need for therapeutic intervention (AUROC 0.707), and rebleeding (AUROC 0.874), respectively (all P < 0.001). The ABC and PNED scores were similarly better at predicting prolonged hospital stay (ABC AUROC: 0.765; PNED AUROC: 0.790; both P < 0.001). Thirty-day mortality was related to sex, systolic blood pressure (SBP), syncope, estimated glomerular filtration rate (eGFR), albumin, heart failure, disseminated malignancy, chronic obstructive pulmonary disease (COPD), and liver cirrhosis. Sex, age, SBP, hematemesis, blood urea nitrogen, and eGFR independently predicted the need for therapeutic intervention. Sex, SBP, pulse, albumin level, heart failure, disseminated malignancy, and COPD predicted rebleeding. CONCLUSION The outcomes of patients with NVUGIB were better predicted by newly developed than by old scoring systems.
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Affiliation(s)
- Hong Jae Jeon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - In Sun Kwon
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
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Li JL, Cheng P, Sheng WY, Zhang JX. Progress in new hemostasis techniques for acute upper gastrointestinal bleeding. Shijie Huaren Xiaohua Zazhi 2021; 29:1035-1042. [DOI: 10.11569/wcjd.v29.i18.1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common acute and critical illnesses in the emergency department. It mainly refers to gastrointestinal bleeding above the Treitz ligament, and the mortality rate is about 2%-10%. The main clinical manifestations are hematemesis and/or hematochezia. The diagnosis is mainly based on clinical manifestations combined with laboratory and imaging findings. Due to the rapid onset and severe nature of the condition, there are various treatment methods according to different causes. This article reviews the diagnosis and treatment of acute upper gastrointestinal bleeding.
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Affiliation(s)
- Jing-Lei Li
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ping Cheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Wei-Yong Sheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jin-Xiang Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Forgerini M, Urbano G, Nadai TRD, Zapata-Cachafeiro M, Kemp R, Mastroianni PDC. EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING SECONDARY TO PEPTIC DISEASE IN A TERTIARY REFERRAL BRAZILIAN HOSPITAL. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:202-209. [PMID: 34190782 DOI: 10.1590/s0004-2803.202100000-36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-variceal upper gastrointestinal bleeding (NVUGIB) secondary to peptic ulcer disease is a medical digestive emergency and could be one of the most serious adverse drug reactions. OBJECTIVE To identify the frequency of diagnosis of NVUGIB secondary to peptic ulcer disease. METHODS Prospective and epidemiological study conducted in a tertiary referral Brazilian hospital, from July 2016 to December 2019. Upper gastrointestinal endoscopies (UGE) reports were evaluated daily. The diagnosis of NVUGIB secondary to peptic ulcer disease was defined through endoscopic findings of peptic ulcer and erosive gastric lesions, and clinical symptoms. The frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was estimated through the ratio between the number of patients diagnosed and the number of patients underwent UGE in the same period. RESULTS A total of 2,779 endoscopic reports (2,503 patients) were evaluated, and 178 patients were eligible. The total frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was 7.1%. The annual frequency of diagnosis between 2017 and 2019 ranged from 9.3% to 5.7%. Most patients were men (72.8%); self-declared white (71.8%); older people (56.7%); and, had no familiar or personal history of gastrointestinal diseases (60.1%). 90% of the patients had a peptic ulcer and melena (62.8%). Patients made chronic use of low-dose aspirin (29.3%), other antiplatelet agents (21.9%) and, oral anticoagulants (11.2%); and non-steroidal anti-inflammatories use in the week a prior to the onset of clinical symptoms (25.8%). CONCLUSION Seven in every 100 patients admitted and underwent UGE in a tertiary hospital were diagnosed with NVUGIB secondary to peptic ulcer disease.
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Affiliation(s)
- Marcela Forgerini
- Universidade Estadual Paulista (UNESP), Faculdade de Ciências Farmacêuticas, Departamento de Fármacos e Medicamentos, Araraquara, SP, Brasil
| | - Gustavo Urbano
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia, Ribeirão Preto, SP, Brasil
| | - Tales Rubens de Nadai
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Saúde Coletiva, Bauru, SP, Brasil
| | - Maruxa Zapata-Cachafeiro
- University of Santiago de Compostela, Department of Preventive Medicine, Santiago de Compostela, Spain
| | - Rafael Kemp
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia Digestiva, Ribeirão Preto, SP, Brasil
| | - Patrícia de Carvalho Mastroianni
- Faculdade de Ciências Farmacêuticas da Universidade Estadual Paulista (UNESP), Departamento de Fármacos e Medicamentos, Araraquara, SP, Brasil
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. [Guidelines for Non-variceal Upper Gastrointestinal Bleeding]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 75:322-332. [PMID: 32581203 DOI: 10.4166/kjg.2020.75.6.322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Kanjee Z, Asombang AW, Berzin TM, B Burns R. How Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2021; 174:836-843. [PMID: 34097431 DOI: 10.7326/m21-1206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., T.M.B., R.B.B.)
| | - Akwi W Asombang
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (A.W.A.)
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., T.M.B., R.B.B.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., T.M.B., R.B.B.)
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Yoo IK, Kim K, Song G, Koh MY, Lee MS, Yeniova AÖ, Lee H, Cho JY. Endoscopic application of mussel-inspired phenolic chitosan as a hemostatic agent for gastrointestinal bleeding: A preclinical study in a heparinized pig model. PLoS One 2021; 16:e0251145. [PMID: 33989307 PMCID: PMC8121352 DOI: 10.1371/journal.pone.0251145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/20/2021] [Indexed: 12/21/2022] Open
Abstract
Marine mussels secrete adhesive proteins to attach to solid surfaces. These proteins contain phenolic and basic amino acids exhibiting wet adhesion properties. This study used a mussel-inspired hemostatic polymer, chitosan-catechol, to treat gastrointestinal bleeding caused by endoscopic mucosal resection in a heparinized porcine model. We aimed to evaluate the hemostatic efficacy and short-term safety of this wet adhesive chitosan-catechol. We used 15 heparinized pigs. Four iatrogenic bleeding ulcers classified as Forrest Ib were created in each pig using an endoscopic mucosal resection method. One ulcer in each pig was untreated as a negative control (no-treatment group). The other three ulcers were treated with gauze (gauze group), argon plasma coagulation (APC group), and chitosan-catechol hemostatic agent (CHI-C group) each. The pigs were sacrificed on Days 1, 5, and 10, and histological examination was performed (n = 5 per day). Rapid hemostasis observed at 2 min after bleeding was 93.3% (14/15) in the CHI-C group, 6.7% (1/15) in the no-treatment group, 13.3% (2/15) in the gauze group, and 86.7% (13/15) in the APC group. No re-bleeding was observed in the CHI-C group during the entire study period. However, a few re-bleeding cases were observed on Day 1 in the no-treatment, gauze, and APC groups and on Day 5 in the gauze and APC groups. On histological analysis, the CHI-C group showed the best tissue healing among the four test groups. Considering the results, chitosan-catechol is an effective hemostatic material with reduced re-bleeding and improved healing.
