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Kerbage A, Hamadeh N, Hashash JG, Rockey D, Barada K. Overt gastrointestinal bleeding in patients with cancer: Clinical characteristics and outcomes. Am J Med Sci 2024; 368:346-354. [PMID: 38825073 DOI: 10.1016/j.amjms.2024.05.023] [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: 09/23/2023] [Revised: 04/22/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The aim of this study was to compare the clinical characteristics and outcomes of gastrointestinal bleeding (GIB) between cancer patients (CP) and non-cancer patients (NCP). METHODS This was a prospective study of patients admitted with overt GIB between 2013 and 2021. GIB etiology, management and outcomes including rebleeding and mortality, were compared between CP and NCP, and among patients with different types of cancer. The associations with categorical variables were assessed with the Chi-square test, and the t-test was used for continuous variables. RESULTS Of 674 patients admitted for GIB, 144 (21%) had cancer. 121(84%) CP had active disease, 49% had stage 4 cancer, and 78% had solid tumors, of whom 28 (20%) had luminal GI cancers. The most common were colorectal cancer, prostate cancer, and lymphomas. Compared to NCP, CP had higher age-adjusted Charlson Comorbidity Index, and were less likely to undergo endoscopy or endoscopic therapy. Severe GIB was equally prevalent in both groups, but CP had more severe anemia. Peptic ulcer was the most common etiology in both groups. Of 28 luminal cancer patients, 17(59%) bled from their tumors. Nine patients bled from cancer metastasis to the GI lumen. CP had higher in-hospital, one-month, one-year, and end-of-follow-up mortality. Length of hospital stay and re-bleeding rates did not differ between CP and NCP. CONCLUSIONS CP with GIB are less likely to have diagnostic and therapeutic endoscopy and have higher mortality than NCP. Steps to identify CP at risk for GIB and to improve their outcomes merit further investigation.
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Affiliation(s)
- Anthony Kerbage
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Najlaa Hamadeh
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Don Rockey
- Digestive Disease Research Center, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kassem Barada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Kavitt RT, Gralnek IM. Ideal strategy for nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol 2024; 40:342-347. [PMID: 38967918 DOI: 10.1097/mog.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology. RECENT FINDINGS Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities. SUMMARY This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.
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Affiliation(s)
- Robert T Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Deng F, Cao Y, Zhao S. Upper gastrointestinal haemorrhage patients' survival: A causal inference and prediction study. Eur J Clin Invest 2024; 54:e14180. [PMID: 38376066 DOI: 10.1111/eci.14180] [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: 07/23/2023] [Revised: 01/11/2024] [Accepted: 02/03/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding is a common medical emergency. This study aimed to develop models to predict critically ill patients with upper GI bleeding in-hospital and 30-day survival, identify the correlation factor and infer the causality. METHODS A total of 2898 patients with upper GI bleeding were included from the Medical Information Mart for Intensive Care-IV and eICU-Collaborative Research Database, respectively. To identify the most critical factors contributing to the prognostic model, we used SHAP (SHapley Additive exPlanations) for machine learning interpretability. We performed causal inference using inverse probability weighting for survival-associated prognostic factors. RESULTS The optimal model using the light GBM (gradient boosting algorithm) algorithm achieved an AUC of .93 for in-hospital survival, .81 for 30-day survival in internal testing and .87 for in-hospital survival in external testing. Important factors for in-hospital survival, according to SHAP, were SOFA (Sequential organ failure assessment score), GCS (Glasgow coma scale) motor score and length of stay in ICU (Intensive critical care). In contrast, essential factors for 30-day survival were SOFA, length of stay in ICU, total bilirubin and GCS verbal score. Our model showed improved performance compared to SOFA alone. CONCLUSIONS Our interpretable machine learning model for predicting in-hospital and 30-day mortality in critically ill patients with upper gastrointestinal bleeding showed excellent accuracy and high generalizability. This model can assist clinicians in managing these patients to improve the discrimination of high-risk patients.
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Affiliation(s)
- Fuxing Deng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Yaoyuan Cao
- Department of Forensic Medicine, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Shuangping Zhao
- Department of Intensive Critical Unit, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Butt N, Usmani MT, Mehak N, Mughal S, Qazi-Arisar FA, Mohiuddin G, Khan G. Risk factors and outcomes of peptic ulcer bleed in a Pakistani population: A single-center observational study. World J Gastrointest Pharmacol Ther 2024; 15:92305. [PMID: 38846968 PMCID: PMC11151881 DOI: 10.4292/wjgpt.v15.i3.92305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/24/2024] [Accepted: 05/20/2024] [Indexed: 05/27/2024] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) remains a significant healthcare burden, contributing to morbidity and mortality worldwide. Despite advancements in therapies, its prevalence persists, particularly in regions with widespread nonsteroidal anti-inflammatory drugs (NSAIDs) use and Helicobacter pylori infection. AIM To comprehensively analyse the risk factors and outcomes of PUD-related upper gastrointestinal (GI) bleeding in Pakistani population. METHODS This retrospective cohort study included 142 patients with peptic ulcer bleeding who underwent upper GI endoscopy from January to December 2022. Data on demographics, symptoms, length of stay, mortality, re-bleed, and Forrest classification was collected. RESULTS The mean age of patients was 53 years, and the majority was men (68.3%). Hematemesis (82.4%) and epigastric pain (75.4%) were the most common presenting symptoms. Most patients (73.2%) were discharged within five days. The mortality rates at one week and one month were 10.6% and 14.8%, respectively. Re-bleed within 24 h and seven days occurred in 14.1% and 18.3% of patients, respectively. Most ulcers were Forrest class (FC) III (72.5%). Antiplatelet use was associated with higher mortality at 7 and 30 d, while alternative medications were linked to higher 24-hour re-bleed rates. NSAID use was associated with more FC III ulcers. Re-bleed at 24 h and 7 d was strongly associated with one-week or one-month mortality. CONCLUSION Antiplatelet use and rebleeding increase the risk of early mortality in PUD-related upper GI bleeding, while alternative medicines are associated with early rebleeding.
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Affiliation(s)
- Nazish Butt
- Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi 75505, Sindh, Pakistan
| | - Muhammad Tayyab Usmani
- National Institute of Liver & GI Diseases, Dow University of Health Sciences, Karachi 75330, Sindh, Pakistan
| | - Nimrah Mehak
- Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi 75505, Sindh, Pakistan
| | - Saba Mughal
- School of Public Health, Dow University of Health Sciences, Karachi 75330, Sindh, Pakistan
| | - Fakhar Ali Qazi-Arisar
- National Institute of Liver & GI Diseases, Dow University of Health Sciences, Karachi 75330, Sindh, Pakistan
| | - Ghulam Mohiuddin
- Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi 75505, Sindh, Pakistan
| | - Gulzar Khan
- Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi 75505, Sindh, Pakistan
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5
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Acehan F, Karsavuranoğlu B, Aslan M, Kalkan C, Sahiner ES, Inan O, Comoglu M, Yilmaz Y, Ates I. Improved outcomes in patients with non-variceal upper gastrointestinal bleeding while undergoing antithrombotic therapy: A propensity score matching analysis. Dig Liver Dis 2024:S1590-8658(24)00741-2. [PMID: 38755023 DOI: 10.1016/j.dld.2024.04.038] [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: 10/27/2023] [Revised: 01/22/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
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.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey.
| | | | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, 06800, Turkey
| | - Enes Seyda Sahiner
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Osman Inan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Mustafa Comoglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Yusufcan Yilmaz
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
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Blanco Nodal I, Roales Gómez V, Olivares Quintanar D, Velasco Martínez E, Molina Tejedor S, Esteban López-Jamar JM, Rey Díaz-Rubio E. Coffee ground emesis and early endoscopy: Is timing actually relevant? GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:457-462. [PMID: 37806346 DOI: 10.1016/j.gastrohep.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Coffee ground vomiting is a classical symptom of upper gastrointestinal bleeding. However, the clinical usefulness is limited, due to the low positive predictive value. Our goal is to determine if whether an urgent endoscopy does modify our therapeutic management with a real impact on survival. PATIENTS AND METHODS It is a retrospective, observational and descriptive study. We selected all patients that underwent a gastroscopy in our center for coffee ground vomiting over the last 4 years (2017-2021). Two groups were established: urgent endoscopy (first 24h) and scheduled (over 24h). Then we studied differences between both groups regarding survival, ICU admission, hospitalization days and rebleeding. RESULTS Three hundred and fourteen patients were identified, from which 276 were included, with 176 belonging to the urgency group and 109 to the scheduled group. There were no differences in the ICU admission, hospitalization days, survival or rebleeding after 30 days. There were no differences either in the number of potentially bleeding lesions or the need of endoscopic therapeutic. CONCLUSIONS Coffee ground vomiting, without any other data supporting upper gastrointestinal bleeding, does not represent a reliable indicator. Performing urgent endoscopy is not beneficial in terms of morbimortality. Therefore, a more conservative strategy would allow to differ endoscopy, decreasing risks and reducing costs, without affecting the prognosis.
