Diagnosis and therapy of non-variceal upper gastrointestinal bleeding

Readmission Events Following EGD for Upper Gastrointestinal Bleed: An Analysis Using the National Readmission Database

Background: Upper Gastrointestinal Bleed (UGIB) is a common and potentially life-threatening condition with an annual incidence of 80-150 per 100,000 individuals and a mortality rate of 2-10%. Esophagogastroduodenoscopy (EGD) is the gold standard for both diagnosis and treatment, but post-discharge outcomes, including readmissions, remain underexplored. Methods: This study utilized the 2021 National Readmission Database (NRD) to analyze 30-day readmission rates following EGD for UGIB. Adult patients (≥18 years) admitted for UGIB and undergoing EGD were included; those who died during the index hospitalization were excluded. Demographic, clinical, and socioeconomic factors associated with readmission were examined using multivariate logistic regression. Results: Among 34,257 patients admitted for UGIB and undergoing EGD, 11,088 (32.4%) were readmitted within 30 days, with 5423 (49%) due to recurrent UGIB. Readmitted patients had a higher mean age (68.46 vs. 67.63 years) and greater prevalence of cirrhosis (16.71% vs. 13.84%). Hospital resource utilization was significantly higher among readmissions, with increased total hospital charges (USD 82,544.82 vs. USD 61,521.17) and longer hospital stays (5.38 vs. 4.97 days). Mortality was lower among readmitted patients (1.46% vs. 3.53%). Multivariate analysis identified cirrhosis (OR 7.20, 95% CI: 6.45-8.02), untreated H. pylori infection (OR 3.43, 95% CI: 2.15-4.30), atrial fibrillation (OR 1.52, 95% CI: 1.36-1.69), and chronic antithrombotic therapy (OR 1.63, 95% CI: 1.41-1.89) as significant predictors of recurrent UGIB readmission. Lower socioeconomic status was also associated with increased readmission risk (OR 1.15, 95% CI: 1.05-1.25). Conclusions: Readmission following EGD for UGIB is common and driven primarily by recurrent bleeding. Cirrhosis, untreated H. pylori infection, atrial fibrillation, and chronic anticoagulation therapy are key risk factors. These findings highlight the need for targeted interventions, including improved post-discharge management and optimization of anticoagulation strategies, to reduce readmission rates and improve patient outcomes.

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

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.

Clinical outcomes of nonvariceal upper gastrointestinal bleeding in nonagenarians and octogenarians: a comparative nationwide analysis

BACKGROUND/AIMS

Nonagenarians will purportedly account for 10% of the United States population by 2050. However, no studies have assessed the outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) in this age group.

METHODS

The National Inpatient Sample database between 2016 and 2020 was used to compare the clinical outcomes of NVUGIB in nonagenarians and octogenarians and evaluate predictors of mortality and the use of esophagogastroduodenoscopy (EGD).

RESULTS

Nonagenarians had higher in-hospital mortality than that of octogenarians (4% vs. 3%, p<0.001). EGD utilization (30% vs. 48%, p<0.001) and blood transfusion (27% vs. 40%, p<0.001) was significantly lower in nonagenarians. Multivariate logistic regression analysis revealed that nonagenarians with NVUGIB had higher odds of mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.3-1.7) and lower odds of EGD utilization (OR, 0.86; 95% CI, 0.83-0.89) than those of octogenarians.

CONCLUSIONS

Nonagenarians admitted with NVUGIB have a higher mortality risk than that of octogenarians. EGD is used significantly in managing NVUGIB among nonagenarians; however, its utilization is comparatively lower than in octogenarians. More studies are needed to assess predictors of poor outcomes and the indications of EGD in this growing population.

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

BACKGROUND

In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.

AIM

To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.

METHODS

We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.

RESULTS

802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.

CONCLUSION

Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.

Outcomes in Patients Admitted for Upper Gastrointestinal Bleeding and COVID-19 Infection: A Study of Two Years of the Pandemic

Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures.

METHODS

We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019.

RESULTS

Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic.

CONCLUSIONS

COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment.