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Affiliation(s)
- In Kyung Yoo
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Keumyeon Kim
- R&D Center, InnoTherapy Inc., Seoul, Republic of Korea
| | - Gawon Song
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Mi-Young Koh
- R&D Center, InnoTherapy Inc., Seoul, Republic of Korea
| | - Moon Sue Lee
- R&D Center, InnoTherapy Inc., Seoul, Republic of Korea
| | - Abdullah Özgür Yeniova
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - Haeshin Lee
- R&D Center, InnoTherapy Inc., Seoul, Republic of Korea
- Department of Chemistry, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
- * E-mail: (HL); (JYC)
| | - Joo Young Cho
- Department of Gastroenterology, CHA Gangnam Medical Center, College of Medicine, Cha University, Seoul, Republic of Korea
- * E-mail: (HL); (JYC)
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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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14
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Cheng Z, Qing R, Hao S, Ding Y, Yin H, Zha G, Chen X, Ji J, Wang B. Fabrication of ulcer-adhesive oral keratin hydrogel for gastric ulcer healing in a rat. Regen Biomater 2021; 8:rbab008. [PMID: 33738122 PMCID: PMC7955710 DOI: 10.1093/rb/rbab008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 12/28/2022] Open
Abstract
Hydrogel has been used for in suit gastric ulcer therapy by stopping bleeding, separating from ulcer from gastric fluids and providing extracellular matrix scaffold for tissue regeneration, however, this treatment guided with endoscopic catheter in most cases. Here, we developed an oral keratin hydrogel to accelerate the ulcer healing without endoscopic guidance, which can specially adhere to the ulcer because of the high-viscosity gel formation on the wound surface in vivo. Approximately 50% of the ulcer-adhesive keratin hydrogel can resident in ethanol-treated rat stomach within 12 h, while approximately 18% of them maintained in health rat stomach in the same amount of time. Furthermore, Keratin hydrogels accelerated the ethanol-induced gastric ulcer healing by stopping the bleeding, preventing the epithelium cells from gastric acid damage, suppressing inflammation and promoting re-epithelization. The oral administration of keratin hydrogel in gastric ulcer treatment can enhance the patient compliance and reduce the gastroscopy complications. Our research findings reveal a promising biomaterial-based approach for treating gastrointestinal ulcers.
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Affiliation(s)
- Zhongjun Cheng
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China.,School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China.,Bijie Institute of Traditional Chinese Medicine, Bijie City, Guizhou Province 551700, China
| | - Rui Qing
- Media Lab, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Shilei Hao
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
| | - Yi Ding
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
| | - Haimeng Yin
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - GuoDong Zha
- HEMOS (Chongqing) Bioscience Co., Ltd, Chongqing 402760, China
| | - Xiaoliang Chen
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China.,Department of Nuclear Medicine, Institution of Chongqing Cancer, Chongqing 400030, China
| | - Jingou Ji
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Bochu Wang
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
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15
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Forgerini M, Lucchetta RC, Urbano G, de Nadai TR, de Carvalho Mastroianni P. Genetic polymorphisms associated with upper gastrointestinal bleeding: a systematic review. THE PHARMACOGENOMICS JOURNAL 2021; 21:20-36. [PMID: 32948830 DOI: 10.1038/s41397-020-00185-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 02/07/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (non-variceal UGIB) is a frequent and severe adverse drug reaction. Idiosyncratic responses due to genetic susceptibility to non-variceal UGIB has been suggested. A systematic review was conducted to assess the association between genetic polymorphisms and non-variceal UGIB. Twenty-one publications and 7134 participants were included. Thirteen studies evaluated genetic polymorphism in patients exposed to non-steroidal anti-inflammatory drugs, low-dose aspirin, and warfarin. Eight studies present at least one methodological problem. Only six studies clearly defined that the outcome evaluated was non-variceal UGIB. Genetic polymorphisms involved in platelet activation and aggregation, angiogenesis, inflammatory process, and drug metabolism were associated with risk of non-variceal UGIB (NOS3, COX-1; COX-2; PLA2G7; GP1BA; GRS; IL1RN; F13A1; CDKN2B-AS1; DPP6; TBXA2R; TNF-alpha; VKORC1; CYP2C9; and AGT). Further well-designed studies are needed (e.g., clear restriction to non-variceal UGIB; proper selection of participants; and adjustment of confounding factors) to provide strong evidence for pharmacogenetic and personalized medicine.
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Affiliation(s)
- Marcela Forgerini
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, Brazil
| | - Rosa Camila Lucchetta
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, Brazil
| | - Gustavo Urbano
- Department of Surgery, School of Medicine, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Tales Rubens de Nadai
- Department of Public Health, Bauru School of Dentistry, University of São Paulo (USP), Bauru, Brazil
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16
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Srivastava A, Verma A, Saraf S, Jain A, Tiwari A, Panda PK, Jain SK. Mucoadhesive gastroretentive microparticulate system for programmed delivery of famotidine and clarithromycin. J Microencapsul 2021; 38:151-163. [PMID: 33205689 DOI: 10.1080/02652048.2020.1851787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The present research was aimed to develop thiolated polyacrylic acid (TPA) based microspheres (MSPs) containing famotidine (FX) and clarithromycin (CLX). METHODS TPA was synthesised from polyacrylic acid and l-cysteine in the presence of 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDAC). The prepared TPA was characterised using FT-IR (Fourier transform-infra red), 1H-NMR (proton nuclear magnetic resonance) spectroscopy, P-XRD (powder X ray diffraction) method, and zeta potential. The analytical tools have supported the formation of TPA. The thiolated microspheres were prepared by emulsion solvent evaporation method using 0.75% w/v polymer concentration and stirring at 400 rpm for 8 hr. RESULTS The average particle size and zeta potential of optimised formulation was found to be 25.2 ± 1.87 μm and -26.68 mV, respectively. The entrapment efficiency of the optimised formulation was obtained 67.20% for FX and 70.20% for CLX. The developed microspheres were swelled only in 4 h from 0.5 to 0.9. The in vitro mucoadhesive study and in vitro drug release studies demonstrated that microspheres showed mucoadhesive property. In in vitro drug release studies, the release of FX and CLX were observed to be 58.68% and 60.48%, respectively from microspheres in 8 h. The thiolated microspheres showed higher adhesion time (7.0 ± 0.8 h) in comparison to the plain microspheres (2.6 ± 0.4 h). CONCLUSION The prepared TPA based mucoadhesive microspheres can be utilised as carriers for the treatment of peptic ulcer caused by Helicobacter pylori which will offer enhanced residence time for the rational drug combination in the gastric region.
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Affiliation(s)
- Aakanksha Srivastava
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
| | - Amit Verma
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
| | - Shivani Saraf
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
| | - Ankit Jain
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India.,Department of Materials Engineering, Indian Institute of Science, Bangalore, India
| | - Ankita Tiwari
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
| | - Pritish K Panda
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
| | - Sanjay Kumar Jain
- Department of Pharmaceutical Sciences, Pharmaceutics Research Projects Laboratory, Dr. Hari Singh Gour Central University, Sagar, India
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17
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Abstract
Ulcer is the most common undesirable result of using non-steroid anti-inflammatory drugs such as indomethacin. In the present study, osajin was experimentally used on indomethacin-induced gastric ulcer in rats. Osajin was purified from Maclura pomifera (Raf.) C. K. Schneid fruits by using the chromatographic methods. Thirty six rats were divided into six groups as follows: healthy (control), IND (indomethacin), RAN (ranitidine, 25 mg/kg), OSJ 100 (osajin, 100 mg/kg), OSJ 200 (200 mg/kg) and OSJ 400 (osajin, 400 mg/kg). Following a 24-h fasting, IND was administered to the treatment groups at a dose of 25 mg/kg. RAN and OSJ were given orally to rats following 5 min of IND administration. Then, gastric tissues were taken 6 h after the IND administration. Determination of the ulcer area, pathological evidence, and biochemical indices such as lipid peroxidation, superoxide dismutase, glutathione, and catalase were performed. IND generated diffuse ulcer areas, severe hyperaemia, oedema, necrotic epithelium, and mononuclear cell infiltration in the mucosa, and significantly increased lipid peroxidation while also decreasing the glutathione concentration, superoxide dismutase and catalase activities of the tissue. OSJ and RAN showed significant amelioration on ulcer area and biochemical indices. Therefore, OSJ may be potentially therapeutic for gastric ulcers.