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Goodoory VC, Morris AJ, Veitch AM. Twitter debate: should upper gastrointestinal bleeding training and certification be formalised? Frontline Gastroenterol 2024; 15:258-260. [PMID: 38665791 PMCID: PMC11042463 DOI: 10.1136/flgastro-2023-102549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 04/28/2024] Open
Affiliation(s)
- Vivek Chand Goodoory
- Leeds Institute of Medical Research at St. James's, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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Sbeit W, Basheer M, Shahin A, Khoury S, Msheael B, Assy N, Khoury T. Clinical Predictors of Gastrointestinal Bleeding Source before Computed Tomography Angiography. J Clin Med 2023; 12:7696. [PMID: 38137765 PMCID: PMC10744149 DOI: 10.3390/jcm12247696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen. METHODS We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA. RESULTS We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB. CONCLUSIONS We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Maamoun Basheer
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Amir Shahin
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Sharbel Khoury
- Department of Radiology, Galilee Medical Center, Nahariya 221001, Israel; (S.K.); (B.M.)
| | - Botros Msheael
- Department of Radiology, Galilee Medical Center, Nahariya 221001, Israel; (S.K.); (B.M.)
| | - Nimer Assy
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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Zhuang Y, Xia S, Chen J, Ke J, Lin S, Lin Q, Tang X, Huang H, Zheng N, Wang Y, Chen F. Construction of a prediction model for rebleeding in patients with acute upper gastrointestinal bleeding. Eur J Med Res 2023; 28:351. [PMID: 37715244 PMCID: PMC10502990 DOI: 10.1186/s40001-023-01349-3] [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: 05/04/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The incidence of rebleeding in patients with upper gastrointestinal bleeding (UGIB) remains despite advances in intervention approaches. Therefore, early prediction of the risk of rebleeding could help to greatly reduce the mortality rate in these patients. We aim to develop and validate a new prediction model to predict the probability of rebleeding in patients with AUGIB. METHODS A total of 1170 AUGIB patients who completed the procedure of emergency gastroscopy within 48 h of admission were included. Logistic regression analyses were performed to construct a new prediction model. A receiver operating characteristic curve, a line graph, and a calibration and decision curve were used to assess the predictive performance of our new prediction model and compare its performance with that of the AIMS65 scoring system to determine the predictive value of our prediction model. RESULTS A new prediction model was constructed based on Lactic acid (LAC), neutrophil percentage (NEUTP), platelet (PLT), albumin (ALB), and D-DIMER. The AUC values and their 95% confidence interval (CI) for the new prediction model and the AIMS65 score were 0.746 and 0.619, respectively, and 0.697-0.795 and 0.567-0.670, respectively. In the training group, the C index values based on the prediction model and the AIMS65 scoring system were 0.720 and 0.610, respectively. In the validation group, the C index values based on the prediction model and the AIMS65 scoring system were 0.828 and 0.667, respectively. The decision and calibration curve analysis also showed that the prediction model was superior to the AIMS65 scoring system in terms of accuracy of prediction, consistency, and net clinical benefit. CONCLUSION The prediction model can predict the probability of rebleeding in AUGIB patients after endoscopic hemostasis therapy.
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Affiliation(s)
- Yangping Zhuang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Department of Emergency, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Shaohuai Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, Guilin, 541001, Guangxi, China
| | - Junwei Chen
- Department of Emergency, The Affiliated Hospital of Putian University, Putian, Fujian, China
| | - Jun Ke
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Shirong Lin
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Qingming Lin
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Xiahong Tang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Hanlin Huang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Nan Zheng
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Yi Wang
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Feng Chen
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China.
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Merza N, Masoud AT, Ahmed Z, Dahiya DS, Nawras A, Kobeissy A. Trends of Upper Gastrointestinal Bleeding Mortality in the United States Before and During the COVID-19 Era: Estimates From the Centers for Disease Control WONDER Database. Gastroenterology Res 2023; 16:165-170. [PMID: 37351079 PMCID: PMC10284642 DOI: 10.14740/gr1626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/13/2023] [Indexed: 06/24/2023] Open
Abstract
Background There have been reports of increased upper gastrointestinal bleeding (UGIB) in patients with coronavirus disease 2019 (COVID-19). Still, only a few studies have examined the mortality rate associated with UGIB in the United States before and during COVID-19. Hereby, we explored the trends of UGIB mortality in the United States before and during COVID-19. The study's objective was to investigate whether the COVID-19 pandemic significantly impacted UGIB mortality rates in the USA. Methods The decedents with UGIB were included. Age-standardized mortality rates were estimated with the indirect method using the 2000 US Census as the standard population. We utilized the deidentified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Linear regression analysis was performed to determine 2021 projected mortality rates based on trends between 2012 and 2019 to quantify the association of the pandemic with UGIB-related deaths. Results The mortality rate increased from 3.3 per 100,000 to 4.3 per 100,000 among the population between 2012 and 2021. There was a significant increase in the overall mortality rate between each year and the following year from 2012 to 2019, ranging from 0.1 to 0.2 per 100,000, while the rise in the overall mortality rate between each year and 2021 ranges from 0.4 to 0.9 per 100,000. Conclusions Our results showed that the mortality rate increased among the population between 2012and 2021, suggesting a possible influence of COVID-19 infection on the incidence and mortality of UGIB.
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Affiliation(s)
- Nooraldin Merza
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | | | - Zohaib Ahmed
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Abdallah Kobeissy
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
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11
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Hozman M, Hassouna S, Grochol L, Waldauf P, Hracek T, Pazdiorova BZ, Adamec S, Osmancik P. Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding. Eur Heart J Suppl 2023; 25:E25-E32. [PMID: 37234230 PMCID: PMC10206644 DOI: 10.1093/eurheartjsupp/suad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Hospital Karlovy Vary, 360 01 Karlovy Vary, Czech Republic
| | - Sabri Hassouna
- Cardiocenter, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Ruska 87, 100 00 Prague, Czech Republic
| | - Lukas Grochol
- 2nd Department of Internal Medicine, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady,100 00 Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | - Tomas Hracek
- Department of General Surgery, 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | | | - Stanislav Adamec
- Department of Gastroenterology, Hospital Cheb, 350 02 Cheb, Czech Republic
| | - Pavel Osmancik
- Corresponding author. Tel: 00420-721544447, Fax: 00420-267162817,
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12
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Kim SH. [Radiologic Diagnosis of Gastrointestinal Bleeding]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:520-535. [PMID: 37325008 PMCID: PMC10265251 DOI: 10.3348/jksr.2022.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/26/2023] [Accepted: 02/19/2023] [Indexed: 06/17/2023]
Abstract
Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.
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Admission care bundles for decompensated cirrhosis are poorly utilised across the UK: results from a multi-centre retrospective study. Clin Med (Lond) 2023; 23:193-200. [PMID: 37236796 PMCID: PMC11046546 DOI: 10.7861/clinmed.2022-0541] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Admission care bundles have been demonstrated to improve clinical outcomes for patients in several settings. Decompensated cirrhosis care bundles have been developed following previous reports demonstrating poor care for inpatients with alcohol-related liver disease (ARLD). We performed a UK multi-centred retrospective observational study to understand how frequently decompensated cirrhosis admission care bundles were utilised, who they were used for and their impact on outcomes. In this study (1,224 admissions, 104 hospitals), we demonstrated that admission care bundle usage was low across the UK (11.44%). They were more likely to be utilised in patients with ARLD or who were jaundiced, and less likely to be used in patients admitted for gastrointestinal bleeding. The admission care bundle improved the standard of alcohol care and requesting initial investigations. However, there were areas where more than 80% compliance was achieved without the use of a care bundle and areas where less than 50% compliance was achieved with the use of a care bundle. Given the low utilisation of care bundles, we were unable to demonstrate an effect on risk-adjusted mortality. Thus, interdisciplinary work is required to develop tools which are widely used and improve care and outcomes for patients with decompensated cirrhosis.
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Wu PH, Hung SK, Ko CA, Chang CP, Hsiao CT, Chung JY, Kou HW, Chen WH, Hsieh CH, Ku KH, Wu KH. Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department. Medicina (B Aires) 2023; 59:medicina59030556. [PMID: 36984556 PMCID: PMC10057917 DOI: 10.3390/medicina59030556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.
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Affiliation(s)
- Po-Han Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Shang-Kai Hung
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chien-An Ko
- Department of Otorhinolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Department of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei City 106, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Wan-Hsuan Chen
- Department of Pediatric, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chiao-Hsuan Hsieh
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Kai-Hsiang Ku
- Department of Emergency Medicine, Sijhih Cathay General Hospital, New Taipei City 221, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
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15
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Marmo R, Occhipinti V, Zullo A, Soncini M. Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study. J Clin Gastroenterol 2023; 57:278-284. [PMID: 35152241 DOI: 10.1097/mcg.0000000000001674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/04/2022] [Indexed: 12/10/2022]
Abstract
GOALS Aim of the study was to determine if patients with acute upper gastrointestinal bleeding (AUGIB) while on antithrombotic agents (ATs) are at higher risk for worse outcomes. BACKGROUND ATs are risk factors of AUGIB, but their impact on clinical outcomes is uncertain. STUDY Patients with AUGIB (nonvariceal, NV-AUGIB or variceal, V-AUGIB) in 50 Italian hospitals were prospectively enrolled from January 1, 2014 to December 31, 2015. Clinical data, laboratory tests, comorbidities, prognostic scores, received therapies, and outcomes (death, rebleeding, surgery/radiology, transfusions, length of hospitalization) were analyzed. RESULTS A total of 3324 patients (2764 NV-AUGIB, 83.2% and 560 V-AUGIB, 16.8%) were enrolled, 1399 (42.1%) on ATs. Patients taking ATs were older (75.4 vs. 62.8 y, P <0.001), had higher American Society of Anesthesiologists (ASA), Rockall and Glasgow-Blatchford scores ( P <0.001). At multivariate analysis considering comorbidities, ATs use resulted an independent protective factor against death [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.45-0.87, P =0.006]. Rebleeding (5.5% vs. 5.8%, P =0.71) and need for salvage surgery/radiology (4.2% vs. 4.8%, P =0.41) were similar in the 2 groups. Considering specific ATs, low-dose aspirin was the most powerful factor lowering the death risk (OR: 0.51, 95% CI: 0.33-0.81, P =0.004). While the generic use of AT therapy did not emerge as a statistically significant independent protective factor considering separately NV-AUGIB (OR: 0.80, 95% CI: 0.56-1.13, P =0.21) and V-AUGIB (OR: 0.40, 95% CI: 0.15-1.07, P =0.068), the protective effect of low-dose aspirin was confirmed for NV-AUGIB (OR: 0.62, 95% CI: 0.41-0.94, P =0.025). CONCLUSIONS ATs use is an independent protective factor against death in AUGIB. The protective effect is mainly derived from low-dose aspirin.