Increasing inpatient mortality of nonvariceal upper gastrointestinal bleeding during the COVID-19 pandemic: a nationwide retrospective cohort study

Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06-1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08-0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93-0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89-0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762-10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.

Does off-hours endoscopic hemostasis affect outcomes of nonvariceal upper gastrointestinal bleeding?

Aim: Different researches showed controversial results about the 'off-hours effect' in nonvariceal upper gastrointestinal bleeding (NVUGIB). Materials & methods: A total of 301 patients with NVUGIB were divided into regular-hours group and off-hours group based on when they received endoscopic hemostasis, and the relationship of the clinical outcomes with off-hours endoscopic hemostasis was evaluated. Results: Patients who received off-hours endoscopy were sicker and more likely to experience worse clinical outcomes. Off-hours endoscopic hemostasis was a significant predictor of the composite outcome in higher-risk patients (adjusted OR: 4.63; 95% CI: 1.35-15.90). However, it did not associate with the outcomes in lower-risk patients. Conclusion: Off-hours effect may affect outcomes of higher-risk NVUGIB patients receiving endoscopic hemostasis (GBS ≥12).

Clinical Recommendations of Russian Gastroenterological Association and RENDO Endoscopic Society on Diagnosis and Treatment of Gastritis and Duodenitis

Aim.The clinical guidelines are intended to supplement specialty decision-making for improved aid quality in patients with gastritis and duodenitis though acknowledging the latest clinical evidence and principles of evidencebased medicine.Key points.Gastritis is an inflammatory disease of stomach mucosa, with a separate definition of acute and chronic gastritis. Chronic gastritis is a cohort of chronic diseases uniting a typical morphology of persistent inflammatory infiltration, impaired cellular renewal with emergent intestinal metaplasia, atrophy and epithelial dysplasia of gastric mucosa. Oesophagogastroduodenoscopy (OGDS) or high-resolution OGDS with magnified or non-magnified virtual chromoendoscopy, including targeted biopsy for atrophy and intestinal metaplasia grading and neoplasia detection, are recommended to verify gastritis and duodenitis, precancer states and/or gastric mucosal changes. All chronic gastritis patients positive for H. рylori should undergo eradication therapy as aetiological and subsidiary for gastric cancer prevention. Chronic gastritis patients with symptoms of dyspepsia (epigastric pain, burning and congestion, early satiety), also combined with functional dyspepsia, are recommended proton pump inhibitors, prokinetics, rebamipide and bismuth tripotassium dicitrate in symptomatic treatment. With focal restricted intestinal metaplasia, follow-up is not required in most cases, mainly when advanced atrophic gastritis is ruled out in high-quality endoscopy with biopsy. However, a familial history of gastric cancer, incomplete intestinal metaplasia and persistent H. pylori infection render endoscopy monitoring with chromoendoscopy and targeted biopsy desirable once in three years. Patients with advanced atrophic gastritis should have high-quality endoscopy every 3 years, and once in 1–2 years if complicated with a familial history of gastric cancer.Conclusion.The recommendations condense current knowledge on the aetiology and pathogenesis of gastritis and duodenitis, as well as laboratory and instrumental diagnostic techniques, main approaches to aetiological H. pylori eradication and treatment of dyspeptic states.

Outcomes of Non-Variceal Upper Gastrointestinal Bleed Stratified by Hospital Teaching Status: Insights From the National Inpatient Sample

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a significant cause of mortality and morbidity in the USA. Currently, there are limited data on the inpatient outcomes of patients admitted with a diagnosis of NVUGIB stratified according to teaching hospital status. We analyzed data from the National Inpatient Sample (NIS) intending to evaluate these outcomes.

METHODS

We queried the NIS 2016 and 2017 databases for NVUGIB hospitalizations by teaching hospital status. The primary outcome was inpatient mortality while secondary outcomes were rate of endoscopy for hemostasis, rate of early endoscopy (endoscopy in 1 day or less), mean time to endoscopy, rate of complications including acute kidney injury (AKI), acute respiratory failure (ARF), need for blood transfusion, development of sepsis, need for endotracheal intubation and mechanical ventilation as well as healthcare utilization.