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18
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Bridi H, de Carvalho Meirelles G, Lino von Poser G. Subtribe Hyptidinae (Lamiaceae): A promising source of bioactive metabolites. JOURNAL OF ETHNOPHARMACOLOGY 2021; 264:113225. [PMID: 32763419 PMCID: PMC7403033 DOI: 10.1016/j.jep.2020.113225] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/24/2020] [Accepted: 07/14/2020] [Indexed: 05/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The subtribe Hyptidinae contains approximately 400 accepted species distributed in 19 genera (Hyptis, Eriope, Condea, Cantinoa, Mesosphaerum, Cyanocephalus, Hypenia, Hyptidendron, Oocephalus, Medusantha, Gymneia, Marsypianthes, Leptohyptis, Martianthus, Asterohyptis, Eplingiella, Physominthe, Eriopidion and Rhaphiodon). This is the Lamiaceae clade with the largest number of species in Brazil and high rates of endemism. Some species have been used in different parts of the world mainly as insecticides/pest repellents, wound healing and pain-relief agents, as well as for the treatment of respiratory and gastrointestinal disorders. AIM OF THE REVIEW This review aims to discuss the current status concerning the taxonomy, ethnobotanical uses, phytochemistry and biological properties of species which compose the subtribe Hyptidinae. MATERIALS AND METHODS The available information was collected from scientific databases (ScienceDirect, Pubmed, Web of Science, Scopus, Google Scholar, ChemSpider, SciFinder ACS Publications, Wiley Online Library), as well as other literature sources (e.g. books, theses). RESULTS The phytochemical investigations of plants of this subtribe have led to the identification of almost 300 chemical constituents of different classes such as diterpenes, triterpenes, lignans, α-pyrones, flavonoids, phenolic acids and monoterpenes and sesquiterpenes, as components of essential oils. Extracts, essential oils and isolated compounds showed a series of biological activities such as insecticide/repellent, antimicrobial and antinociceptive, justifying some of the popular uses of the plants. In addition, a very relevant fact is that several species produce podophyllotoxin and related lignans. CONCLUSION Several species of Hyptidinae are used in folk medicine for treating many diseases but only a small fraction of the species has been explored and most of the traditional uses have not been validated by current investigations. In addition, the species of the subtribe appear to be very promising as alternative sources of podophyllotoxin-like lignans which are the lead compounds for the semi-synthesis of teniposide and etoposide, important antineoplastic agents. Thus, there is a wide-open door for future studies, both to support the popular uses of the plants and to find new biologically active compounds in this large number of species not yet explored.
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Affiliation(s)
- Henrique Bridi
- Universidade Federal Do Rio Grande Do Sul, Programa de Pós-Graduação Em Ciências Farmacêuticas, Avenida Ipiranga 2752, Porto Alegre, Brazil
| | - Gabriela de Carvalho Meirelles
- Universidade Federal Do Rio Grande Do Sul, Programa de Pós-Graduação Em Ciências Farmacêuticas, Avenida Ipiranga 2752, Porto Alegre, Brazil
| | - Gilsane Lino von Poser
- Universidade Federal Do Rio Grande Do Sul, Programa de Pós-Graduação Em Ciências Farmacêuticas, Avenida Ipiranga 2752, Porto Alegre, Brazil.
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19
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Borges LF, Robertson JM, Kappler SM, Venkatan SK, Jin DX, Barnes EL, Jaffer FA, Saldana FL, Dudzinski DM, Stefanescu Schmidt AC, Drachman DE, Young MN, Hayden EM, Pelletier SR, Shields HM. Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:969-976. [PMID: 33376436 PMCID: PMC7755877 DOI: 10.2147/amep.s270272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/22/2020] [Indexed: 06/12/2023]
Abstract
PURPOSE Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. PATIENTS AND METHODS We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session. RESULTS Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. CONCLUSION We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.
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Affiliation(s)
- Lawrence F Borges
- Division of Gastroenterology, Mount Auburn Hospital and Harvard Medical School, Cambridge, MA, USA
| | - Jamie M Robertson
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Steven M Kappler
- Cleveland Clinic Digestive Diseases Center, Port St. Lucie, FL, USA
| | - Suresh K Venkatan
- Learning Laboratory, Massachusetts General Hospital, Boston, MA, USA
| | - David X Jin
- Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Edward L Barnes
- Division of Gastroenterology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Farouc A Jaffer
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fidencio L Saldana
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Dudzinski
- Learning Laboratory, Massachusetts General Hospital, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ada C Stefanescu Schmidt
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Douglas E Drachman
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael N Young
- Cardiology Division, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine, Lebanon, NH, USA
| | - Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen R Pelletier
- Office of Educational Quality Improvement, Harvard Medical School, Boston, MA, USA
| | - Helen M Shields
- Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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20
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Lee MW, Katz PO. Nonsteroidal Antiinflammatory Drugs, Anticoagulation, and Upper Gastrointestinal Bleeding. Clin Geriatr Med 2020; 37:31-42. [PMID: 33213773 DOI: 10.1016/j.cger.2020.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Advanced age, history of peptic ulcer disease, Helicobacter pylori, coadministration of nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, anticoagulation, and antiplatelets are risk factors for gastrointestinal bleeding in the elderly. Awareness of these risks and appropriate use of NSAIDs, particularly in those needing antiplatelet or anticoagulant therapy, is critical to optimal management. Careful selection of elderly patients requiring antiplatelet, anticoagulation, or chronic NSAID therapy for cotherapy with proton pump inhibitors can significantly reduce morbidity and mortality from gastrointestinal bleeding.
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Affiliation(s)
- Mindy Winghin Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA
| | - Philip O Katz
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA.
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21
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Active delivery of multi-layer drug-loaded microneedle patches using magnetically driven capsule. Med Eng Phys 2020; 85:87-96. [PMID: 33081968 DOI: 10.1016/j.medengphy.2020.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022]
Abstract
In this paper, we propose the active delivery of multi-layer drug-loaded microneedle (MN) patches using a capsule that can be driven by an external magnetic field. Firstly, the multi-layer drug-loaded MN patches consist of three delivered MN patches which are composed of a drug-loaded MN patch and polydimethylsiloxane layer. The drug-loaded MN patch is made of a 10% gelatin solution and a drug. The multi-layer MN patches are attached to a permanent magnet in a magnetically driven capsule. Under an external magnetic field generated by an electromagnetic actuation system, the capsule with the multi-layer MN patches can reach the target lesions, and each MN patch can be delivered to the target lesions for medical treatment. The active delivery of the multi-layer MN patches using the proposed magnetically driven capsule was confirmed via phantom experiments. Accordingly, the adhesion of the three separated faces of the multi-layer MN patches and the adhesion between the porcine small intestine and the MN patch were measured using a load cell. We demonstrate the feasibility of the active delivery of the multi-layer MN patches to the target lesions on a porcine small intestine. Consequently, we expect that the active delivery of the multi-layer drug-loaded MN patches using the magnetically driven capsule presented in this study can be a useful method for drug delivery to lesions at various locations in the gastrointestinal tract.
