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Long B, Gottlieb M. Emergency medicine updates: Lower gastrointestinal bleeding. Am J Emerg Med 2024; 81:62-68. [PMID: 38670052 DOI: 10.1016/j.ajem.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/26/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS An understanding of literature updates can improve the care of patients with LGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine Rush, University Medical Center, Chicago, IL, USA
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Komatsu T, Sato Y, Kuroki Y, Yoshida Y, Aoyama N, Iijima Y, Nakamoto Y, Kato M, Kiyokawa H, Tanabe K, Matsunaga K, Maehata T, Yasuda H, Matsumoto N, Tateishi K. Impact of the COVID-19 pandemic on the time to emergency endoscopy and clinical outcomes in patients with upper gastrointestinal bleeding. DEN OPEN 2024; 4:e310. [PMID: 37954400 PMCID: PMC10638502 DOI: 10.1002/deo2.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/27/2023] [Accepted: 10/21/2023] [Indexed: 11/14/2023]
Abstract
Objectives To investigate endoscopic management and clinical outcomes in patients with non-variceal upper gastrointestinal (GI) bleeding during the coronavirus disease 2019 pandemic. Methods We retrospectively analyzed the data of 332 patients with non-variceal upper GI bleeding who underwent emergency upper GI endoscopy at three hospitals during the pandemic (April 2020-June 2021) and before the pandemic (January 2019-March 2020). The number of emergency upper GI endoscopies, time from hospital arrival to endoscopy, mortality within 30 days, rebleeding within 30 days, interventional radiology (IVR)/surgery requirement, composite outcome, rates of endoscopic hemostasis procedures, and second-look endoscopy were investigated using logistic regression. Results Overall, 152 and 180 patients underwent emergency upper GI endoscopies during and before the pandemic, respectively. The mean time from arrival to endoscopy was longer during the pandemic than before it (11.7 vs. 6.1 h, p < 0.01). Multivariate analysis revealed that mortality within 30 days (odds ratio [OR]: 2.27, p = 0.26), rebleeding within 30 days (OR: 0.43, p = 0.17), IVR/surgery requirement (OR: 1.79, p = 0.33), and composite outcome (OR: 0.98, p = 0.96) did not differ significantly between the periods; conversely, endoscopic hemostasis procedures (OR: 0.38, p < 0.01) and second-look endoscopies (OR: 0.04, p < 0.01) were less likely to be performed during the pandemic than before it. Conclusions Although the time from arrival to endoscopy was significantly longer during the pandemic, it did not affect mortality and rebleeding.
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Affiliation(s)
- Takumi Komatsu
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
- Department of GastroenterologySt Marianna University School of Medicine, Yokohama Seibu HospitalKanagawaJapan
| | - Yoshinori Sato
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Yuichiro Kuroki
- Department of GastroenterologySt Marianna University School of Medicine, Yokohama Seibu HospitalKanagawaJapan
| | - Yoshihito Yoshida
- Department of GastroenterologySt Marianna University School of Medicine, Yokohama Seibu HospitalKanagawaJapan
| | - Natsumi Aoyama
- Department of GastroenterologyKawasaki Municipal Tama HospitalKanagawaJapan
| | - Yoshihiko Iijima
- Department of GastroenterologyKawasaki Municipal Tama HospitalKanagawaJapan
| | - Yusuke Nakamoto
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Masaki Kato
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Hirofumi Kiyokawa
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Kenichiro Tanabe
- Pathophysiology and BioregulationSt. Marianna University Graduate School of MedicineKanagawaJapan
| | - Koutaro Matsunaga
- Department of GastroenterologyKawasaki Municipal Tama HospitalKanagawaJapan
| | - Tadateru Maehata
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Hiroshi Yasuda
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
| | - Nobuyuki Matsumoto
- Department of GastroenterologySt Marianna University School of Medicine, Yokohama Seibu HospitalKanagawaJapan
| | - Keisuke Tateishi
- Department of GastroenterologySt Marianna University School of MedicineKanagawaJapan
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Alali AA, Almadi MA, Barkun AN. Review article: Advances in the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2024; 59:632-644. [PMID: 38158721 DOI: 10.1111/apt.17859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/15/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. AIMS To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. RESULTS The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. CONCLUSIONS The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.
