Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases

Improved outcomes in patients with non-variceal upper gastrointestinal bleeding while undergoing antithrombotic therapy: A propensity score matching analysis

BACKGROUND

This study sought to examine the effect of antithrombotic use on clinical outcomes in non-variceal upper gastrointestinal bleeding (UGIB).

METHODS

Patients consecutively diagnosed with non-variceal UGIB between February 2019 and September 2020 were divided into two groups based on their antithrombotic use: users and non-users. Using propensity score matching (PSM) and multivariable regression analyses, the impact of antithrombotic use prior to UGIB presentation on clinical outcomes was examined.

RESULTS

In the entire cohort, there were 210 and 260 patients in the antithrombotic user and non-user groups, respectively. Using PSM analysis with seven covariates, two matched groups of 157 patients were created at a 1:1 ratio. In the matched cohort, despite their longer hospital stays and a higher rate of intensive care unit admissions, the patients in the user group had lower 30- and 90-day mortality rates (4.5% vs. 14.0 %; p = 0.003 and 8.9% vs. 18.5 %; p = 0.014, respectively). In the entire cohort, multivariable analyses adjusted for confounding factors revealed that antithrombotic use was associated with lower risks of in-hospital (adjusted OR: 0.437; 95 % CI: 0.191-0.999), 30-day (adjusted OR: 0.261; 95 % CI: 0.099-0.689), and 90-day (adjusted OR: 0.386; 95 % CI: 0.182-0.821) mortality.

CONCLUSION

Antithrombotic use prior to UGIB presentation was found to be an independent protective factor for all-cause mortality.

Similar Effect of Vonoprazan and Oral Proton Pump Inhibitors for Preventing Rebleeding in Cases of Upper Gastrointestinal Bleeding

Objective The use of a proton pump inhibitor (PPI) reduces rebleeding and mortality in patients with upper gastrointestinal bleeding (UGIB). Vonoprazan is a novel oral agent with strong and sustained acid-inhibitory activity. We clarified the effect of vonoprazan compared with oral PPIs in such patients. Methods We analyzed the Diagnosis Procedure Combination database. The primary outcome was rebleeding, and secondary outcomes were in-hospital mortality and in-hospital mortality after rebleeding. Propensity score matching was performed to balance the comparison groups, and logistic regression analyses were used to compare the outcomes between vonoprazan and oral PPIs. Patients Patients on vonoprazan or oral PPIs who underwent endoscopic hemostasis for UGIB between 2014 and 2019 were included. Results We enrolled 78,964 patients, of whom 27,101 and 51,863 were prescribed vonoprazan and a PPI, respectively. After propensity score matching, the rebleeding rate of vonoprazan did not significantly differ from that of oral PPIs [6.4% vs. 6.1%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.98-1.13]; similarly, the in-hospital mortality rate (1.4% vs. 1.5%; OR, 0.91; 95% CI, 0.79-1.05) and in-hospital mortality after rebleeding (0.3% vs. 0.2%; OR, 1.09; 95% CI, 0.78-1.54) also did not significantly differ between the groups. The acquired findings were robust across dose-restricted analyses and several sensitivity analyses. Conclusion Rebleeding and in-hospital mortality risks in patients on vonoprazan were similar to those in patients on oral PPIs. Considering the higher cost of vonoprazan, oral PPIs might be an optimal oral agent as an acid-suppressive therapy in such patients.

Nature and Clinical Outcomes of Acute Hemorrhagic Rectal Ulcer

Acute hemorrhagic rectal ulcer (AHRU) is a relatively rare disease that can lead to massive hematochezia. Although AHRU is a potentially life-threatening disease, its characteristics and clinical course are not fully understood. In this study, the clinical features were compared between AHRU and lower gastrointestinal bleeding (LGIB) from other causes (non-AHRU). Then, risk factors for all-cause in-hospital mortality in patients with AHRU were identified. A total of 387 consecutive adult patients with LGIB who were managed at two tertiary academic hospitals in Akita prefecture in Japan were retrospectively enrolled. Subjects were divided into AHRU and non-AHRU groups according to the source of bleeding. Regression analyses were used to investigate significant associations, and the results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). AHRU was found as the bleeding source in 72 (18.6%) of the patients. In comparison to non-AHRU, having AHRU was significantly associated with in-hospital onset, age > 65 years, and systolic blood pressure < 90 mmHg. The AHRU group had a significantly higher in-hospital mortality rate in comparison to the non-AHRU group (18.0% vs. 8.3, p = 0.02), and hypoalbuminemia (<2.5 g/dL) was significantly associated with in-hospital mortality in the AHRU group (OR, 4.04; 95%CI, 1.11−14.9; p = 0.03). AHRU accounts for a substantial portion (18.6%) of LGIB in our area, where the aging rate is the highest in Japan. Since AHRU is a potentially life-threatening disease that requires urgent identification and management, further studies to identify robust risk factors associated with serious clinical outcomes are required.

Nature and treatment outcomes of bleeding post-bulbar duodenal ulcers

BACKGROUND

Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs).

METHODS

Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses.

RESULTS

Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in-hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs.

CONCLUSION

This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location.

Usefulness of the CHAMPS score for risk stratification in lower gastrointestinal bleeding

We have recently developed a simple prediction score, the CHAMPS score, to predict in-hospital mortality in patients with upper gastrointestinal bleeding. In this study, the primary outcome of this study was the usefulness of the CHAMPS score for predicting in-hospital mortality with lower gastrointestinal bleeding (LGIB). Consecutive adult patients who were hospitalized with LGIB at two tertiary academic medical centers from 2015 to 2020 were retrospectively enrolled. The performance for predicting outcomes with CHAMPS score was assessed by a receiver operating characteristic curve analysis, and compared with four existing scores. In 387 patients enrolled in this study, 39 (10.1%) of whom died during the hospitalization. The CHAMPS score showed good performance in predicting in-hospital mortality in LGIB patients with an AUC (95% confidence interval) of 0.80 (0.73–0.87), which was significantly higher in comparison to the existing scores. The risk of in-hospital mortality as predicted by the CHAMPS score was shown: low risk (score ≤ 1), 1.8%; intermediate risk (score 2 or 3), 15.8%; and high risk (score ≥ 4), 37.1%. The CHAMPS score is useful for predicting in-hospital mortality in patients with LGIB.