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Alruzug IM, Aldarsouny TA, Semaan T, Aldaher MK, AlMustafa A, Azzam N, Aljebreen A, Almadi MA. Time trends of causes of upper gastrointestinal bleeding and endoscopic findings. Saudi J Gastroenterol 2020; 27:28-34. [PMID: 33078720 PMCID: PMC8083243 DOI: 10.4103/sjg.sjg_378_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a frequent cause for emergency endoscopy and, in a proportion, requires the application of endotherapy. We aim to evaluate the proportion of variceal and nonvariceal upper gastrointestinal bleeding (NVUGIB), the endoscopic findings that were detected, as well as the temporal trends of endoscopic findings over a period of 13 years. METHODS This is a retrospective study of patients who underwent an esophagogastroduodenoscopy with an indication of UGIB or presented with hematemesis, melena, or both, as well as those who had hematochezia, from January 2004 to December 2016 (13 years). RESULTS A total of 2075 patients were included with a mean age of 56.8 years (range 18-113) and males constituted 67.9%, while 65.9% had at least one comorbidity. Symptoms on presentation included hematemesis (52.5%), melena (31.2%), both hematemesis & melena (15.1%), and hematochezia (1.2%). The majority of UGIB were from a NVUGIB source (80.5%) and a variceal source was found in 13.1%, while no endoscopic findings were found in 6.4% of cases. The most common endoscopic diagnosis was gastroduodenal erosions (23.8%), duodenal ulcers (23.5%), reflux esophagitis (16.0%), esophageal varices (12.1%), and gastric ulcers (10.8%). There was no change in the endoscopic findings over the time period of the study. A third of duodenal ulcers (33.3%) as well as 21.9% of gastric ulcers were actively bleeding at the time of endoscopy, while 3.3% of duodenal ulcers had an adherent clot. CONCLUSIONS NVUGIB composed the majority of cases presenting with UGIB and variceal bleeding was lower than that described in prior studies, but there were no clear trends in the proportion of causes of UGIB during the study duration.
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Affiliation(s)
| | | | - Toufic Semaan
- Department of Medicine, King Saud Medical City, Riyadh, Saudi Arabia
| | - Manhal K. Aldaher
- Department of Medicine, King Saud Medical City, Riyadh, Saudi Arabia
| | - Adnan AlMustafa
- Department of Medicine, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nahla Azzam
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Aljebreen
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A. Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada,Address for correspondence: Prof. Majid A. Almadi, Professor of Medicine and Consultant, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh 11451, Saudi Arabia. E-mail:
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23
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Almadi MA, Almutairdi A, Alruzug IM, Aldarsouny TA, Semaan T, Aldaher MK, AlMustafa A, Azzam N, Batwa F, Albawardy B, Aljebreen A. Upper gastrointestinal bleeding: Causes and patient outcomes. Saudi J Gastroenterol 2020; 27:20-27. [PMID: 33047678 PMCID: PMC8083248 DOI: 10.4103/sjg.sjg_297_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) remains a healthcare burden and is associated with considerable morbidity and mortality. We aim to describe the presentation, clinical, and laboratory characteristics of patients presenting with UGIB as well as important patient outcomes. METHODS This is a retrospective study performed at a tertiary care university hospital in Riyadh. Electronic endoscopic reports of patients undergoing gastroscopies for the indication of UGIB from January 2006 to January 2015 were included. Demographic data, past medical conditions, medications used, symptoms on presentation, as well as the patients' hemodynamic status, laboratory investigations on presentations, the need for blood products, the need for admission to an intensive care unit, rebleeding, and in-hospital mortality rates were retrieved from medical records. RESULTS Two hundred fifty-nine patients were included with a mean age of 57.1 years and males constituted 66.8% of the study cohort. At least one comorbidity was present in 88.2%, while 20.7% had a history of prior UGIB, 12.6% had a history of peptic ulcer disease, and 9.2% had known esophageal varices. A nonvariceal source represented 80.1% of the causes (95% CI: 75.4 to 85.3%), 15.5% required admission to the intensive care unit (ICU), the rebleeding rate was 8.9% (95% CI; 5.7% to 12.2%) while the in-hospital mortality was 4.4% (95% CI; 2.4% to 6.9%). The mean pre-endoscopic Rockall score was 2.6 (range: 0 to 5), while the total Rockall score was 4.4 (range: 1 to 9). There was no association between the pre-endoscopic Rockall score and rebleeding (3.0 vs. 2.5, P = 0.27) or need for ICU admission (3.2 vs. 2.4, P = 0.08), the total Rockall score and rebleeding (5.0 vs. 4.4, P = 0.58) or need for ICU admission (5.0 vs. 4.3, P = 0.36). CONCLUSION Causes of UGIB in this patient population were predominantly nonvariceal and the rebleeding and mortality rates resembled those of other studies.
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Affiliation(s)
- Majid A. Almadi
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Jeddah, Saudi Arabia,Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Abdulelah Almutairdi
- Gastroenterology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ibrahim M. Alruzug
- Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Thamer A. Aldarsouny
- Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Toufic Semaan
- Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Manhal K. Aldaher
- Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Adnan AlMustafa
- Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nahla Azzam
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Jeddah, Saudi Arabia
| | - Faisal Batwa
- Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Badr Albawardy
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, USA
| | - Abdulrahman Aljebreen
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Jeddah, Saudi Arabia,Address for correspondence: Prof. Abdulrahman Aljebreen, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. E-mail:
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. Guidelines for Nonvariceal Upper Gastrointestinal Bleeding. Gut Liver 2020; 14:560-570. [PMID: 32581203 PMCID: PMC7492499 DOI: 10.5009/gnl20154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Optimal Timing of Feeding After Endoscopic Hemostasis in Patients With Peptic Ulcer Bleeding: A Randomized, Noninferiority Trial (CRIS KCT0001019). Am J Gastroenterol 2020; 115:548-554. [PMID: 32205642 DOI: 10.14309/ajg.0000000000000584] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The optimal duration of fasting after endoscopic hemostasis in patients with peptic ulcer bleeding has not yet been determined. We investigated the appropriate timing of feeding after endoscopic hemostasis in patients with high-risk peptic ulcer bleeding. METHODS This study was a randomized, single center, noninferiority trial. Between February 2014 and March 2019, consecutive patients with peptic ulcer bleeding were randomized to resume feeding either 24 or 48 hours after successful endoscopic hemostasis. A total of 209 eligible patients were included in the intention-to-treat analysis and 200 in the per-protocol (PP) analysis. The primary outcome measure was recurrent bleeding within 7 days of hemostasis. Noninferiority testing was performed in the PP population, and the noninferiority margin was set at 10%. Secondary outcomes included 30-day rebleeding and mortality, transfusion requirements, and length of hospital stay. RESULTS Recurrent bleeding rates at 7 days were 7.9% in the 24-hour group and 4.0% in the 48-hour group in the PP analysis; tests for noninferiority did not reach statistical significance (difference: 3.9%, 95% confidence interval [CI]: -2.7 to 10.5, P value for noninferiority = 0.034). The recurrent bleeding rates within 30 days were 10.9% and 4.0% in the 24- and 48-hour groups (difference: 6.9%, 95% CI: -0.5 to 14.2), and the 30-day mortality rates were 5.9% and 14.1%, respectively (difference: -8.2%, 95% CI: -16.5 to 0.1) in the PP analysis. The transfusion requirement and the length of hospital stay were similar between the 2 groups. DISCUSSION Early refeeding at 24 hours after endoscopic hemostasis is not noninferior to later refeeding at 48 hours for rebleeding in patients with high-risk peptic ulcer bleeding. Our results do not allow a recommendation of refeeding at 24 hours, rather than later refeeding in this population.
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Laine L. Colonoscopy for Lower Gastrointestinal Bleeding-Time Is Not of the Essence. Gastroenterology 2020; 158:38-39. [PMID: 31730767 DOI: 10.1053/j.gastro.2019.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut and VA Connecticut Healthcare System, West Haven, Connecticut.