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Affiliation(s)
| | | | - Angelo Zullo
- Nuovo Regina Margherita Hospital, Gastroenterology and Digestive Endoscopy, Rome
| | - Marco Soncini
- Department of Internal Medicine, A. Manzoni Hospital, Lecco, Italy
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Marks I, Janmohamed IK, Malas S, Mavrou A, Banister T, Patel N, Ayaru L. Derivation and validation of a novel risk score to predict need for haemostatic intervention in acute upper gastrointestinal bleeding (London Haemostat Score). BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001008. [PMID: 36997237 PMCID: PMC10069503 DOI: 10.1136/bmjgast-2022-001008] [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: 08/08/2022] [Accepted: 02/09/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency, which takes up considerable healthcare resources. However, only approximately 20%-30% of bleeds require urgent haemostatic intervention. Current standard of care is for all patients admitted to hospital to undergo endoscopy within 24 hours for risk stratification, but this is difficult to achieve in practice, invasive and costly. AIM To develop a novel non-endoscopic risk stratification tool for AUGIB to predict the need for haemostatic intervention by endoscopic, radiological or surgical treatments. We compared this with the Glasgow-Blatchford Score (GBS). DESIGN Model development was carried out using a derivation (n=466) and prospectively collected validation cohort (n=404) of patients who were admitted with AUGIB to three large hospitals in London, UK (2015-2020). Univariable and multivariable logistic regression analysis was used to identify variables that were associated with increased or decreased chances of requiring haemostatic intervention. This model was converted into a risk scoring system, the London Haemostat Score (LHS). RESULTS The LHS was more accurate at predicting need for haemostatic intervention than the GBS, in the derivation cohort (area under the receiver operating curve (AUROC) 0.82; 95% CI 0.78 to 0.86 vs 0.72; 95% CI 0.67 to 0.77; p<0.001) and validation cohort (AUROC 0.80; 95% CI 0.75 to 0.85 vs 0.72; 95% CI 0.67 to 0.78; p<0.001). At cut-off scores at which LHS and GBS identified patients who required haemostatic intervention with 98% sensitivity, the specificity of the LHS was 41% vs 18% with the GBS (p<0.001). This could translate to 32% of inpatient endoscopies for AUGIB being avoided at a cost of only a 0.5% false negative rate. CONCLUSIONS The LHS is accurate at predicting the need for haemostatic intervention in AUGIB and could be used to identify a proportion of low-risk patients who can undergo delayed or outpatient endoscopy. Validation in other geographical settings is required before routine clinical use.
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Affiliation(s)
- Isobel Marks
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sadek Malas
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Athina Mavrou
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas Banister
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Nisha Patel
- Surgery and Cancer, Imperial College London, London, UK
| | - Lakshmana Ayaru
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
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Poszler A, Nguyen E, Braunisch MC, Rasch S, Abdelhafez M, Ulrich J, Wiessner J, Schmid RM, Lahmer T. Identification of risk factors for upper gastrointestinal bleeding in intensive care unit patients (GIBICU study). Scand J Gastroenterol 2022; 57:1417-1422. [PMID: 35771587 DOI: 10.1080/00365521.2022.2089860] [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: 02/04/2023]
Abstract
BACKGROUND AND GOALS Risk stratification for the need for therapeutic endoscopy and prediction of mortality in patients with upper gastrointestinal bleeding (UGIB) can be assessed by several scores. However, current scores are not validated for variceal bleeding and Intensive Care Unit (ICU) patients. The aim of this study was to evaluate potential parameters for the prediction of UGIB and patient outcomes. PATIENTS AND STUDY METHODS In this monocenter retrospective observational study, data from all esophagogastroduodenoscopies (EGD) between November 2014 and February 2020 with suspected hemorrhage in our ICU were evaluated. RESULTS Out of 345 included EGD, 42.3% of UGIB was diagnosed. 51.9% needed endoscopic intervention. Overall, 52.3% of included patients with UGIB died. Logistic regression showed that preceding variceal or non-variceal UGIB (p < .001), serum lactate (p = .001), heart rate (HR) (p = .005), and blood transfusions (p = .001) were significant predictors of UGIB. Previous UGIB (p < .001), male sex (p = .015), known varices (p < .001), serum albumin (p = .19) and use of catecholamines (p = .040) were significant predictors for the need of endoscopic intervention. Higher mortality was significantly associated with the usage of steroids (p < .001), malignant preconditions (p = .021), serum albumin (p = .020) and prolonged PTT (partial thromboplastin time) (p = .001). CONCLUSIONS We were able to identify additional parameters that had previously not been included in existing scores to predict the risk of UGIB, the need for therapeutic endoscopy and mortality in ICU patients. Therefore, an extension of these scores is necessary. Further validation of identified parameters in multicenter trials is needed to improve risk scores for ICU patients.
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Affiliation(s)
- Alexander Poszler
- Department of Gastroenterology, Krankenhaus Agatharied, Hausham, Germany
| | - Evelyn Nguyen
- Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Christoph Braunisch
- Klinikum Rechts der Isar, Department of Nephrology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sebastian Rasch
- Klinikum Rechts der Isar, Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Mohamed Abdelhafez
- Klinikum Rechts der Isar, Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jörg Ulrich
- Klinikum Rechts der Isar, Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Wiessner
- Department of Gastroenterology and Hepatology Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Roland M Schmid
- Klinikum Rechts der Isar, Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Lahmer
- Klinikum Rechts der Isar, Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
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Analysis of the patients with nonvariceal upper gastrointestinal bleeding and comparison of Rockall and Glasgow-Blatchford scores. Indian J Gastroenterol 2022; 41:576-582. [PMID: 36571703 DOI: 10.1007/s12664-022-01290-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 07/31/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (UGB) has important morbidity and mortality. Predicting high-risk patients for mortality and rebleeding is necessary for a treatment plan. In the present study, we aimed to define the epidemiological and etiological characteristics of patients presenting with nonvariceal UGB and to observe mortality and morbidity rates. We also aimed to compare Rockall and Glasgow-Blatchford scoring systems in predicting rebleeding and mortality. METHODS Subjects presenting with nonvariceal UGB over a 3-year period were included. Demographic characteristics, symptoms, and signs on physical examination, laboratory data, endoscopic signs and diagnosis, interventions during hospitalization and follow-up period were recorded. Glasgow-Blatchford and Rockall scores were calculated for every participant at the first day of the admission. RESULTS A total of 709 patients were enrolled in the study. A total of 490 of them (69.1%) were men. The mean age of the women and men was 60.7±1.2 and 58.6± 0.7 years, respectively. Melena was the most common presenting symptom. Duodenal ulcer (31%), gastric ulcer (20.7%), and erosive disease (17.6%) were the most common causes of bleeding. History of use of aspirin and/or nonsteroidal anti-inflammatory drug use were present in 63.7% of the subjects. All patients were followed up for 30th-day mortality. Overall, rebleeding and mortality rates were 11% and 7%, respectively. A Rockall score greater than 6 was the most important predictor of mortality (odds ratio:39.1) and rebleeding (odds ratio:4.7). CONCLUSION Nonvariceal UGB patients with a Rockall score greater than 6 should undergo aggressive endoscopic treatment and inpatient care.
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19
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Kudu E, Danış F, Danis F. The Evolution of Gastrointestinal Bleeding: A Holistic Investigation of Global Outputs with Bibliometric Analysis. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2022; 33:1012-1024. [PMID: 36510400 PMCID: PMC9797799 DOI: 10.5152/tjg.2022.22007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal bleeding is one of the main presentations in emergency department admissions. Although there has been much improvement in prevention, diagnosis, and treatment recently, patients with GIB still have high morbidity and mortality. This study aimed to analyze the scientific articles on gastrointestinal bleeding published between 1980 and 2020 using statistical and bibliometric methods. METHODS Articles about gastrointestinal bleeding published between 1980 and 2020 were downloaded using the Web of Science data base and analyzed using statistical methods. Network visualization maps were used to identify trending topics. Correlation studies were evaluated using Spearman's correlation coefficient. Nonlinear regression analysis (exponential model) was used to estimate the number of articles in future years. RESULTS A total of 12 568 publications about gastrointestinal bleeding were found. Forty percent (n = 5033) of these publications were articles. The top 3 contributing countries to the literature were the United States of America (1646, 32.7%), the United Kingdom (433, 9%), and Germany (391, 7.7%). The top three journals with the most publications were Gastrointestinal Endoscopy (172), American Journal of Gastroenterology (165), and Digestive Diseases and Sciences (161). The effect of countries' gross domestic product levels on article productivity on gastrointestinal bleeding was significant (r = 0. 770, P < .001). CONCLUSION In this comprehensive study, a summary of 5033 articles was presented. We think that these detailed analyses will be a quick source to show the past, present, and future of this subject to those who are currently working on gastrointestinal bleeding.