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Affiliation(s)
- Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
| | - Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
- Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023; 118:208-231. [PMID: 36735555 DOI: 10.14309/ajg.0000000000002130] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.
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Montoro M, Cucala M, Lanas Á, Villanueva C, Hervás AJ, Alcedo J, Gisbert JP, Aisa ÁP, Bujanda L, Calvet X, Mearin F, Murcia Ó, Canelles P, García López S, Martín de Argila C, Planella M, Quintana M, Jericó C, García Erce JA. Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts. Front Med (Lausanne) 2022; 9:903739. [PMID: 36186804 PMCID: PMC9519983 DOI: 10.3389/fmed.2022.903739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.
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Affiliation(s)
- Miguel Montoro
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, Huesca, Spain
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS), Zaragoza, Spain
- *Correspondence: Miguel Montoro,
| | | | - Ángel Lanas
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS), Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Cándido Villanueva
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servei de Digestiu, Hospital de la Santa Creu y Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Antonio José Hervás
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - Javier Alcedo
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Javier P. Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Ángeles P. Aisa
- Servicio de Aparato Digestivo, Hospital Universitario Costa del Sol, Marbella, Spain
| | - Luis Bujanda
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Donostia, Donostia, Spain
- Instituto de Investigación Sanitaria Biodonostia, Universidad del País Vasco (UPV/EHU), Donostia, Spain
| | - Xavier Calvet
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servei de Digestiu, Corporació Sanitaria Park Taulí, Sabadell, Spain
- Department of Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Fermín Mearin
- Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, Spain
| | - Óscar Murcia
- Servicio de Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
| | - Pilar Canelles
- Servicio de Aparato Digestivo, Hospital General Universitario de Valencia, Valencia, Spain
| | - Santiago García López
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Montserrat Planella
- Servei de Digestiu, Hospital Universitario Arnau de Vilanova, Lleida, Spain
- Department of Medicine, Universidad de Lleida, Lleida, Spain
| | - Manuel Quintana
- Servicio a Medicina Intensiva, Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
- PBM Group, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Carlos Jericó
- Servicio de Medicina Interna, Complex Hospitalari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
| | - José Antonio García Erce
- PBM Group, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
- Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain
- Instituto Aragonés de Ciencias de la Salud, Universidad de Zaragoza, Zaragoza, Spain
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Almaghrabi M, Gandhi M, Guizzetti L, Iansavichene A, Yan B, Wilson A, Oakland K, Jairath V, Sey M. Comparison of Risk Scores for Lower Gastrointestinal Bleeding: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2214253. [PMID: 35622365 PMCID: PMC9142877 DOI: 10.1001/jamanetworkopen.2022.14253] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Clinical prediction models, or risk scores, can be used to risk stratify patients with lower gastrointestinal bleeding (LGIB), although the most discriminative score is unknown. OBJECTIVE To identify all LGIB risk scores available and compare their prognostic performance. DATA SOURCES A systematic search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1990, through August 31, 2021, was conducted. Non-English-language articles were excluded. STUDY SELECTION Observational and interventional studies deriving or validating an LGIB risk score for the prediction of a clinical outcome were included. Studies including patients younger than 16 years or limited to a specific patient population or a specific cause of bleeding were excluded. Two investigators independently screened the studies, and disagreements were resolved by consensus. DATA EXTRACTION AND SYNTHESIS Data were abstracted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline independently by 2 investigators and pooled using random-effects models. MAIN OUTCOMES AND MEASURES Summary diagnostic performance measures (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) determined a priori were calculated for each risk score and outcome combination. RESULTS A total of 3268 citations were identified, of which 9 studies encompassing 12 independent cohorts and 4 risk scores (Oakland, Strate, NOBLADS [nonsteroidal anti-inflammatory drug use, no diarrhea, no abdominal tenderness, blood pressure ≤100 mm Hg, antiplatelet drug use (nonaspirin), albumin <3.0 g/dL, disease score ≥2 (according to the Charlson Comorbidity Index), and syncope], and BLEED [ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, and unstable comorbid disease]) were included in the meta-analysis. For the prediction of safe discharge, the AUROC for the Oakland score was 0.86 (95% CI, 0.82-0.88). For major bleeding, the AUROC was 0.93 (95% CI, 0.90-0.95) for the Oakland score, 0.73 (95% CI, 0.69-0.77) for the Strate score, 0.58 (95% CI, 0.53-0.62) for the NOBLADS score, and 0.65 (95% CI, 0.61-0.69) for the BLEED score. For transfusion, the AUROC was 0.99 (95% CI, 0.98-1.00) for the Oakland score and 0.88 (95% CI, 0.85-0.90) for the NOBLADS score. For hemostasis, the AUROC was 0.36 (95% CI, 0.32-0.40) for the Oakland score, 0.82 (95% CI, 0.79-0.85) for the Strate score, and 0.24 (95% CI, 0.20-0.28) for the NOBLADS score. CONCLUSIONS AND RELEVANCE The Oakland score was the most discriminative LGIB risk score for predicting safe discharge, major bleeding, and need for transfusion, whereas the Strate score was best for predicting need for hemostasis. This study suggests that these scores can be used to predict outcomes from LGIB and guide clinical care accordingly.