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Effectiveness of Opuntia ficus indica L. inermis Seed Oil in the Protection and the Healing of Experimentally Induced Gastric Mucosa Ulcer. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:1568720. [PMID: 31827668 PMCID: PMC6881774 DOI: 10.1155/2019/1568720] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
Gastric ulcer is a painful lesion of the gastric mucosa which can be disabling, or even more very serious in the case of a perforation of the stomach and internal hemorrhage. Traditional pharmacopeias have shown the efficacy of various plant extracts in the treatment of this pathology. Some extracts from Opuntia ficus indica (OFI) have been proven to have medicinal therapeutic benefits. The aim of this study was to investigate the preventive and curative effects of OFI seed oil extracted by cold pressing on an ethanol-induced gastric ulcer model in rats. Gastroprotective activities of the oil were assessed as pretreatments prior to ethanol gavage of Wistar rats compared to reference drugs. Two oil dose effects were tested. Ulcer and gastric parameters were measured (ulcerated areas (mm2), % of ulcer inhibition, gastric juice volume and pH, and mucus weight). Macroscopical and microscopical assessments of the stomachs as well as gastric biopsy histological studies were carried out. OFI oil exhibited a high efficiency in the protection of the cytoarchitecture and function of the gastric mucosa against the severe damages provoked by ethanol intake. Ulcerated areas were very significantly reduced and the % of ulcer inhibition was the highest under OFI oil pretreatment. Mucus production was stimulated, gastric juice volume was reduced, and its pH was increased. Histopathological examination of H&E-stained biopsies collected from gastric mucosae from the different experimental groups confirmed the gastroprotective efficacy of OFI oil against ethanol-induced symptoms such as inflammation and damages like bleeding, erosions, lesions, necrosis, and ulcers. Furthermore, OFI oil treatment speeded-up the reduction of the surface of ethanol-induced ulcerated areas in a dose-dependent manner, leading to a time gain in the healing process. The healing rate reached 91% on day 2 and 99% on day 3, and a complete heal was attained at the fourth day under OFI oil treatment, while ulcer areas were still partially unhealed in all the other groups. The therapeutic effects of OFI oil against gastric ulcer could be mediated by its varied bioactive compounds that we have demonstrated in the analytical study. They could act synergistically or in a delayed manner to optimize the healing process through protective antioxidant properties, as well as an antagonism against histamine H2-receptors, a stimulation of the signaling pathways necessary for mucus and bicarbonate production, and reduction of inflammatory processes in the gastric mucosa. Additionally, OFI oil fatty acids (especially unsaturated) and triacylglycerols contribute to the reconstruction and the repair of the cell membrane lipid bilayer during the gastric ulcer healing process.
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Vogt C, Allo G, Buerger M, Kasper P, Chon SH, Gillessen J, Goeser T, Schramm C. Assessing guideline adherence in patients with non-variceal upper gastrointestinal bleeding receiving antiplatelet and anticoagulant therapy. Scand J Gastroenterol 2019; 54:1357-1363. [PMID: 31718330 DOI: 10.1080/00365521.2019.1688384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background & aims: Non-variceal upper gastrointestinal bleeding (NVUGIB) occurs frequently and is associated with a significant morbidity and mortality, especially in patients receiving antiplatelet or anticoagulant therapy (APT and ACT, respectively). We aimed to evaluate adherence to guideline recommendations published by European Society of Gastrointestinal Endoscopy (ESGE).Methods: Retrospective analysis of patients with NVUGIB und prior exposition to APT or ACT at a single university hospital between 01 January 2016 and 31 December 2017.Results: 270 patients were identified (70.4% male, median age 72 years). 6/17 (35.3%) patients receiving APT for primary cardiovascular prophylaxis, 39/71 (54.9%) and 35 (49.3%) patients receiving APT for secondary cardiovascular prophylaxis (using strict and liberal definition, respectively) and 13/25 (52%) patients receiving dual antiplatelet therapy (DAPT) were not managed according to current recommendations. Management of ACT for secondary thromboembolic prophylaxis did not follow guideline recommendations in 59/93 (63.4%) and 34/93 (36.6%) patients (using strict and liberal definition, respectively). 23.7% of patients with NVUGIB were exposed to combined APT and ACT for whom no guideline recommendations exist. Mortality for any reason was twice as high in patients who were not managed according to guideline recommendations (18.8% vs. 8% using strict definition, 20.5% vs. 10.2% using liberal definition), which did not remain significant after adjusting for comorbidities, whereas cardiovascular events were observed at similar rates.Conclusion: A significant number of patients with NVUGIB receiving APT or ACT is not managed according to current ESGE guideline recommendations. Strategies to implement these guidelines into daily practice need to be developed.
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Affiliation(s)
- Carolin Vogt
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Buerger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Beyda R, Johari D. Tranexamic Acid for Upper Gastrointestinal Bleeding. Acad Emerg Med 2019; 26:1181-1182. [PMID: 31329328 DOI: 10.1111/acem.13835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Raymond Beyda
- Department of Emergency MedicineDownstate Medical Center& Kings County HospitalBrooklyn NY
| | - Davood Johari
- Department of Internal Medicine Division of Pulmonary and Critical Care State University of New YorkDownstate Medical Center& Kings County Hospital Brooklyn NY
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Kaminskis A, Ivanova P, Kratovska A, Ponomarjova S, Ptašņuka M, Demičevs J, Demičeva R, Boka V, Pupelis G. Endoscopic hemostasis followed by preventive transarterial embolization in high-risk patients with bleeding peptic ulcer: 5-year experience. World J Emerg Surg 2019; 14:45. [PMID: 31516544 PMCID: PMC6734378 DOI: 10.1186/s13017-019-0264-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease is one of the leading causes of death in patients with non-variceal bleeding, resulting in up to 10% mortality rate, and the patient group at high risk of rebleeding (Forrest IA, IB, and IIA) often requires additional therapy after endoscopic hemostasis. Preventive transarterial embolization (P-TAE) after endoscopic hemostasis was introduced in our institution in 2014. The aim of the study is an assessment of the intermediate results of P-TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high risk of rebleeding. Methods During the period from 2014 to 2018, a total of 399 patients referred to our institution with a bleeding peptic ulcer, classified as type Forrest IA, IB, or IIA with the Rockall score ≥ 5, after endoscopic hemostasis was prospectively included in two groups—P-TAE group and control group, where endoscopy alone (EA) was performed. The P-TAE patients underwent flow-reducing left gastric artery or gastroduodenal artery embolization according to the ulcer type. The rebleeding rate, complications, frequency of surgical interventions, transfused packed red blood cells (PRBC), amount of fresh frozen plasma (FFP), and mortality rate were analyzed. Results From 738 patients with a bleeding peptic ulcer, 399 were at high risk for rebleeding after endoscopic hemostasis. From this cohort, 58 patients underwent P-TAE, and 341 were allocated to the EA. A significantly lower rebleeding rate was observed in the P-TAE group, 3.4% vs. 16.2% in the EA group; p = 0.005. The need for surgical intervention reached 10.3% vs. 20.6% in the P-TAE and EA groups accordingly; p = 0.065. Patients that underwent P-TAE required less FFP, 1.3 unit vs. 2.6 units in EA; p = 0.0001. The mortality rate was similar in groups with a tendency to decrease in the P-TAE group, 5.7% vs. 8.5% in EA; p = 0.417. Conclusion P-TAE is a feasible and safe procedure, and it may reduce the rebleeding rate and the need for surgical intervention in patients with a bleeding peptic ulcer when the rebleeding risk remains high after primary endoscopic hemostasis.