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Affiliation(s)
- Emre Kudu
- Department of Emergency Medicine, Marmara University Pendik Education and Research Hospital, İstanbul, Turkey,Corresponding author: Emre Kudu, e-mail:
| | - Faruk Danış
- Department of Emergency Medicine, Bolu İzzet Baysal Training and Research Hospital, Bolu, Turkey
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20
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Laursen SB, Stanley AJ, Laine L, Schaffalitzky de Muckadell OB. Rebleeding in peptic ulcer bleeding - a nationwide cohort study of 19,537 patients. Scand J Gastroenterol 2022; 57:1423-1429. [PMID: 35853234 DOI: 10.1080/00365521.2022.2098050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rebleeding is a frequent complication of peptic ulcer bleeding (PUB). The associated prognosis remains rather unclear because previous studies generally also included non-ulcer lesions. OBJECTIVE We aimed to identify predictors for rebleeding; clarify the prognostic consequence of rebleeding; and develop a score for predicting rebleeding. METHODS Nationwide cohort study of consecutive patients presenting to hospital with PUB in Denmark from 2006-2014. Logistic regression analyses were used to identify predictors for rebleeding, evaluate the association between rebleeding and 30-day mortality, and develop a score to predict rebleeding. Patients with persistent bleeding were excluded. RESULTS Among 19,258 patients (mean age 74 years, mean ASA-score 2.4), 10.8% rebled, and 10.2% died. Strongest predictors for rebleeding were endoscopic high-risk stigmata of bleeding (Odds Ratio (OR): 2.12 [95% Confidence Interval (CI): 1.91-2.36]), bleeding from duodenal ulcers (OR: 1.87 [95% CI: 1.69-2.08]), and presentation with hemodynamic instability (OR: 1.55 [95% CI: 1.38-1.73]). Among patients with all three factors (7.9% of total), 24% rebled, 50% with rebleeding failed endoscopic therapy, and 23% died. Rebleeding was associated with increased mortality (OR: 2.04 [95% CI: 1.78-2.32]). We were unable to develop an accurate score to predict rebleeding. CONCLUSION Rebleeding occurs in ∼10% of patients with PUB and is overall associated with a two-fold increase in 30-day mortality. Patients with hemodynamic instability, duodenal ulcers, and high-risk endoscopic stigmata are at highest risk of rebleeding. When rebleeding occurs in such patients, consultation with surgery and/or interventional radiology should be obtained prior to repeat endoscopy.
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Affiliation(s)
- Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Adrian J Stanley
- Department of Gastroenterology, Walton Building, Glasgow Royal Infirmary, Glasgow, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ove B Schaffalitzky de Muckadell
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
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Zhu W, Chen L, Zhang J, Wang P. Effects of high-dose versus low-dose proton pump inhibitors for treatment of gastrointestinal ulcer bleeding: a meta-analysis of randomized controlled trials. J Int Med Res 2022; 50:3000605211067396. [PMID: 35414289 PMCID: PMC9014724 DOI: 10.1177/03000605211067396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background We performed a meta-analysis to compare the effects of high-dose (80 mg/day) versus low-dose (40 mg/day) proton pump inhibitors (PPIs) on gastrointestinal ulcer bleeding. Methods We retrieved studies of randomized controlled trials of PPIs administered according to different schedules for the treatment of gastrointestinal ulcer bleeding from Medline, Embase, Web of Science, Clinical Trials, and the Cochrane Database in April 2020. Results Nine randomized controlled trials including 2329 patients were included in this meta-analysis. There were no significant differences in the incidences of re-bleeding, operation intervention, postoperative mortality, and length of hospital stay between the low-dose and high-dose groups. However, the blood transfusion volume was significantly higher in the high-dose group. Conclusion Compared with low-does PPIs, high-dose PPIs had no effect on the incidence of re-bleeding, operation intervention, or postoperative mortality, and did not reduce hospital stay in patients treated with endoscopic hemostasis for gastrointestinal bleeding.
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Affiliation(s)
- Wei Zhu
- Department of Gastrointestinal Vascular Pediatric Surgery, Dongfeng General Hospital of National Medicine, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Liang Chen
- Department of Gastrointestinal Surgery, Affiliated Huadu Hospital of Southern Medical University (People's Hospital of Huadu District), Guangzhou, Guangdong, P.R. China
| | - Jian Zhang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Pei Wang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
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Randomized controlled trial of early endoscopy for upper gastrointestinal bleeding in acute coronary syndrome patients. Sci Rep 2022; 12:5798. [PMID: 35388113 PMCID: PMC8986851 DOI: 10.1038/s41598-022-09911-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/30/2022] [Indexed: 12/14/2022] Open
Abstract
Acute upper gastrointestinal bleeding (UGIB) in acute coronary syndrome (ACS) patients are not uncommon, particularly under dual antiplatelet therapy (DAPT). The efficiency and safety of early endoscopy (EE) for UGIB in these patients needs to be elucidated. This multicenter randomized controlled trial randomized recent ACS patients presenting acute UGIB to non-EE and EE groups. All eligible patients received intravenous proton pump inhibitor therapy. Those in EE group underwent therapeutic endoscopy within 24 h after bleeding. The data regarding efficacy and safety of EE were analyzed. It was early terminated because the UGIB rate was lower than expected and interim analysis was done. In total, 43 patients were randomized to non-EE (21 patients) and EE (22 patients) groups. The failure rate of control hemorrhage (intention-to-treat [ITT] 4.55% vs. 23.81%, p < 0.001; per-protocol [PP] 0% vs. 4.55%, p = 0.058) and 3-day rebleeding rate (ITT 4.55% vs. 28.57%, p = 0.033; PP 0% vs. 21.05%, p = 0.027) were lower in EE than non-EE group. The mortality, minor and major complication rates were not different between two groups. Male patients were at higher risk of minor and major complications after EE with OR (95% CI) of 3.50 (1.15–10.63) and 4.25 (1.43–12.63), respectively. In multivariate analysis, EE was associated with lower needs for blood transfusion (HR 0.13, 95% CI 0.02–0.98). Among patients who discontinued DAPT during acute UGIB, a higher risk (OR 5.25, 95% CI 1.21–22.74) of coronary artery stent re-thrombosis within 6 months was noticed. EE for acute UGIB in recent ACS patients has higher rate of bleeding control, lower 3-day rebleeding rate and lower needs for blood transfusion, but more complications in male patients. Further enrollment is mandatory to avoid bias from small sample size (ClinicalTrial.gov Number NCT02618980, registration date 02/12/2015).
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Ting KH, Shiu BH, Yang SF, Liao PL, Huang JY, Chen YY, Yeh CB. Risk of Mortality among Patients with Gastrointestinal Bleeding with Early and Late Treatment with Tranexamic Acid: A Population-Based Cohort Study. J Clin Med 2022; 11:jcm11061741. [PMID: 35330064 PMCID: PMC8951209 DOI: 10.3390/jcm11061741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic pharmacological agent, but its use in gastrointestinal bleeding remains contentious. Moreover, studies on the timing of TXA administration are limited. We examined whether early TXA administration reduced the risk of mortality in patients with gastrointestinal bleeding in a Taiwanese population. We used the National Health Insurance Research Database to identify patients diagnosed with gastrointestinal bleeding with early and late TXA treatment. We defined early treatment as initial TXA treatment in an emergency department and late treatment as initial TXA treatment after hospitalization. Mortality within 52 weeks was the primary outcome. A multivariable analysis using a multiple Cox regression model was applied for data analysis. Propensity score matching (PSM) was performed to reduce the potential for bias caused by measured confounding variables. Of the 52,949 selected patients with gastrointestinal bleeding, 5127 were assigned to either an early or late TXA treatment group after PSM. The incidence of mortality was significantly decreased during the first and fourth weeks (adjusted HR (aHR): 0.65, 95% CI: 0.56−0.75). A Kaplan−Meier curve revealed a significant decrease in cumulative incidence of mortality in the early TXA treatment group (log-rank test: p < 0.0001). Multiple Cox regression analysis revealed significantly lower mortality in the early TXA treatment group compared with the late treatment group (aHR: 0.64, 95% CI: 0.57−0.73). Thromboembolic events were not significantly associated with early or late TXA treatment (aHR: 1.03, 95% CI: 0.94−1.12). A Kaplan−Meier curve also revealed no significant difference in either venous or arterial events (log-rank test: p = 0.3654 and 0.0975, respectively). In conclusion, early TXA treatment was associated with a reduced risk of mortality in patients with gastrointestinal bleeding compared with late treatment, without an increase in thromboembolic events. The risk of rebleeding and need for urgent endoscopic intervention require further randomized clinical trials.
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Affiliation(s)
- Ke-Hsin Ting
- Division of Cardiology, Department of Internal Medicine, Changhua Christian Hospital, Yunlin Branch, Yunlin 648, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
| | - Bei-Hao Shiu
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Pei-Lun Liao
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yin-Yang Chen
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
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Ágústsson AS, Ingason AB, Rumba E, Pálsson D, Reynisson IE, Hreinsson JP, Björnsson ES. Causes of gastrointestinal bleeding in oral anticoagulant users compared to non-users in a population-based study. Scand J Gastroenterol 2022; 57:239-245. [PMID: 34749581 DOI: 10.1080/00365521.2021.1998600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Causes of gastrointestinal bleeding (GIB) in patients on oral anticoagulants (OACs) are not well established. The aims of the study were to compare the causes of GIB in patients on OACs and those not on OAC therapy. METHODS A nationwide study of all GIB events in patients on OACs in Iceland from 2014-2019 was conducted. Bleeding events were obtained through ICD-10 codes and review of endoscopy databases, confirmed by review of medical records. For comparison, patients not on OACs from previous Icelandic population-based studies were used. RESULTS Among 752 GIB events in 12,005 patients on OACs, 273 (1.9%) had verified upper and 391 (2.7%) had verified lower GIB. For lower GIB, multivariate analysis showed that OAC users were more likely to have colonic polyps (OR 6.6, 95% CI: 2.4 - 17.8, p < .001) or colorectal cancer (OR 3.7, 95% CI: 2.0 - 7.0, p < .001) but less likely to have ischemic colitis (OR 0.11, 95% CI: 0.04 - 0.26, p < .001). For upper GIB, bleeding from mucosal erosions (OR 4.0 95% CI: 2.5 - 7.9, p < .001) and angiodysplasia (OR 3.6, 95%CI: 1.5 - 8.6, p = .003) were more common in OAC users. CONCLUSIONS A high proportion of GIB caused by colonic polyps and colorectal cancer among OAC patients indicates that OACs treatment may facilitate cancer diagnosis. The low proportion of ischemic colitis among those on OACs suggests that OACs provide a protective effect against ischemic colitis. OACs seem to increase the bleeding from angiodysplasia and mucosal erosive disease.