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Affiliation(s)
- Majed Almaghrabi
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Mandark Gandhi
- Department of Medicine, Grand River Hospital, Kitchener, Ontario, Canada
| | | | - Alla Iansavichene
- Library Services, London Health Sciences Centre, London, Ontario, Canada
| | - Brian Yan
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Aze Wilson
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Kathryn Oakland
- Digestive Diseases Department, HCA Healthcare UK, London, United Kingdom
| | - Vipul Jairath
- Division of Gastroenterology, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Michael Sey
- Division of Gastroenterology, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
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Zhao Y, Jia L, Jia R, Han H, Feng C, Li X, Wei Z, Wang H, Zhang H, Pan S, Wang J, Guo X, Yu Z, Li X, Wang Z, Chen W, Li J, Li T. A New Time-Window Prediction Model For Traumatic Hemorrhagic Shock Based on Interpretable Machine Learning. Shock 2022; 57:48-56. [PMID: 34905530 PMCID: PMC8663521 DOI: 10.1097/shk.0000000000001842] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/26/2021] [Indexed: 12/29/2022]
Abstract
ABSTRACT Early warning prediction of traumatic hemorrhagic shock (THS) can greatly reduce patient mortality and morbidity. We aimed to develop and validate models with different stepped feature sets to predict THS in advance. From the PLA General Hospital Emergency Rescue Database and Medical Information Mart for Intensive Care III, we identified 604 and 1,614 patients, respectively. Two popular machine learning algorithms (i.e., extreme gradient boosting [XGBoost] and logistic regression) were applied. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of the models. By analyzing the feature importance based on XGBoost, we found that features in vital signs (VS), routine blood (RB), and blood gas analysis (BG) were the most relevant to THS (0.292, 0.249, and 0.225, respectively). Thus, the stepped relationships existing in them were revealed. Furthermore, the three stepped feature sets (i.e., VS, VS + RB, and VS + RB + sBG) were passed to the two machine learning algorithms to predict THS in the subsequent T hours (where T = 3, 2, 1, or 0.5), respectively. Results showed that the XGBoost model performance was significantly better than the logistic regression. The model using vital signs alone achieved good performance at the half-hour time window (AUROC = 0.935), and the performance was increased when laboratory results were added, especially when the time window was 1 h (AUROC = 0.950 and 0.968, respectively). These good-performing interpretable models demonstrated acceptable generalization ability in external validation, which could flexibly and rollingly predict THS T hours (where T = 0.5, 1) prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed THS prediction models.
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Affiliation(s)
- Yuzhuo Zhao
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lijing Jia
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ruiqi Jia
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Hui Han
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Cong Feng
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xueyan Li
- Management School, Beijing Union University, Beijing, China
| | | | - Hongxin Wang
- Department of Emergency, Armed Police Characteristic Medical Center, Tianjin, China
| | - Heng Zhang
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shuxiao Pan
- College of Computer Science and Artificial Intelligence, Wenzhou University
| | - Jiaming Wang
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Xin Guo
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zheyuan Yu
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Xiucheng Li
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Zhaohong Wang
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Wei Chen
- Department of Emergency, The Third Medical Center of Chinese PLA General Hospital, Beijing, China
- Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Jing Li
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Tanshi Li
- Department of Emergency, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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Milling TJ, Refaai MA, Sengupta N. Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines. Dig Dis Sci 2021; 66:3698-3714. [PMID: 33403486 PMCID: PMC9245141 DOI: 10.1007/s10620-020-06728-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). AIM To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. METHODS This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. RESULTS GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. CONCLUSIONS The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.
