Chronic kidney disease severely deteriorates the outcome of gastrointestinal bleeding: A meta-analysis

Gastrointestinal bleeding of undetermined origin: What diagnostic strategy to propose?

Gastrointestinal bleeding of undetermined origin (GBUO) is defined as gastrointestinal bleeding without an identified cause or location despite an endoscopic assessment including an esogastroduodenal endoscopy (EOGD) and a total colonoscopy. A distinction is made between exteriorized GBUO and non-exteriorized occult GBUO. The causes in the majority of cases (vascular, inflammatory and tumoral) are located in the small intestine. The diagnostic strategy aiming to locate the origin of the GBUO is a real challenge. Innovation in endoscopic and imaging techniques has enabled minimally invasive exploration of the small intestine. In Europe, there is a strong consensus to recommend a video-capsule endoscopy (VCE) as the first-intention study. If there is reason to suspect intestinal obstruction, VCE is contraindicated and a CT-enteroscopy is then performed as first intention. Enteroscopy is performed as a second-line treatment, either for therapeutic purposes after a positive VCE or CT-enteroclysis, or for diagnostic purposes after a negative VCE. Finally, intraoperative enteroscopy (IOE) coupled with surgical exploration should be reserved either for therapeutic purposes in the event of impossibility or failure of preoperative enteroscopy, or for diagnostic purposes in the event of recurrent GBUO after failure of all other studies and explorations of the small intestine.

Refractory gastric ulcer bleeding responsive to long-term octreotide

Upper gastrointestinal tract bleeding is a common condition that can cause hemodynamic instability and death if left untreated. Endoscopic hemostasis is often successful; however, some patients may develop refractory bleeding. Pharmacologic management with octreotide is beneficial in patients with variceal bleeding and has been shown in some studies to be effective in refractory bleeding due to angiodysplasia. There is a paucity of literature regarding the usage of long-term octreotide in refractory bleeding secondary to a peptic ulcer. We present a case of a bleeding gastric ulcer that was refractory to endoscopic management but responsive to long-term octreotide therapy.

Very High Yield of Urgent Small-Bowel Capsule Endoscopy for Ongoing Overt Suspected Small-Bowel Bleeding Irrespective of the Usual Predictive Factors

Evidence for an urgent approach to ongoing overt suspected small-bowel bleeding (SSBB) is scarce. We aimed to analyze our series of urgent small-bowel capsule endoscopies (SBCEs) for ongoing overt SSBB and to identify factors associated with positive findings and outcomes. A retrospective study of all SBCEs performed in the first 48 h after admission for overt SSBB between January 2006 and February 2022 was performed. Descriptive and inferential analyses (univariate and multivariable) were performed. Eighty-three urgent SBCEs were performed for overt SSBB. Patients were mostly men (69.2%, median age 68) and were followed for a median of 58.2 months (range 5-176). The diagnostic yield was 80.7%; in 60.2%, blood was detected in the small bowel (SB), while in 50.6%, a bleeding lesion was identified, mostly angioectasia. Patients with diabetes mellitus or taking NSAIDs were more prone to present SB findings, yet the explanatory power was low. Endoscopic or surgical treatments were performed in 28.9% and 19.3%, respectively, with the "non-conservative" therapeutic yield being 56.6%. Rebleeding occurred in 20.5% and was associated in the multivariable analysis with the female gender and anticoagulants use. This cohort of urgent SBCE, the largest from a European center, reinforces the usefulness of SBCE for ongoing overt SSBB management. This prompt performance of this procedure is highly effective, regardless of patients' features.

Risk of Mortality among Patients with Gastrointestinal Bleeding with Early and Late Treatment with Tranexamic Acid: A Population-Based Cohort Study

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.

Lower rates of endoscopy and higher mortality in end-stage renal disease patients with gastrointestinal bleeding: A propensity matched national study

BACKGROUND AND AIM

Patients with end-stage renal disease (ESRD) on hemodialysis are considered to be at higher risk of gastrointestinal bleeding (GIB) as compared with those without renal disease (NRD). We conducted a population-based study using the National Inpatient Sample (NIS) database to study the outcomes of GIB in ESRD.

METHODS

Patients admitted with GIB (upper and lower) from 2005 to 2013 were extracted from the NIS database using ICD-9 codes. Patients were divided into NRD and ESRD groups, and a 1:1 propensity matched analysis was performed. Various outcomes were compared in both groups, and subgroup analysis based on the timing of endoscopy was also performed.

RESULTS

A total of 218 032 patients were included in the study. There was an increase in inpatient admissions among ESRD patients with GIB with significant reduction in mortality (P < 0.001). In-hospital mortality, length of stay, and total costs were significantly higher in ESRD patients as compared with NRD. ESRD patients were less likely to undergo endoscopic evaluation compared with NRD (P < 0.001). Late endoscopy (> 48 h) was associated with increased need for transfusion and health-care utilization but without a significant difference in mortality as compared with early endoscopy. On multivariate analysis, endoscopy was associated with significantly lower rate of mortality in ESRD patients with GIB (odds ratio 0.28, P < 0.0001).

CONCLUSION

End-stage renal disease patients with GIB had a significantly higher rate of mortality and a higher health-care utilization with a lower rate of endoscopic evaluation. Endoscopy was associated with a lower mortality rate on multivariate analysis.