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Affiliation(s)
| | | | - Aina Kratovska
- 1Riga East University Hospital, University of Latvia, Riga, Latvia
| | | | | | | | | | | | - Guntars Pupelis
- 1Riga East University Hospital, University of Latvia, Riga, Latvia.,2Riga Stradins University, Riga, Latvia
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Tsai SS, Chiu HF, Yang CY. Ambient Air Pollution and Hospital Admissions for Peptic Ulcers in Taipei: A Time-Stratified Case-Crossover Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16111916. [PMID: 31151209 PMCID: PMC6603676 DOI: 10.3390/ijerph16111916] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/23/2019] [Accepted: 05/26/2019] [Indexed: 01/19/2023]
Abstract
Very few studies have been performed to determine whether there is a relationship between air pollution and increases in hospitalizations for peptic ulcer, and for those that have occurred, their results may not be completely relevant to Taiwan, where the mixture of ambient air pollutants differ. We performed a time-stratified case-crossover study to investigate the possible association between air pollutant levels and hospital admissions for peptic ulcer in Taipei, Taiwan. To do this, we collected air pollution data from Taiwan's Environmental Protection Agency and hospital admissions for peptic ulcer data for the years 2009-2013 from Taiwan's National Health Insurance's research database. We used conditional logistic regression to analyze the possible association between the two, taking temperature and relative humidity into account. Risk was expressed as odds ratios and significance was expressed with 95% confidence intervals. In our single pollutant model, peptic ulcer admissions were significantly associated with all pollutants (PM10, PM2.5, SO2, NO2, CO, and O3) on warm days (>23 °C). On cool days (<23 °C), peptic ulcer admissions were significantly associated with PM10, NO2, and O3. In our two-pollutant models, peptic ulcer admissions were significantly associated NO2 and O3 when combined with each of the other pollutants on warm days, and with PM10, NO2, and O3 on cool days. It was concluded that the likelihood of peptic ulcer hospitalizations in Taipei rose significantly with increases in air pollutants during the study period.
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Affiliation(s)
- Shang-Shyue Tsai
- Department of Healthcare Administration, I-Shou University, Kaohsiung 82445, Taiwan.
| | - Hui-Fen Chiu
- Department of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan.
| | - Chun-Yuh Yang
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung 80708, Taiwan.
- National Institute of Environmental Health Sciences, National Health Research Institute, Miaoli 35053, Taiwan.
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Proton pump inhibitors for upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101609. [PMID: 31785730 DOI: 10.1016/j.bpg.2019.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/15/2019] [Indexed: 02/07/2023]
Abstract
Acute upper gastrointestinal bleeding (UGIB) remains a public health burden with a persistent high mortality despite advances in modern day management. Proton pump inhibitors (PPI) as medical therapy is an attractive adjuvant to endoscopic treatment in UGIB but the method and dose of PPI therapy remains controversial. This chapter aims to describe the current evidence addressing acute PPI use in the management of UGIB. It will explore the evidence behind the timing, the dosage and the mode of administration of PPI during initial UGIB management, prior to and immediately following endoscopy, as well as in the short-term following discharge.
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Abstract
Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
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Affiliation(s)
- Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
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Jung K, Moon W. Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World J Gastrointest Endosc 2019; 11:68-83. [PMID: 30788026 PMCID: PMC6379746 DOI: 10.4253/wjge.v11.i2.68] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/02/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.
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Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
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Siddique SM, Mehta SJ, Lewis JD, Neuman MD, Werner RM. Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities. Clin Gastroenterol Hepatol 2019; 17:90-97.e3. [PMID: 29704683 PMCID: PMC6347415 DOI: 10.1016/j.cgh.2018.04.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/26/2018] [Accepted: 04/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed to characterize heterogeneity in outcomes of subgroups of patients with gastrointestinal bleeding. METHODS We performed was a cross-sectional, claims-based retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding in 2014 (159,000 hospitalizations). The primary outcome was unplanned readmission within 30 days of discharge from the hospital (30-day readmission). Secondary outcomes included length of stay, inpatient mortality, and death within 30 days of admission to the hospital (30-day mortality). Analyses were adjusted for age, sex, race, and Elixhauser comorbidities using logistic and Poisson regression, adjusting for clustering within hospitals. RESULTS The 30-day readmission rate was 16.0%. Readmission rates varied among patients with different types of gastrointestinal bleeding, ranging from 13.5% for diverticular bleeding to 18.6% for small bowel bleeding. The mean length of stay was 4.2 days and 30-day mortality was 6.9% (ranging from 3.4% for diverticular bleeding to 12.1% for upper gastrointestinal bleeding not otherwise specified). When hospitalizations were stratified by MS-DRGs, the main source of variation in rates of readmission and mortality was MS-DRGs. CONCLUSIONS In a retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding, we found that 16% of these patients are readmitted to the hospital. Rates of hospital readmission, length of stay, and mortality vary with type of gastrointestinal bleeding, but MS-DRGs account for the largest source of variation. Policies focused on quality and value should account for this heterogeneity.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Shivan J Mehta
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mark D Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Schmidt A, Gölder S, Goetz M, Meining A, Lau J, von Delius S, Escher M, Hoffmann A, Wiest R, Messmann H, Kratt T, Walter B, Bettinger D, Caca K. Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers. Gastroenterology 2018; 155:674-686.e6. [PMID: 29803838 DOI: 10.1053/j.gastro.2018.05.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding. METHODS We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy. RESULTS Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints. CONCLUSIONS In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.
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Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany; Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Gölder
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Goetz
- Interdisciplinary Endoscopy, University of Tübingen, Tübingen, Germany
| | | | - James Lau
- Department of Surgery, University of Hong Kong, Hong Kong
| | - Stefan von Delius
- Department of Gastroenterology, Klinikum Rechts der Isar, TU München, München, Germany
| | - Markus Escher
- Department of Gastroenterology, Robert Bosch Krankenhaus Stuttgart, Stuttgart, Germany
| | - Arthur Hoffmann
- Department of Gastroenterology, Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Reiner Wiest
- Department of Gastroenterology, Inselspital Bern, Bern, Switzerland
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Thomas Kratt
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Benjamin Walter
- Department of Gastroenterology, University of Ulm, Ulm, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany.
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Kishi P, vanSonnenberg E, Stroker M. Life-Threatening Pancreatitis in Jehovah's Witness Patients With Severe Anemia Treated Without Transfusions and by Interventional Radiology Techniques. J Intensive Care Med 2018; 34:165-170. [PMID: 29902958 DOI: 10.1177/0885066618782161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood transfusions in anemic patients frequently are used for critically ill patients as a life-saving therapeutic maneuver. Jehovah's Witness (JW) patients typically refuse blood transfusions due to religious beliefs. Numerous clinical reports, in a wide spectrum of medical specialties, have shown no greater morbidity or mortality in JW patients or others who refused transfusions compared to those patients who accept transfusions. We report our experience with two JW patients who presented with severe anemia and life-threatening pancreatitis. Despite undergoing percutaneous drainages by interventional radiology (IR) for complex pancreatic collections (and other IR drainages), neither patient suffered any adverse effect from the IR procedures, even though they refused blood transfusions. Our experience suggests that IR procedures also may be successful with this more limited blood product protocol.
