Upper gastrointestinal bleeding: Causes and patient outcomes

Importance of risk assessment, endoscopic hemostasis, and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) is a common medical emergency in clinical practice. While the incidence has significantly reduced, the mortality rates have not undergone a similar reduction in the last few decades, thus presenting a significant challenge. This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis. Since ANUVGIB predominantly affects the elderly population, the impact of comorbidities may be responsible for the poor outcomes. A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly. Early risk stratification plays a crucial role in deciding the line of management and predicting mortality. Emerging scoring systems such as the ABC (age, blood tests, co-morbidities) score show promise in predicting mortality and guiding clinical decisions. While conventional endoscopic therapies remain cornerstone approaches, novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives, particularly in cases refractory to traditional modalities. By integrating validated scoring systems and leveraging novel therapeutic modalities, clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

Causes of gastrointestinal bleeding in children based on endoscopic evaluation at a tertiary care center in Bahrain

BACKGROUND

Gastrointestinal bleeding (GIB) is a serious health problem worldwide, particularly during childhood. This can be an alarming sign of an underlying disease. Gastrointestinal endoscopy (GIE) is a safe method for the diagnosis and treatment of GIB in most cases.

AIM

To determine the incidence, clinical presentation, and outcomes of GIB in children in Bahrain over the last two decades.

METHODS

This was a retrospective cohort review of the medical records of children with GIB who underwent endoscopic procedures in the Pediatric Department at Salmaniya Medical Complex, Bahrain, between 1995 and 2022. Demographic data, clinical presentation, endoscopic findings, and clinical outcomes were recorded. GIB was classified into upper (UGIB) and lower (LGIB) GIB according to the site of bleeding. These were compared with respect to patients’ sex, age, and nationality using the Fisher’s exact, Pearson’s χ², or the Mann-Whitney U tests.

RESULTS

A total of 250 patients were included in this study. The median incidence was 2.6/100000 per year (interquartile range, 1.4-3.7) with a significantly increasing trend over the last two decades (P < 0.0001). Most patients were males (n = 144, 57.6%). The median age at diagnosis was 9 years (5–11). Ninety-eight (39.2%) patients required upper GIE alone, 41 (16.4%) required colonoscopy alone, and 111 (44.4%) required both. LGIB was more frequent (n = 151, 60.4%) than UGIB (n = 119, 47.6%). There were no significant differences in sex (P = 0.710), age (P = 0.185), or nationality (P = 0.525) between the two groups. Abnormal endoscopic findings were detected in 226 (90.4%) patients. The common cause of LGIB was inflammatory bowel disease (IBD) (n = 77, 30.8%). The common cause of UGIB was gastritis (n = 70, 28%). IBD and undetermined cause for bleeding were higher in the 10–18 years group (P = 0.026 and P = 0.017, respectively). Intestinal nodular lymphoid hyperplasia, foreign body ingestion, and esophageal varices were more common in the 0–4 years group (P = 0.034, P < 0.0001, and P = 0.029, respectively). Ten (4%) patients underwent one or more therapeutic interventions. The median follow-up period was two years (0.5-3). No mortality was reported in this study.

CONCLUSION

GIB in children is an alarming condition, whose significance is increasing. LGIB, commonly due to IBD, was more common than UGIB, commonly due to gastritis.

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A retrospective study

OBJECTIVES

To compare the effectiveness of intermittent and continuous proton pump inhibitors (PPIs) infusion on the outcomes of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).

METHODS

The study was a single-centred retrospective study in adult patients with active upper gastrointestinal bleeding who received intermittent or continuous PPI infusion at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2013 to October 2019. The outcomes assessed were rebleeding, length of hospital stays and mortality within 30 days of admission, and were compared between the treatment groups. A statistically significant p-value was set at 0.05.

RESULTS

The study involved 97 patients with NVUGIB treated with intermittent (n=56) and continuous (n=41) PPI infusions, with mean (±SD) ages of 66.0±16.1 and 58.0±19.5 years, respectively. The baseline and clinical characteristics between the 2 treatment groups; age (p=0.116), gender (p=0.345) and comorbidities (p=0.401), were comparable. There were no significant differences in rebleeding rates within 30 days (5 [8.9%] versus 1 [2.4%], p=0.396), length of hospital stays (4 vs 5, p=0.067), and mortality rate (1 [1.7%] vs 3 [7.3%], p=0.308) between the 2 groups.

CONCLUSION

The management of NVUGIB with intermittent and continuous PPI infusions demonstrated comparable outcomes in reducing rebleeding rate, length of hospital stays, and mortality rate among patients attending the university hospital in Saudi Arabia.

Endoscopic Findings in Patients With Upper Gastrointestinal Bleeding in Ogun State, Nigeria

Introduction

Although the global incidence of upper gastrointestinal bleeding (UGIB) appears to have reduced substantially in the past few decades, acute UGIB still carries significant morbidity and mortality worldwide. There are currently no published data on UGIB in Ogun State, Nigeria. This study examined the endoscopic findings in patients with UGIB in Ogun State. 

Methodology

The study was a retrospective cross-sectional survey of patients with UGIB who had upper gastrointestinal endoscopy at three endoscopy centers in Ogun State, Southwest Nigeria, from January 2015 to December 2021. Patients’ data, which included age, gender, and endoscopic findings, were extracted from the endoscopy registers into a spreadsheet and analyzed statistically. Summary statistics included means ± standard deviation for continuous variables and frequencies and percentages for categorical variables. Categorical variables were compared for differences by chi-square test or Fisher’s exact test as appropriate. The statistical significance cutoff was p-value <0.05.

Results

A total of 171 had endoscopy for UGIB during the period under review but 168 had complete data. Out of the 168, 113 (67.3%) were males, giving a male-to-female ratio of 2:1. The mean age of the patients was 52.4 ± 18.1 years, with an age range of 7-85 years. The modal age group was ≥60 years (75; 39.9%). The most common endoscopic finding was peptic ulcer disease (77; 45.8%), followed by esophagogastric varices (27; 16.1%), erosive mucosal disease (25; 14.9 %), portal hypertensive gastropathy (15; 8.9%), suspected malignancies (11; 6.6%), hemorrhagic gastritis (7; 4.2%), gastric antral vascular ectasia (2; 1.2%), and Mallory-Weiss tear (1; 0.6%), respectively. Forty-four patients (26.2%) had no lesion that could explain UGIB. 

Conclusion

Peptic ulcer disease was the most common cause of UGIB among our patient population, and the elderly male patients were the most affected.