[Mortality Risk Factors for Inpatients with Ischemic Heart Disease Complicated with Gastrointestinal Bleeding]

OBJECTIVE

To investigate the risk factors of in-hospital mortality in patients with combined ischemic heart disease (IHD) and gastrointestinal bleeding (GIB).

METHODS

Patients who were hospitalized and received treatment for IHD combined with GIB at West China Hospital, Sichuan University between Jan. 2015 and Jan. 2018 were included in the study. Information concerning their baseline data, comorbidities, history of anticoagulant and antiplatelet medication, laboratory data on admission, and in-hospital treatments was collected. In-hospital death of all causes was taken as the primary endpoint event of the study, and multivariate logistic regression analysis was conducted to identify the independent risk factors of mortality during their hospital stay for this specific type of patients. Then, receiver operating characteristic ( ROC) curve was drawn and the area under curve ( AUC) was calculated accordingly.

RESULTS

A total of 395 patients met the enrollment criteria and were included in the study. Among them, 342 patients were discharged after their condition improved, and 53 patients died during hospitalization. Analysis of the cause of death revealed that cardiogenic death was the leading cause of death (54.7%), which was followed by infection-caused death (24.5%). Logistic regression analysis revealed that patients with ST-segment elevation myocardial infarction (STEMI) had a 2.527-fold risk of mortality compared with patients with non-acute coronary syndrome (odds ratio [ OR]=2.527, 95% confidence interval [ CI]: 1.152-8.277, P=0.043), and patients with comorbidity of chronic renal disease (CKD) had a 2.89-fold risk of mortality ( OR=2.89, 95% CI:1.187-7.037, P=0.019). It was also shown the higher level of WBC count ( OR=1.123, 95% CI: 1.057-1.193, P<0.001) and lower hemoglobin ( OR=1.014, 95% CI: 1.003-1.025, P=0.013) on admission were related to in-hospital mortality. On the other hand, endoscopy ( OR=0.305, 95% CI: 0.103-0.881, P=0.029) was identified as a protective factor in hospital treatment that decreased the risk of in-hospital mortality. ROC curve was drawn by combining the aforementioned variables to predict in-hospital mortality, which had an AUC of 0.79.

CONCLUSION

The actual type of IHD being STEMI, the patient's condition being complicated with chronic kidney disease, and having high white blood cells and low hemoglobin levels upon admission were considered independent risk factors for in-hospital death outcome of IHD patients complicated with GIB, while undergoing endoscopy during hospitalization was considered as a protective factor.

Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis

BACKGROUND AND AIMS

We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States.

METHODS

UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables.

RESULTS

The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%.

CONCLUSIONS

UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.

Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Renal Dysfunction

Atrial fibrillation and renal dysfunction often coexist, each disorder may predispose to the other and contribute to worsening prognosis. Both atrial fibrillation and chronic kidney disease are associated with increased risk of stroke and thromboembolic complications. Oral anticoagulation for stroke prevention is therefore recommended in patients with atrial fibrillation and decreased renal function. Each direct oral anticoagulant has unique pharmacologic properties of which clinician should be aware to optimally manage patients. The doses of direct oral anticoagulants require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault equation, should be used to estimate glomerular filtration rate in patients with atrial fibrillation treated with direct oral anticoagulants. Our review tries to find arguments for benefit of direct oral anticoagulants in patients with renal dysfunction.

End-stage renal disease and lower gastrointestinal bleeding-A propensity-matched analysis of nationwide inpatient sample

AIMS

We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients.

MATERIAL AND METHODS

The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients.

RESULTS

We identified 2 187 954 ESRD patients, of whom 242 075 has LGIB, and 1 945 879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P = .00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P = .00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P = .002). Advanced age (OR 1.02 CI 1.02-1.03 P = .00), anaemia (OR 1.04 CI 1.59-1.91 P = .006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P = .00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P = .00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P = .00) and sepsis (OR 1.5, CI 4.1-5.08, P = .00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8 ± 14.9 vs 6.3 ± 8.5, P < .01) and mean total charges (37 054 $ vs 18 080 $, P < .01) were also higher.

CONCLUSIONS

In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher.

Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study

Background

Patients with chronic kidney disease (CKD) with or without hemodialysis were considered to have bleeding tendency and higher risk for gastrointestinal (GI) bleeding. Previous studies had documented that hemodialysis may increase the gastroduodenal ulcer bleeding. Few studies evaluated the relationship between CKD and lower GI bleeding. Materials and Methods. An observational cohort study design was conducted. The end-stage renal disease (ESRD) patients receiving regular hemodialysis (dialysis CKD), CKD patients without dialysis (dialysis-free CKD), and controls were selected from 1 million randomly sampled subjects in the National Health Insurance Research Database of Taiwan. These three group subjects were matched by age, sex, comorbidity, and enrollment time in a 1 : 2 : 2 ratio. The Cox proportional hazard regression models were used to identify the potential risk factors for lower gastrointestinal bleeding.

Results

Dialysis CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both

Conclusion

Hemodialysis may have higher risk of lower GI bleeding and angiodysplasia bleeding.

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.