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Affiliation(s)
- Patrick Kishi
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.,Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Eric vanSonnenberg
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Misa Stroker
- St. Mary's Medical Center, Creighton University School of Medicine, San Francisco, CA, USA
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Misoprostol for small bowel ulcers in patients with obscure bleeding taking aspirin and non-steroidal anti-inflammatory drugs (MASTERS): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Gastroenterol Hepatol 2018; 3:469-476. [PMID: 29754836 DOI: 10.1016/s2468-1253(18)30119-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The incidence of obscure gastrointestinal bleeding, which originates from the small bowel and is mainly associated with the use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), is rising. We assessed the efficacy and safety of misoprostol for the treatment of small bowel ulcers and erosions in patients taking low-dose aspirin or NSAIDs with obscure gastrointestinal bleeding. METHODS mg/L, or positive faecal occult blood test) and normal upper endoscopy and colonoscopy. Patients were randomly assigned (1:1) using an interactive voice response system to receive 200 μg oral misoprostol or placebo four times daily for 8 weeks. Patients, investigators, and assessors were masked to treatment allocation. The primary endpoint was the complete healing of small bowel ulcers and erosions, assessed by video capsule endoscopy after 8 weeks of treatment. Primary analysis was by modified intention to treat, which included all randomised patients who received at least one dose of study treatment. Safety was assessed in the same population. The trial is registered with ClinicalTrials.gov, number NCT02202967. FINDINGS Between Jan 7, 2016, and Oct 11, 2017, we randomly allocated 104 eligible patients: 52 to receive misoprostol and 52 to receive placebo. Two patients allocated to misoprostol were later found to meet one of the exclusion criteria, thus 50 randomly assigned patients in the misoprostol group and 52 patients in the placebo group received at least one dose of study treatment. Complete healing of small bowel ulcers and erosions was noted at week 8 in 27 (54%) of 50 patients in the misoprostol group and nine (17%) of 52 patients in the placebo group (percentage difference 36·7%, 95% CI 19·5-53·9; p=0·0002). Adverse events occurred in 23 (46%) of 50 patients in the misoprostol group and 22 (42%) of 52 patients in the placebo group. The most common adverse events were abdominal pain (ten [20%] in the misoprostol group vs 13 [25%] in the placebo group), nausea or vomiting (nine [18%] vs seven [13%]), and diarrhoea (11 [22%] vs six [12%]). Four (8%) of 50 patients in the misoprostol group had severe adverse events, compared with none in the placebo group. No serious adverse events were reported. INTERPRETATION Misoprostol is effective for the treatment of small bowel ulcers and erosions in patients using low-dose aspirin and NSAIDs. Misoprostol might represent a pharmacological treatment option for lesions causing obscure gastrointestinal bleeding that is associated with aspirin and NSAIDs, but its use should be balanced against the risk of side-effects. FUNDING National Health Service (NHS) Greater Glasgow and Clyde and NHS Ayrshire and Arran.
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Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
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Triadafilopoulos G, Lewis D. Exposé: Different Faces of a Bleeding Giant Duodenal Ulcer. Dig Dis Sci 2018; 63:845-850. [PMID: 28871345 DOI: 10.1007/s10620-017-4736-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M-211, Stanford, CA, 94305, USA.
| | - David Lewis
- Internal Medicine, El Camino Hospital, Mountain View, CA, 94040, USA
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Lo GH, Reiberger T. Peptic ulcer bleeding in patients with cirrhosis: Is it as bad as variceal bleeding? Hepatology 2018; 67:1219-1220. [PMID: 29171065 DOI: 10.1002/hep.29680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, Division of Gastroenterology, Department of Medicine, E-DA Hospital, School of Medicine for international students, I-Shou University, Kaohsiung, Taiwan
| | - Thomas Reiberger
- Hepatic Hemodynamic Lab, Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Affiliation(s)
- Jeremy W Cannon
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and the F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD
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Kaminskis A, Ivanova P, Ponomarjova S, Mukans M, Boka V, Pupelis G. Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding. Gastroenterology Res 2018; 10:339-346. [PMID: 29317941 PMCID: PMC5755635 DOI: 10.14740/gr909w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/19/2017] [Indexed: 12/11/2022] Open
Abstract
Background Transarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Methods Out of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group). Results There were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly. Conclusion The Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.
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Affiliation(s)
- Aleksejs Kaminskis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Patricija Ivanova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Sanita Ponomarjova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradins University, Riga, Latvia
| | | | - Guntars Pupelis
- Surgical Department, Riga East University Hospital, Riga, Latvia
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"Weekend Effect" in Patients With Upper Gastrointestinal Hemorrhage: A Systematic Review and Meta-analysis. Am J Gastroenterol 2018; 113:13-21. [PMID: 29134968 DOI: 10.1038/ajg.2017.430] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 10/09/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES "Weekend effect" refers to worse outcomes among patients presenting to the hospital on weekends or holidays. We performed a systematic review and meta-analysis of observational studies assessing the impact of the "weekend effect" in patients with upper gastrointestinal hemorrhage (UGIH). METHODS We searched key bibliographic databases using keywords and MeSH terms related to gastrointestinal hemorrhage and "weekend effect". Our primary analysis evaluated mortality in patients with UGIH who were hospitalized on the weekend or after-hours compared with a weekday. Secondary outcomes included need for definitive therapy and length of hospital stay. Relevant data were extracted and meta-analyses were performed using random effects model. Subgroup sensitivity analyses were also performed to assess the effects of key variables. RESULTS A total of 21 of 224 identified studies met inclusion criteria. Overall, there was no association between weekend admission and mortality among patients with UGIH (Odds Ratio (OR): 1.06; 95% confidence interval (CI): 0.99-1.14). However, meta-analysis using only the nine studies that did not report having a weekend rounder showed a significant increase in mortality (OR: 1.12; 95% CI: 1.07-1.17). There was no effect of weekend admission on any of our secondary outcomes. CONCLUSIONS Current evidence suggests that weekend admission is associated with significant increase in mortality in patients with non-variceal UGIH but no difference in mortality was noted in patients with variceal UGIH. Our findings are relevant to policymakers, practitioners and providers who should ensure the creation of consistent quality and access to care throughout the week.
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Mearin F, Lanas Á, Bujanda L, Canelles P, Cotter J, Hervás A, Martín de Argila C, Montoro M, Gisbert JP. Open questions and misconceptions in the diagnosis and management of anemia in patients with gastrointestinal bleeding. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:63-76. [PMID: 29107389 DOI: 10.1016/j.gastrohep.2017.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/17/2017] [Accepted: 08/29/2017] [Indexed: 02/07/2023]
Abstract
Despite high prevalence of iron deficiency anemia (IDA) in patients with acute or chronic gastrointestinal bleeding (GIB), IDA and iron deficiency (ID) are frequently untreated. Reasons may be misconceptions about the impact and diagnosis of IDA and the efficacy of new treatments. Addressing these misconceptions, this article summarizes current evidence for better understanding and management of GIB-associated IDA. Despite only few controlled studies evaluated the efficacy of iron treatment in patients with GIB, there is consistent evidence suggesting that: (a) IDA should be diligently investigated, (b) effective treatment of ID/IDA improves outcomes such as health-related quality of life and can avoid severe cardiovascular consequences, and (c) intravenous iron should be considered as well-tolerated treatment in this setting. Overall, the misconceptions and practices outlined in this article should be replaced with strategies that are more in line with current guidelines and best practice in GIB and other underlying conditions of ID/IDA.