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Affiliation(s)
- Truman J. Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil Sengupta
- Section of Gastroenterology Hepatology and Nutrition, The University of Chicago, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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9
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Radaelli F, Frazzoni L, Repici A, Rondonotti E, Mussetto A, Feletti V, Spada C, Manes G, Segato S, Grassi E, Musso A, Di Giulio E, Coluccio C, Manno M, De Nucci G, Festa V, Di Leo A, Marini M, Ferraris L, Feliziani M, Amato A, Soriani P, Del Bono C, Paggi S, Hassan C, Fuccio L. Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study. Dig Liver Dis 2021; 53:1141-1147. [PMID: 33509737 DOI: 10.1016/j.dld.2021.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/02/2021] [Accepted: 01/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIM Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management. METHODS Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded. RESULTS Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients. CONCLUSION Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412].
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Affiliation(s)
| | | | - Alessandro Repici
- Istituto Clinico Humanitas, Humanitas Research Hospital, Rozzano, Italy
| | | | | | | | | | | | - Sergio Segato
- Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | - Alessandro Musso
- Città della Salute e della Scienza, Presidio Le Molinette, Torino, Italy
| | | | | | - Mauro Manno
- Azienda USL di Modena, Ospedale di Carpi e Mirandola, Italy
| | | | | | | | - Mario Marini
- Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luca Ferraris
- ASST Valle Olona, Presidio Ospedaliero di Gallarate, Italy
| | | | - Arnaldo Amato
- Gastroenterology Unit, Ospedale Valduce, Como, Italy
| | - Paola Soriani
- Azienda USL di Modena, Ospedale di Carpi e Mirandola, Italy
| | - Chiara Del Bono
- Policlinico Sant'Orsola Malpighi, Università di Bologna, Italy
| | - Silvia Paggi
- Gastroenterology Unit, Ospedale Valduce, Como, Italy
| | | | - Lorenzo Fuccio
- Policlinico Sant'Orsola Malpighi, Università di Bologna, Italy
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10
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Niikura R, Nagata N, Yamada A, Honda T, Hasatani K, Ishii N, Shiratori Y, Doyama H, Nishida T, Sumiyoshi T, Fujita T, Kiyotoki S, Yada T, Yamamoto K, Shinozaki T, Takata M, Mikami T, Mabe K, Hara K, Fujishiro M, Koike K. Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding. Gastroenterology 2020; 158:168-175.e6. [PMID: 31563627 DOI: 10.1053/j.gastro.2019.09.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). METHODS We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. RESULTS SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. CONCLUSIONS In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.
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Affiliation(s)
- Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan; Gastroenterological Endoscopy, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki-shi, Nagasaki, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui-shi, Fukui, Japan
| | - Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Ishikawa, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka-shi, Osaka, Japan
| | - Tetsuya Sumiyoshi
- Department of Gastroenterology, Tonan Hospital, Sapporo-shi, Hokkaido, Japan
| | - Tomoki Fujita
- Department of Gastroenterology, Otaru Ekisaikai Hospital, Otaru-shi, Hokkaido, Japan; Department of Gastroenterology, Sapporo Century Hospital, Sapporo-shi, Hokkaido, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai-shi, Yamaguchi, Japan
| | - Tomoyuki Yada
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine Kohnodai Hospital, Ichikawa-shi, Chiba, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka-shi, Osaka, Japan
| | - Tomohiro Shinozaki
- Department of Biostatistics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Shinjuku-ku, Tokyo, Japan
| | - Munenori Takata
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki-shi, Aomori, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate-shi, Hokkaido, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya-shi, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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12
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Affiliation(s)
- Ali S Taha
- Gastroenterology Unit, University Hospital Crosshouse & University of Glasgow, Scotland, UK.,Department of Medicine & Gastroenterology, Baylor College of Medicine, Houston, Texas.,Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, China
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13
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Kherad O, Jairath V. Editorial: blood transfusion for lower gastrointestinal bleeding-authors' reply. Aliment Pharmacol Ther 2019; 49:957. [PMID: 30868633 DOI: 10.1111/apt.15189] [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)
- Omar Kherad
- Department of Internal Medicine, La Tour Hospital and University of Geneva, Geneva, Switzerland
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