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Affiliation(s)
- Arnar S Ágústsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Arnar B Ingason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Daníel Pálsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Jóhann P Hreinsson
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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25
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Haigh SM. Managing a patient presenting to the emergency department with upper gastrointestinal bleeding. Emerg Nurse 2022; 30:17-23. [PMID: 35076189 DOI: 10.7748/en.2022.e2120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 11/09/2022]
Abstract
Upper gastrointestinal (GI) bleeding is a common presentation in emergency departments (EDs). This medical emergency has a mortality rate of up to 14%, particularly in men and older people. The most frequent cause of upper GI bleeding is peptic ulcer disease. Management has not changed significantly in the past 50 years and there is ongoing debate in the literature about the most effective treatment protocols. This article uses a case study of a patient who presented to an ED with upper GI bleeding caused by peptic ulcer disease to examine the evidence on treatment and management. The article also discusses a care bundle that has been developed for rapid assessment and management of patients with acute upper GI bleeding.
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Affiliation(s)
- Sandra Michelle Haigh
- emergency department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, England
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26
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Siebenhüner K, Blaser J, Nowak A, Cheetham M, Mueller BU, Battegay E, Beeler PE. Comorbidities Associated with Worse Outcomes Among Inpatients Admitted for Acute Gastrointestinal Bleeding. Dig Dis Sci 2022; 67:3938-3947. [PMID: 34365536 PMCID: PMC8349143 DOI: 10.1007/s10620-021-07197-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 07/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multimorbidity increases healthcare resource utilization. Little is known on specific comorbidity combinations. AIMS To identify comorbidities associated with increased resource utilization among inpatients admitted for gastrointestinal bleeding (GIB). METHODS This retrospective cross-sectional study, 1/2010-5/2018 at the University Hospital Zurich, Switzerland, analyzed electronic health records of patients with upper (UGIB) and lower (LGIB) GIB, focusing on length of stay (LOS) and 30-day readmissions for resource use and clinical outcomes, investigated by multivariable regression adjusted for antithrombotics. RESULTS Of 1101 patients, 791 had UGIB and 310 LGIB, most often melena and bleeding diverticula, respectively. In UGIB, thromboembolic events showed a trend toward 27% increased LOS (1.27; 95% confidence interval [CI] 1.00-1.61), antithrombotics independently associated with 46% increased LOS (1.46; 95% CI 1.32-1.62). Cancer (odds ratio [OR] 2.86; 95% CI 1.68-4.88) independently associated with 30-day readmissions, anemia showed a trend (OR 1.68; 95% CI 1.00-2.84). In LGIB, none of the investigated comorbidities associated with increased LOS, but antithrombotics independently associated with 25% increased LOS (1.25; 95% CI 1.07-1.46). Atrial fibrillation/flutter (OR 2.69; 95% CI 1.06-6.82) and cancer (OR 4.76; 95% CI 1.40-16.20) associated strongly with 30-day readmissions. CONCLUSIONS In both groups, cancer associated with 30-day readmissions, antithrombotics with increased LOS. Thromboembolic events and anemia showed clinically important trends in UGIB. Atrial fibrillation/flutter associated with 30-day readmissions in LGIB. Prospective studies are needed to investigate these complex multimorbid populations and establish appropriate guidelines.
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Affiliation(s)
- K. Siebenhüner
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland ,Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland ,Centre of Competence Multimorbidity, University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - J. Blaser
- Directorate of Research and Education, University Hospital of Zurich, Zurich, Switzerland
| | - A. Nowak
- Department of Endocrinology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, Psychiatry University Hospital Zurich, Zurich, Switzerland
| | - M. Cheetham
- Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - B. U. Mueller
- Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - E. Battegay
- Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland ,Centre of Competence Multimorbidity, University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - P. E. Beeler
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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27
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Lin WY, Hong MY, Lin CH, Chang PP, Chu SC, Kao CL. Association of ABO Blood Type with Bleeding Severity in Patients with Acute Gastroesophageal Variceal Bleeding. Medicina (B Aires) 2021; 57:medicina57121323. [PMID: 34946268 PMCID: PMC8707329 DOI: 10.3390/medicina57121323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: ABO blood types have been implicated as potential risk factors for various hemorrhagic diseases. No study has investigated the association between gastroesophageal variceal bleeding and ABO blood types. We aimed to evaluate the impact of ABO blood types on mortality and bleeding risk in acute gastroesophageal variceal bleeding. Materials and Methods: This is a retrospective observational study. Patients presenting with acute gastroesophageal varices bleeding diagnosed by endoscopy were enrolled, and were divided by blood type into a type O group and non-type O group. The outcomes were death within 30 days and the proportion of further bleeding. We used generalized linear mixed-effects models to analyze the outcomes. Results: A total of 327 patients and 648 records of emergency room visits were included. The 30-day mortality was 14.8% (21 of 142 patients) in the type O group, and 16.2% (30 of 185 patients) in the non-type O group (p = 0.532). Further bleeding within 30 days occurred in 34 cases (12.6%) in the type O group, and in 26 cases (6.9%) in the non-type O group (p = 0.539). Conclusions: There was no significant difference in blood transfusion volume in 24 h, recurrent bleeding rates, or mortality between patients with blood type O and those with non-type O.
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Affiliation(s)
- Wei-Yu Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
- Department of Emergency Medicine, Ministry of Health and Welfare Tainan Hospital, Tainan 70403, Taiwan
| | - Ming-Yuan Hong
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
| | - Peng-Peng Chang
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
| | - Shao-Chung Chu
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
| | - Chia-Lung Kao
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (W.-Y.L.); (M.-Y.H.); (C.-H.L.); (P.-P.C.); (S.-C.C.)
- Correspondence: ; Tel.: +886-6-2353535-2237
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28
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Rees J, Evison F, Mytton J, Patel P, Trudgill N. The outcomes of emergency hospital admissions with non-malignant upper gastrointestinal bleeding in England between 2003 and 2015. Endoscopy 2021; 53:1210-1218. [PMID: 33601430 DOI: 10.1055/a-1330-7118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant mortality. Despite developments in endoscopic and clinical management, only minor improvements in outcomes have been reported. METHODS This was a retrospective cohort study of patients with non-malignant UGIB emergency admissions in England between 2003 and 2015, using Hospital Episode Statistics. Multilevel logistic regression analysis examined the associations with mortality. RESULTS 242 796 patients with an UGIB admission were identified (58.8 % men; median age 70 [interquartile range (IQR) 53 - 81]). Between 2003 and 2015, falls occurred in both 30-day mortality (7.5 % to 7.0 %; P < 0.001) and age-standardized mortality (odds ratio (OR) 0.74, 95 % confidence interval [CI] 0.69 - 0.80; P < 0.001), including from variceal bleeding (OR 0.63, 95 %CI 0.45 - 0.87; P < 0.005). Increasing co-morbidity (Charlson score > 5, OR 2.94, 95 %CI 2.85 - 3.04; P < 0.001), older age (> 83 years, OR 6.50, 95 %CI 6.09 - 6.94; P < 0.001), variceal bleeding (OR 2.03, 95 %CI 1.89 - 2.18; P < 0.001), and a weekend admission (Sunday, OR 1.18, 95 %CI 1.12 - 1.23; P < 0.001) were associated with 30-day mortality. Of deaths at 30 days, 8.9 % were from ischemic heart disease (IHD) and the cardiovascular age-standardized mortality rate following UGIB was high (IHD deaths within 1 year, 1188.4 [95 %CI 1036.8 - 1353.8] per 100 000 men in 2003). CONCLUSIONS Between 2003 and 2015, 30-day mortality among emergency admissions with non-malignant UGIB fell by 0.5 % to 7.0 %. Mortality was higher among UGIB admissions at the weekend, with important implications for service provision. Patients with UGIB had a much greater risk of subsequently dying from cardiovascular disease and addressing this risk is a key management step in UGIB.
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Affiliation(s)
- James Rees
- Department of Gastroenterology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jemma Mytton
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Prashant Patel
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell & West Birmingham NHS Trust, West Bromwich, UK
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29
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GEDİK MS, HAKKOYMAZ H, KİLCİ Aİ, GÜLER Ö, SOLAK Y. XXXXXXX ÜNİVERSİTESİ TIP FAKÜLTESİ ACİL SERVİSİNE AKUT ÜST GASTROİNTESTİNAL SİSTEM KANAMASI İLE BAŞVURAN HASTALARIN ANALİZİ. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.1012667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç
Gastrointestinal sistem kanamalar hastanelerde acil serviste sıkça karşılaşılan ve hayatı tehdit etme potansiyeli yüksek olan bir sağlık sorunudur. Acil servisimize başvuran ve üst gastrointestinal sistem kanama tanısı alan hastalardaki etiyolojik sebepleri, klinik bulguları, endoskopik bulguları ve prognozu belirlemek için bu çalışmayı planladık.