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Affiliation(s)
- Fermín Mearin
- Servicio de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - Ángel Lanas
- Servicio de Enfermedades Digestivas, Hospital Universitario, Universidad de Zaragoza, Instituto de Investigación Sanitaria Aragón (IIS Aragón), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Hospital Clínico Universitario, Zaragoza, España
| | - Luis Bujanda
- Departamento de Gastroenterología, Hospital Donostia/Instituto Biodonostia; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD); Universidad del País Vasco (UPV/EHU), San Sebastián, España
| | - Pilar Canelles
- Servicio de Patología Digestiva, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - José Cotter
- Departamento de Gastroenterología, Hospital da Senhora da Oliveira, Guimarães, Portugal; Instituto de Investigación en Ciencias de la Vida y la Salud (ICVS), Escuela de Ciencias de la Salud, Universidad de Minho, Portugal; ICVS/3B's, Laboratorio Asociado al Gobierno de Portugal, Braga/Guimarães, Portugal
| | - Antonio Hervás
- Servicio de Digestivo, Hospital Universitario Reina Sofía, Córdoba, España
| | - Carlos Martín de Argila
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España
| | - Miguel Montoro
- Departamento de Gastroenterología, Hospital General San Jorge, Huesca, España
| | - Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa e Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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Owczarek K, Lewandowska U. The Impact of Dietary Polyphenols on COX-2 Expression in Colorectal Cancer. Nutr Cancer 2017; 69:1105-1118. [PMID: 29068698 DOI: 10.1080/01635581.2017.1367940] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Polyphenols are natural compounds with high structural diversity whose common occurrence in plants renders them intrinsic dietary components. They are known to be secondary metabolites characterized by a wide spectrum of biological activities, and a growing body of evidence indicates they have anti-inflammatory potential. It is well known that inflammation plays a key role in many chronic diseases such as circulatory diseases, pulmonary diseases, autoimmune diseases, diabetes, cancer, and neurodegenerative diseases. Polyphenols influence the inflammatory process by controlling and inhibiting pro-inflammatory cytokines such as IL-1β, IL-6, IL-8, and TNF-α, and cyclooxygenase-2 (COX-2) enzyme involved in the metabolism of arachidonic acid. Furthermore, polyphenols exhibit anti-inflammatory activity on many levels via NF-κB inhibition, and MAPK, iNOS, and growth factors regulation. This paper reviews the current state of knowledge concerning the potential of various dietary polyphenols to inhibit the effects of COX-2 in colon cancer, by examining the available evidence regarding the efficacy and safety of these compounds obtained from in vitro and animal studies.
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Affiliation(s)
- Katarzyna Owczarek
- a Department of Biochemistry , Faculty of Medicine, Medical University of Lodz , Lodz , Poland
| | - Urszula Lewandowska
- a Department of Biochemistry , Faculty of Medicine, Medical University of Lodz , Lodz , Poland
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Tian L, Qiu H, Sun S, Tsang H, Chan KP, Leung WK. Association between emergency admission for peptic ulcer bleeding and air pollution: a case-crossover analysis in Hong Kong's elderly population. Lancet Planet Health 2017; 1:e74-e81. [PMID: 29851584 DOI: 10.1016/s2542-5196(17)30021-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/24/2017] [Accepted: 03/29/2017] [Indexed: 05/28/2023]
Abstract
BACKGROUND Air pollution increases intestinal permeability, alters the gut microbiome, and promotes inflammation, which might contribute towards gastrointestinal bleeding. In the present study, we aim to examine whether short-term elevations in air pollution are associated with increased numbers of emergency hospital admissions for peptic ulcer bleeding in Hong Kong. METHODS Daily air pollution (particulate matter with aerodynamic diameter less than 2·5 μm [PM2·5], nitric oxide [NO2], sulpher dioxide [SO2], and ozone [O3]) data during 2005-10 were collected from the Environmental Protection Department and emergency admission data for peptic ulcer bleeding in elderly people (aged 65 years or older) from the Hospital Authority of Hong Kong. A time stratified case-crossover analysis with conditional logistic regression was used to estimate the excess risk of peptic ulcer bleeding associated with each air pollutant, in single-pollutant and multi-pollutant models. Cardiorespiratory diseases were used as positive controls. FINDINGS 8566 emergency admissions for peptic ulcer bleeding were recorded among Hong Kong's elderly population during 2005-10; the daily number of admissions ranged from 0 to 13. An IQR increment of 5-day moving average (lag04) of NO2 concentration (25·8 μg/m3) was associated with a 7·6% (95% CI 2·2-13·2) increase in emergency admissions for peptic ulcer bleeding. Multi-pollutant models confirmed the robustness of the risk estimates for NO2. Other pollutants (PM2·5, SO2, and O3) were not associated with peptic ulcer bleeding admissions. INTERPRETATION Short-term elevation in ambient NO2 might trigger peptic ulcer bleeding events and increase the risk of emergency admissions for peptic ulcer bleeding in Hong Kong's elderly population. These findings strengthen the hypothesis that air pollution affects not just cardiopulmonary diseases, but also certain diseases of the digestive system. FUNDING None.
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Affiliation(s)
- Linwei Tian
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Hong Qiu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Shengzhi Sun
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Hilda Tsang
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - King-Pan Chan
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wai K Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Sengupta N, Tapper EB. Derivation and Internal Validation of a Clinical Prediction Tool for 30-Day Mortality in Lower Gastrointestinal Bleeding. Am J Med 2017; 130:601.e1-601.e8. [PMID: 28065767 DOI: 10.1016/j.amjmed.2016.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/09/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are limited data to predict which patients with lower gastrointestinal bleeding are at risk for adverse outcomes. We aimed to develop a clinical tool based on admission variables to predict 30-day mortality in lower gastrointestinal bleeding. METHODS We used a validated machine learning algorithm to identify adult patients hospitalized with lower gastrointestinal bleeding at an academic medical center between 2008 and 2015. The cohort was split randomly into derivation and validation cohorts. In the derivation cohort, we used multiple logistic regression on all candidate admission variables to create a prediction model for 30-day mortality, using area under the receiving operator characteristic curve and misclassification rate to estimate prediction accuracy. Regression coefficients were used to derive an integer score, and mortality risk associated with point totals was assessed. RESULTS In the derivation cohort (n = 4044), 8 variables were most associated with 30-day mortality: age, dementia, metastatic cancer, chronic kidney disease, chronic pulmonary disease, anticoagulant use, admission hematocrit, and albumin. The model yielded a misclassification rate of 0.06 and area under the curve of 0.81. The integer score ranged from -10 to 26 in the derivation cohort, with a misclassification rate of 0.11 and area under the curve of 0.74. In the validation cohort (n = 2060), the score had an area under the curve of 0.72 with a misclassification rate of 0.12. After dividing the score into 4 quartiles of risk, 30-day mortality in the derivation and validation sets was 3.6% and 4.4% in quartile 1, 4.9% and 7.3% in quartile 2, 9.9% and 9.1% in quartile 3, and 24% and 26% in quartile 4, respectively. CONCLUSIONS A clinical tool can be used to predict 30-day mortality in patients hospitalized with lower gastrointestinal bleeding.
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Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medical Center, Ill.
| | - Elliot B Tapper
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
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50
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Dovjak P. [Duodenal ulcers, gastric ulcers and Helicobacter pylori]. Z Gerontol Geriatr 2017; 50:159-169. [PMID: 28150170 DOI: 10.1007/s00391-017-1190-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 01/12/2017] [Accepted: 01/13/2017] [Indexed: 12/12/2022]
Abstract
The mortality in elderly patients over the age of 80 years with peptic ulcers in the case of complications, such as bleeding and perforation is higher than in the general population. Duodenal ulcers are associated with Helicobacter pylori infections in 90% of cases and in 70% of gastric ulcers. The treatment of elderly patients is often difficult due to multimorbidity and polypharmacy and necessitates a geriatric approach. Ulcers are often caused by medication with nonsteroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid. Despite the fact that progress in therapy has improved the prevalence and prognosis, the treatment of elderly patients with ulcers is complex.
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Affiliation(s)
- Peter Dovjak
- Abteilung für Akutgeriatrie und Remobilisation, Salzkammergut-Klinikum Gmunden, Miller-von- Aichholzstr. 49, 4810, Gmunden, Österreich.
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