Materyal ve Metod
Üst gastrointestinal sistem kanaması nedeniyle XXXXXX Hastanesi Acil Servisi’ne başvuran hastaların dosyaları retrospektif olarak incelendi. Çalışmaya alınan 31 hastanın demografik verileri, klinik özellikleri, etiyolojik sebepleri, laboratuvar ve endoskopi sonuçları incelendi. İstatistiksel değerlendirmede Student t ve Oneway ANOVA testi ve SPSS 20.0 paket programı kullanıldı. İstatistiksel olarak p
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Affiliation(s)
| | | | | | - Özlem GÜLER
- KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNİVERSİTESİ, TIP FAKÜLTESİ
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30
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [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: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Ak R, Hökenek NM. Comparison of AIMS65 and Glasgow Blatchford scores in predicting mortality in patients with upper gastrointestinal bleeding. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2021; 67:766-770. [PMID: 34550270 DOI: 10.1590/1806-9282.20210580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/27/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Several mortality prediction scores are available for patients with upper gastrointestinal bleeding who visited the emergency department; however, most of the available scores include endoscopic data. Endoscopy is difficult or impossible to access for many emergencies departments worldwide. The aim of this study was to evaluate and compare the performance of the albumin, INR, alteration in mental status, systolic blood pressure and age 65 score and the Glasgow-Blatchford score in predicting mortality in patients with upper gastrointestinal bleeding who visited the emergency department and for which endoscopic data were not required. METHODS The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were retrospectively analyzed. The data were obtained from the hospital automation system using the international classification of disease codes via computer registration. The prediction accuracy of AIMS65 and Glasgow-Blatchford score was compared using the area under the receiver operating characteristic curve method. RESULTS There were 422 patients in total; the mean age of these patients was 68.5 while 62.6% were males. The mortality rate was 30 (7.1%). The AIMS65 score performed better with an AUC 0.706 [95%CI 0.660-0.749; p<0.001] compared with the Glasgow-Blatchford score (AUC 0.542; 95%CI 0.4693-0.576; p=0.11). CONCLUSION In this study, it was revealed that AIMS65, which is a score that can be easily calculated only with the data in the emergency department, outperformed Glasgow-Blatchford score in predicting mortality in patients with acute upper gastrointestinal bleeding who visited the emergency department.
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Affiliation(s)
- Rohat Ak
- Istanbul Kartal Dr. Lutfi Kirdar City Hospital, Department of Emergency Medicine - Istanbul, Turkey
| | - Nihat Müjdat Hökenek
- Kartal Dr. Lütfi Kırdar City Hospital, Department of Emergency Medicine - Istanbul, Turkey
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Kwack WG. Clinical outcomes of esophagogastroduodenoscopy in critically ill patients using high-dose proton pump inhibitor for suspected bleeding: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e27028. [PMID: 34449479 PMCID: PMC8389866 DOI: 10.1097/md.0000000000027028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 08/07/2021] [Indexed: 01/04/2023] Open
Abstract
Esophagogastroduodenoscopy (EGD) is a useful procedure performed for gastrointestinal (GI) bleeding. No definite clinical guidelines recommend EGD implementation in intensive care unit (ICU) patients with suspected GI bleeding. The objective of this study was to compare the clinical effectiveness of EGD in critically ill patients who are using high-dose proton pump inhibitor (PPI) for suspected GI bleeding.We retrospectively analyzed ICU patients using high-dose PPI for suspected GI bleeding from January 2012 to September 2020. Major cases of GI bleeding, such as those with hematemesis and hematochezia, were excluded, and 1:1 propensity score matching was performed. The change in hemoglobin level, requirement of red blood cell transfusion, re-suspected bleeding event, length of ICU stay, and ICU mortality were compared between the EGD and non-EGD groups.Of the 174 subjects included, 52 patients underwent EGD within 24 hours of PPI administration. In the EGD group, 22 (42.3%) patients showed normal findings, while esophagitis and gastritis were most common abnormal finding (n = 11, 21.2%), and 14 patients (26.9%) underwent a hemostatic procedure. While comparing the 2 groups, the EGD group required a higher amount of red blood cell transfusion (packs) than the non-EGD group for a week (3.04 ± 0.44 vs 2.07 ± 0.25, P = .01). There was no significant difference in the change in hemoglobin level after 1 week (P = .15). After propensity score matching, the EGD group showed similar the requirement of red blood cell transfusion and change in hemoglobin level for a week (P = .52, P = .97, respectively). In analyses for all patients and propensity score matched patients, there was no statistically significant difference in term of re-suspected bleeding event rate, duration of ICU stay, and ICU mortality. However, re-suspected bleeding event rate and ICU mortality were lower trend in the EGD group than the non-EGD group.This study showed that EGD had no definite clinical benefit in ICU patients using high-dose PPI for suspected GI bleeding and aggressive EGD is not necessarily recommended. However, it is necessary to consider EGD in patients who are tolerant.
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Ejtehadi F, Sivandzadeh GR, Hormati A, Ahmadpour S, Niknam R, Pezeshki Modares M. Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review. Middle East J Dig Dis 2021; 13:177-185. [PMID: 36606214 PMCID: PMC9489462 DOI: 10.34172/mejdd.2021.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/02/2021] [Indexed: 01/07/2023] Open
Abstract
Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.
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Affiliation(s)
- Fardad Ejtehadi
- Associate Professor of Medicine, Gastroentrohepatology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholam Reza Sivandzadeh
- Assistant Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
,Corresponding Author: Gholam Reza Sivandzadeh, MD Department of Internal Medicine, Gasteroenetrohepatology Research Center, Department of Internal Medicine, School of Medicine, Shiraz University of Medical Sciences, Namazi Hospital, Zand St., Shiraz, 7193711351, Fars, Iran. Tel: + 98 711 6473236 Fax: + 98 711 6474316
| | - Ahmad Hormati
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sajjad Ahmadpour
- Assistant Professor of Radiopharmacy, Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Ramin Niknam
- Associate Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Pezeshki Modares
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
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Scherdin Y, Halldestam I, Redeen S. Incidence and Mortality Related to Gastrointestinal Bleeding, and the Effect of Tranexamic Acid on Gastrointestinal Bleeding. Gastroenterology Res 2021; 14:165-172. [PMID: 34267831 PMCID: PMC8256901 DOI: 10.14740/gr1383] [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] [Received: 03/30/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022] Open
Abstract
Background Gastrointestinal bleeding is a common and potentially life-threatening condition. The incidence of gastrointestinal bleeding has not decreased despite new prophylaxis and treatments. Ulcer is still one of the most common etiologies for upper gastrointestinal bleeding. It is routinely treated with proton pump inhibitors (PPIs) and endoscopic interventions, sometimes endovascular procedures, and rarely today, open surgery with suture to stop the bleeding. The fibrinolytic tranexamic acid (TXA) has a role in bleeding treatment, and is routinely used for example within trauma care, postpartum bleeding and orthopedic surgery. The aim of this study is to assess the incidence of gastrointestinal bleeding. A further aim was to investigate if TXA has any role in medical treatment of gastrointestinal bleeding today. Methods We performed a retrospective cohort study with a review of medical records, involving patients with clinical signs of gastrointestinal bleeding and endoscopically verified ulcers between the years of 2010 and 2016 at the University Hospital of Linkoping, Sweden. The cities of Motala and Linkoping have the primary acute admissions at this Hospital. Results We found in total 1,331 patients with gastrointestinal bleeding. The overall incidence for patients with gastrointestinal bleeding was 98.6 (98.6/100,000 inhabitants and year). For those with endoscopically verified ulcer (386 patients), the incidence for peptic ulcer was 28.6/100,000/year. In the group with endoscopically verified ulcer, 25 patients died, giving the 30-day mortality of 6.4%. TXA is still used for treatment of bleeding ulcers. We had two groups, those with and without TXA treatment. They were equal in age, gender and comorbidity. Clinically we saw no major differences in respect to hemodynamic stability. There were more patients with overt bleeding symptoms in the TXA group. We also saw more patients in need of intensive care in the TXA group. Conclusions The incidence of gastrointestinal bleeding has not significantly decreased during the last years. There was no significant positive effect of TXA in patients with upper gastrointestinal bleeding in this study. The difference between the two groups is probably more a question of whom we treat with TXA (e.g., the patients in worse condition or at higher risk) than a difference in drug effect. It is time to quit with TXA treatment in all patients with gastrointestinal bleeding, even those at intensive care unit (ICU).
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Affiliation(s)
- Ylva Scherdin
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
| | - Ingvar Halldestam
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
| | - Stefan Redeen
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
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Chue KM, Boey JY, Ng BSM, Teh JL, Kim G, Shabbir A, Chan YH, Hartman M, So JBY. Admission discipline and timing of admission may influence outcomes for gastrointestinal bleeding patients. ANZ J Surg 2021; 91:1832-1840. [PMID: 33982881 DOI: 10.1111/ans.16873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 03/27/2021] [Accepted: 04/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bleeding of the gastrointestinal tract (BGIT) is a common gastrointestinal emergency. There is no consensus whether this condition should be admitted to medical or surgical discipline. Timing of presentation may also impact patient outcomes due to differences in healthcare resource availability. This study thus aims to investigate the impact of admitting discipline and timing of admission on patient outcomes in BGIT. METHODS A 2-year tertiary institution database was retrospectively reviewed. Outcome measures included 30-day mortality, 30-day readmissions and rebleeding requiring repeat endoscopic, angiographic or surgical interventions. Secondary outcome measures included time to endoscopy, percutaneous angiographic interventions and surgery. The effect of admission discipline (medical versus surgical) and time of admission (office-hours versus after office-hours) were analysed using a propensity-score-adjusted estimate. RESULTS A total of 1384 patients were included for analysis, medical (n = 853), surgical (n = 530); during office-hours (n = 785) and after office-hours (n = 595). After propensity-score-adjusted analysis, no significant differences in mortality or readmissions were noted between medical or surgical admissions. Patients admitted under surgery were less likely to sustain rebleeding (P = 0.004) for lower BGIT and had an earlier time to endoscopy for upper BGIT (P = 0.04). Patients admitted after office-hours had similar outcomes with those admitted during office hours apart from a delay in time to endoscopy (P = 0.02). CONCLUSION For BGIT patients, admission to a surgical discipline compared to a medical discipline appeared to have at least equivalent patient outcomes. Patients presenting with BGIT after office-hours were more likely to experience a delay to endoscopy, although it did not affect patient mortality.
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Affiliation(s)
- Koy Min Chue
- Department of Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore
| | | | - Bridget Si Min Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jun Liang Teh
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Guowei Kim
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Hospital, National University Health System, Singapore.,Division of Surgical Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Asim Shabbir
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Hospital, National University Health System, Singapore.,Division of Surgical Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mikael Hartman
- Department of Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jimmy Bok Yan So
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Hospital, National University Health System, Singapore.,Division of Surgical Oncology, National University Cancer Institute, National University Health System, Singapore
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36
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Laursen SB, Oakland K, Laine L, Bieber V, Marmo R, Redondo-Cerezo E, Dalton HR, Ngu J, Schultz M, Soncini M, Gralnek I, Jairath V, Murray IA, Stanley AJ. ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study. Gut 2021; 70:707-716. [PMID: 32723845 DOI: 10.1136/gutjnl-2019-320002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Existing scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB. DESIGN AND SETTING International cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score's performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk. PARTICIPANTS AND RESULTS We included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81-84) than existing scores (AUROCs: 0.65-0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4-7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p<0.001). In LGIB, patients with low, medium and high ABC scores had in-hospital mortality rates of 0.6%, 6.3% and 18%, respectively. CONCLUSIONS In contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.
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Affiliation(s)
- Stig Borbjerg Laursen
- Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare UK, London, UK
| | - Loren Laine
- Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Vered Bieber
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Riccardo Marmo
- Gastroenterology Unit, Azienda Sanitaria Locale Salerno, Polla Sa, Italy
| | - Eduardo Redondo-Cerezo
- Department of Gastroenterology, University Hospital Centre Virgen de las Nieves, Granada, Spain
| | - Harry R Dalton
- Gastroenterology Unit, Royal Cornwall Hospital, Truro, UK
| | - Jeffrey Ngu
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Michael Schultz
- Department of Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand.,Gastroenterology Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Marco Soncini
- Department of Internal Medicine, Alessandro Manzoni Hospital, Lecco, Italy
| | - Ian Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Vipul Jairath
- Department of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Iain A Murray
- Gastroenterology Unit, Royal Cornwall Hospital, Truro, UK
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Yadav RS, Bargujar P, Pahadiya HR, Yadav RK, Upadhyay J, Gupta A, Lakhotia M. Acute Upper Gastrointestinal Bleeding in Hexagenerians or Older (≥60 Years) Versus Younger (<60 Years) Patients: Clinico-Endoscopic Profile and Outcome. Cureus 2021; 13:e13521. [PMID: 33786228 PMCID: PMC7994108 DOI: 10.7759/cureus.13521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background and aims Acute upper gastrointestinal (UGI) bleeding is one of the serious and potentially life-threatening medical emergencies, causing significant mortality and morbidity. This study aimed to evaluate the clinico-endoscopic profile and outcome among patients aged <60 years who presented for UGI bleeding compared to those aged ≥60 years. Methods This prospective observational study was conducted among 194 patients who presented with symptoms or signs of UGI bleed. All patients were divided into two groups, group A (age <60 years), and group B (age ≥60 years). UGI endoscopy was performed using Olympus N19 Endoscope. Rockall scoring (RS) system and Glasgow Blatchford score (GBS) were used to predict the prognosis and re-bleeding. Results Of the total, group A included 150 (77.31%) patients and group B 44 (22.69%) patients. The most common presentation was hematemesis and melena in both groups, whilst isolated hematochezia was more common in group A (6.67%, vs. 2.27%, p>0.05). The main cause of bleeding was a variceal bleed in both groups, but it was significantly higher in group A patients (p<0.05). Elderly patients had a significantly higher number of peptic ulcer and malignancy-related bleed (p<0.05). Group A patients had a significantly higher proportion of patients with tachycardia (45.33%, vs. 27.27%, p<0.05), shock (43.33% vs. 13.63%, p<0.05), pallor (76.66% vs. 56.81%, p<0.05), and blood transfusion requirement (64% vs. 45.45%, p<0.05) as compared to group B. Thirty days re-bleeding and mortality rate were similar in both the groups. RS in both groups was 5.02±2.12 vs. 5.98±1.91, p>0.05. GBS was 11.65±4.61 vs. 10.68±4.65, p>0.05. Mortality was significantly higher in patients with RS ≥6 and GBS ≥10. Conclusion This study concluded variceal bleeding as a predominant cause of UGI bleed in both age groups, and it was significantly higher in younger. Interestingly, younger patients were more hemodynamically unstable, probably due to the presence of more severe anemia, shock, and hematochezia. The presence of multiple co-morbidities in both the group kept the 30 days mortality and re-bleed rates similar.
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Affiliation(s)
- Rajpal S Yadav
- Internal Medicine, Dr. Sampurnanand Medical College, Jodhpur, IND
| | - Payal Bargujar
- Pediatrics, Sawai Man Singh Medical College, Jaipur, IND
| | | | - Rahul K Yadav
- Medicine, Sawai Man Singh Medical College, Jaipur, IND
| | | | - Alok Gupta
- Internal Medicine, Dr. Sampurnanand Medical College, Jodhpur, IND
| | - Manoj Lakhotia
- Internal Medicine, Dr. Sampurnanand Medical College, Jodhpur, IND
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Abstract
Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.
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Affiliation(s)
- Nicholas J Costable
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustav L Levy Place, New York, NY 10029, USA
| | - David A Greenwald
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 11th Floor, New York, NY 10029, USA.
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Morgan TG, Carlsson T, Loveday E, Collin N, Collin G, Mezes P, Pullyblank AM. Needle or knife? The role of interventional radiology in managing uncontrolled gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200018] [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: 11/22/2022] Open
Affiliation(s)
- Thomas G. Morgan
- Dpeartment of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Eric Loveday
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Neil Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Graham Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Peter Mezes
- Departments of Radiology, Southmead Hospital, Bristol, UK
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Ray-Offor E, Opusunju K. Re-bleed and Mortality Amongst Patients Following Initial Endoscopy for Upper Gastrointestinal Bleeding: A Single-Center Nigeria Study. Cureus 2021; 13:e12939. [PMID: 33654618 PMCID: PMC7909892 DOI: 10.7759/cureus.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and aim Clinical and endoscopic parameters are predictive of patient outcome following acute upper gastrointestinal bleeding. The study aimed to investigate factors related to re-bleed and mortality following initial endoscopy among Nigerian patients with recent upper gastrointestinal bleeding (UGIB). Methods This is a cohort study of patients undergoing endoscopy for recent-onset UGIB at a referral endoscopy facility in Port Harcourt, Rivers State, Nigeria, from April 2014 to November 2020. Patients' demographic and clinical data, American Society of Anesthesiologists (ASA) physical status, amount of blood transfusion, endoscopy results, and Rockall scores were retrieved from patients' charts. The re-bleed and mortality rates were noted on follow-up by telephone. Statistical analysis was performed using SPSS version 20 (IMB Inc., Armonk, USA). Results A total of 560 patients had flexible video oesophagogastroduodenoscopy during the study period, and 46 (8.2%) of these were included in the study. Their age ranged from 28 years to 84 years (mean 58.6 ± 15.8 years) with 32 (69.6%) males and 14 (30.4%) females. Peptic ulcer disease (PUD) and gastritis/gastric erosions were the leading endoscopic diagnoses in 24 (52.2%) and 12 (26.1%) patients, respectively. Multiple comorbidities (p=0.021) and higher ASA score (mean 3.0; 95% confidence interval CI: 2.47-3.53; p=0.021) are associated with re-bleed, which was recorded in seven (15.2%) patients. Four (8.7%) cases of mortality were recorded in patients with a mean full Rockall score of 4.25 (95% CI: 1.52-6.97; p=0.021). Conclusion Re-bleed is more common in patients with multiple comorbidities, ASA score of three or more, and bleeding gastro-oesophageal varices at initial endoscopy. Mortality was significantly higher in patients with a full Rockall score of more than three.
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Affiliation(s)
- Emeka Ray-Offor
- Digestive Disease Unit, Oak Endoscopy Centre, Port Harcourt, NGA.,Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, NGA
| | - Kalanne Opusunju
- Digestive Disease Unit, Oak Endoscopy Centre, Port Harcourt, NGA
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Innocenti T, Dragoni G, Roselli J, Macrì G, Mello T, Milani S, Galli A. Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study. Clin Res Hepatol Gastroenterol 2021; 45:101409. [PMID: 32245690 DOI: 10.1016/j.clinre.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/23/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding. METHODS A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam. RESULTS Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding. CONCLUSIONS Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.
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Affiliation(s)
- Tommaso Innocenti
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy.
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
| | - Jenny Roselli
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
| | - Giuseppe Macrì
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
| | - Tommaso Mello
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
| | - Stefano Milani
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
| | - Andrea Galli
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G. B. Morgagni 50, 50134 Florence, Italy
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Hreinsson JP, Jonsson A, Bjornsson ES. Acute upper gastrointestinal bleeding: a population-based, five-year follow-up study. Scand J Gastroenterol 2021; 56:1-5. [PMID: 33226862 DOI: 10.1080/00365521.2020.1849384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Data on long-term rebleeding risk and mortality in acute upper gastrointestinal bleeding (AUGIB) patients are scarce and comparison to controls are lacking. Aimsof the study were to assess long-term prognosis of AUGIB patients and compare to controls. METHODS A population-based retrospective case-control study conducted at the National University Hospital of Iceland and included all patients who underwent endoscopy in 2010-2011. AUGIB was defined as haematemesis or coffee ground vomiting leading to hospitalization or occurring in a hospitalized patient. Controls underwent endoscopy in 2010-2011, matched for sex/age. Rebleeding was defined as AUGIB >14 days up to five years after index bleeding. RESULTS Overall, 303 patients had AUGIB, mean age 67 (±18), controls66 years (±19), females, 51 and 46%, respectively. The five-year rebleeding rate for AUGIB patients was 13% (95%CI 9-17%), higher than the rate of bleeding events in controls, 3% (95%CI 1-5%; log-rank <0.001), hazard ratio (HR) 6.0 (95%CI 2.4-15) when correcting for comorbidities, NSAID's, PPI's and antithrombotics. The mortality of AUGIB patients at end of follow-up was higher when compared to controls, 39% (95%CI 49-33%) vs. 26% (95%CI 30-21%), log-rank <0.001, comorbidity-adjusted HR 1.4 (1.1-1.9). A subanalysis of non-variceal AUGIB yielded similar results in regard to rebleeding and mortality rates. CONCLUSIONS AUGIB patients were at 6-fold risk of rebleeding compared to bleeding events in controls at five years of follow-up. Five-year mortality was higher in AUGIB patients when compared to controls even when correcting for age and comorbidities, suggesting that an episode of AUGIB indicates serious frailty.
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Affiliation(s)
- Johann P Hreinsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Armann Jonsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Einar S Bjornsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Choi C, Lim H, Kim MJ, Lee BY, Kim SY, Soh JS, Kang HS, Moon SH, Kim JH. Relationship between angiography timing and angiographic visualization of extravasation in patients with acute non-variceal gastrointestinal bleeding. BMC Gastroenterol 2020; 20:426. [PMID: 33317472 PMCID: PMC7737270 DOI: 10.1186/s12876-020-01570-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/04/2020] [Indexed: 12/17/2022] Open
Abstract
Background Angiographic embolization is now considered the first-line therapy for acute gastrointestinal (GI) bleeding refractory to endoscopic therapy. The success of angiographic embolization depends on the detection of the bleeding site. This study aimed to identify the clinical and procedural predictors for the angiographic visualization of extravasation, including angiography timing, as well as analyze the outcomes of angiographic embolization according to the angiographic visualization of extravasation. Methods The clinical and procedural data of 138 consecutive patients (mean age, 66.5 years; 65.9% men) who underwent angiography with or without embolization for acute non-variceal GI bleeding between February 2008 and July 2018 were retrospectively analyzed. Results Of the 138 patients, 58 (42%) had active extravasation on initial angiography and 113 (81.9%) underwent embolization. The angiographic visualization of extravasation was significantly higher in patients with diabetes (p = 0.036), a low platelet count (p = 0.048), high maximum heart rate (p = 0.002) and AIMS65 score (p = 0.026), upper GI bleeding (p = 0.025), and short time-to-angiography (p = 0.031). The angiographic embolization was successful in all angiograms, with angiographic visualization of extravasation (100%). The clinical success of patients without angiographic visualization of extravasation (83.9%) was significantly higher than that of patients with angiographic visualization of extravasation (65.5%) (p = 0.004). In multivariate analysis, the time-to-angiography (odds ratio 0.373 [95% CI 0.154–0.903], p = 0.029) was the only significant predictor associated with the angiographic visualization of extravasation. The cutoff value of time-to-angiography was 5.0 h, with a sensitivity and specificity of 79.3% and 47.5%, respectively (p = 0.012). Conclusions Angiography timing is an important factor that is associated with the angiographic visualization of extravasation in patients with acute GI bleeding. Angiography should be performed early in the course of bleeding in critically ill patients.
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Affiliation(s)
- Chungjo Choi
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Hyun Lim
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea.
| | - Min-Jeong Kim
- Department of Radiology, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Bo Young Lee
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Sung-Yeun Kim
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Jae Seung Soh
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Ho Suk Kang
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Sung Hoon Moon
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
| | - Jong Hyeok Kim
- Department of Internal Medicine, University of Hallym College of Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170-gil, Dongan-gu, Anyang, 431-796, Republic of Korea
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Lee PL, Yang KS, Tsai HW, Hou SK, Kang YN, Chang CC. Tranexamic acid for gastrointestinal bleeding: A systematic review with meta-analysis of randomized clinical trials. Am J Emerg Med 2020; 45:269-279. [PMID: 33041136 DOI: 10.1016/j.ajem.2020.08.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding is a common life-threatening emergent condition. Immediate tranexamic acid is useful for reducing hemorrhage following operation and bleeding trauma, but evidence on the effects of tranexamic acid in patients with gastrointestinal bleeding is limited or highly heterogeneous. It is still unclear about using tranexamic acid in the emergent condition of gastrointestinal bleeding. This study, therefore, aimed to determine whether or not tranexamic acid should be used in gastrointestinal bleeding management through systematic review and meta-analysis. METHODS We searched three biomedical databases for relevant randomized controlled trials on this topic. Two authors independently selected studies and extracted data for bias assessment and meta-analysis of bleeding, further intervention, mortality, transfusion, and intensive care unit admission. Available data were pooled using a random-effects model, and the results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity and small study effects were also assessed. RESULTS Thirteen randomized controlled trials (n = 2271) were included in the present synthesis. Our meta-analysis revealed that tranexamic acid significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo. CONCLUSION According to the available evidence, the present synthesis confirms that tranexamic acid is an effective medication for patients with upper gastrointestinal bleeding. Early administration of tranexamic acid may be worth to be recommended for treating upper gastrointestinal bleeding in the emergency department. However, the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification.
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Affiliation(s)
- Po-Lin Lee
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kai-Suan Yang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hong-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-No Kang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, Taipei, Taiwan.
| | - Chun-Chao Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan.
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Darmon I, Rebibo L, Diouf M, Chivot C, Riault C, Yzet T, Le Mouel JP, Regimbeau JM. Management of bleeding peptic duodenal ulcer refractory to endoscopic treatment: surgery or transcatheter arterial embolization as first-line therapy? A retrospective single-center study and systematic review. Eur J Trauma Emerg Surg 2020; 46:1025-1035. [PMID: 32246169 DOI: 10.1007/s00068-020-01356-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objective of this study was to compare the results of transcatheter arterial embolization (TAE) with surgery in terms of efficacy in the context of bleeding duodenal ulcer (BDU) refractory to endoscopic treatment. MATERIALS AND METHODS From January 2006 to December 2016, all patients treated for a BDU refractory to endoscopic treatment were included in this observational, comparative, retrospective, single-center study. Primary endpoint was the overall success of treatment of BDU requiring surgical and/or TAE. The secondary endpoints were pre-interventional data, recurrence rates, feasibility of secondary treatment, morbidity and mortality of surgical and radiological treatment, intensive care unit and length of stay. A systematic review of the literature was performed to compare results of surgery and TAE. RESULTS 59 out of 396 patients (14.9%) treated for BDU required embolization and/or surgery: 15 patients underwent surgery (group S) including 7 patients after embolization failure and 44 patients underwent TAE (group TAE). The overall treatment success in intention to treat (85.7% vs 67.3%), per protocol (80% vs 79.5%) and bleeding recurrence rates (20% vs 15.9%) were also identical. Mortality (14.2% vs 15.3%) was similar between the two groups. Our study data were pooled with data from eight published studies and suggest that surgery have significant increased overall success (68.3% vs. 55.4%, p < 0.005). CONCLUSION The overall success rate was in favour of surgery according our meta-analysis. Our single-center study highlights the fact that predictive factors for recurrent bleeding after TAE must be identified to select good candidates for TAE and/or surgery.
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Affiliation(s)
- Ilan Darmon
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Momar Diouf
- Biostatistics Unit, Clinical Research and Innovation Department, Amiens-Picardie University Hospital, 80054, Amiens, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Clémentine Riault
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Thierry Yzet
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean Philippe Le Mouel
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France.
- SSPC (Simplification of Surgical Patients Care), Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.
- Service de Chirurgie Digestive, CHU Amiens-Picardie, Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054, Amiens Cedex 1, France.
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Mullady DK, Wang AY, Waschke KA. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology 2020; 159:1120-1128. [PMID: 32574620 DOI: 10.1053/j.gastro.2020.05.095] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/19/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
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Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Kevin A Waschke
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
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Ket SN, Sparrow RL, McQuilten ZK, Gibson PR, Brown GJ, Wood EM. Critical peptic ulcer bleeding requiring massive blood transfusion: outcomes of 270 cases. Intern Med J 2020; 51:2042-2050. [DOI: 10.1111/imj.15009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Shara N. Ket
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Rosemary L. Sparrow
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Zoe K. McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Peter R. Gibson
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Gregor J. Brown
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
- Epworth Hospital Richmond Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
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Gottlieb M, Slagle W, Ruff J. What Is the Efficacy of Tranexamic Acid for Acute Upper Gastrointestinal Bleeding? Ann Emerg Med 2020; 77:371-373. [PMID: 32782082 DOI: 10.1016/j.annemergmed.2020.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - William Slagle
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Joshua Ruff
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Is coffee ground vomiting important? Findings from a large bleeding unit database and outcomes at 30 days. Eur J Gastroenterol Hepatol 2020; 32:797-803. [PMID: 32175981 DOI: 10.1097/meg.0000000000001701] [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: 12/10/2022]
Abstract
OBJECTIVES 'Coffee ground' vomiting (CGV) has classically been considered a sign of upper gastrointestinal bleeding. There is a paucity of data concerning endoscopic findings and outcomes in patients presenting with CGV. The aim of this study was to analyze endoscopic yield and 30-day outcomes in CGV patients. METHODS Analysis was performed over the period 1992-2005 and four groups were identified: CGV alone, hematemesis alone, melena alone, and hematemesis and melena. Endoscopic yield, requirement for blood transfusion, rebleeding, and mortality rate at 30 days were calculated and compared using logistic regression analysis. RESULTS 6054 patients (mean age 61.3 years, 3538 male) were included in the study. The hematemesis group was younger compared with the other groups. Therefore, endoscopic yield was adjusted for age and sex. CGV was associated with a significantly lower risk of gastric ulcer, duodenal ulcer, varices, gastric cancer, esophageal cancer, and Mallory-Weiss tears compared with some or all of the other groups. CGV was associated with an increased risk of esophagitis and no source was found. CGV was associated with a lower rate of blood transfusion and rebleeding (all P < 0.0001) but 30-day mortality rates were similar. CGV was less likely to require endoscopic intervention compared with the other groups (all P < 0.001). CONCLUSIONS CGV is associated with a lower endoscopic yield, requirement for blood transfusion, rebleeding rate, and potential for intervention compared to those with hematemesis, melena or both. Mortality rates are similar suggesting a nonbleeding cause and therefore questions the role of endoscopy in CGV.
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