RESULTS

There were over 71 million weighted discharges in the combined 2016 and 2017 NIS database. A total of 94,900 NVUGIB cases were identified with 63.4% admitted in teaching hospitals. The in-hospital mortality for patients admitted with an NVUGIB in teaching hospitals was 1.98% compared to 1.5% in non-teaching hospitals (adjusted odds ratio (aOR): 1.38, 95% confidence interval (CI): 1.08 - 1.77, P = 0.010) when adjusted for biodemographic and hospital characteristics as well as comorbidities. Patients admitted with a diagnosis of NVUGIB in teaching hospitals had a 10% adjusted increased odds of getting endoscopy for hemostasis (27.0% vs. 24.5%, aOR: 1.10, 95% CI: 1.02 - 1.19, P = 0.016) compared to patients in non-teaching hospitals. There was, however, no difference in early endoscopy between the two groups.

CONCLUSION

Patients admitted at teaching hospitals for an NVUGIB had worse outcomes during hospitalizations including mortality, median length of stay, and total hospital charges when compared to NVUGIB patients managed at non-teaching hospitals.

Does timing of endoscopy affect outcomes in patients with upper gastrointestinal bleeding: a systematic review and meta-analysis

BACKGROUND AND AIMS

The timing of esophagogastroduodenoscopy (EGD) for the management of upper gastrointestinal bleeding (UGIB) remains controversial. Early EGD (E-EGD) (within 24 h of presentation) has been compared to late EGD (L-EGD) (after 24 h) in numerous studies with conflicting results. The previous systematic review included three randomized controlled trials (RCTs); however, the cutoff time for performing EGD was arbitrary. We performed an updated systematic review and meta-analysis of the studies comparing the outcomes of E-EGD and L-EGD group.

METHODS

A comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was undertaken to include both RCTs and cohort studies. Primary outcomes including overall mortality and secondary outcomes (recurrent bleeding, need for transfusion, and length of stay) were compared. Risk ratios and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated.

RESULTS

A total of 13 observational studies (with over 1.8 million patients) were included in the final analysis. No significant difference in overall mortality (risk ratio: 0.97; CI, 0.74-1.27), recurrent bleeding (risk ratio: 1.12; CI, 0.62-2.00), and length of stay (SMD: -0.07, CI, -0.31 to 0.18) was observed for E-EGD group compared to L-EGD group. The possibility of endoscopic intervention was higher in E-EGD group (risk ratio: 1.70, CI, 1.28-2.27). Consistent results were obtained for subgroup analysis of studies with 100% nonvariceal bleed (NVB) patient (risk ratio: 1.12; CI, 0.84-1.50).

CONCLUSION

Given the outcomes and limitations, our meta-analysis did not demonstrate clear benefit of performing EGD within 24 h of presentation for UGIB (particularly NVB).

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated.

AIM

To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB.

METHODS

This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups.

RESULTS

A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.

CONCLUSION

In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Octreotide Added to a Proton Pump Inhibitor Versus a Proton Pump Inhibitor Alone in Nonvariceal Upper-Gastrointestinal Bleeds

Background: Literature indicating clinically relevant benefits of an adjunctive somatostatin analog to standard therapies in nonvariceal upper-gastrointestinal bleeding (NVUGIB) is lacking. Objective: The primary objective of this study was to find the association between outcomes in patients with NVUGIB treated with octreotide and a proton pump inhibitor (PPI; combination group) compared with those treated with a PPI alone. Methods: We conducted a retrospective cohort study of adults admitted within a 5-hospital health care system with a NVUGIB treated with a PPI continuous infusion with or without an octreotide infusion. Notable exclusion criteria included varices, history of cirrhosis without endoscopy, or active gastrointestinal cancer. The primary outcome was association of combination treatment versus PPI alone with hospital length of stay (LOS). Results: A total of 180 patients were included (combination group: n = 90; PPI: n = 90). In univariate analyses, the median hospital and intensive care unit (ICU) LOS in the combination group versus PPI was 6.1 versus 4.9 days (P = 0.25) and 2.3 versus 1.9 days (P = 0.24), and rebleeding and mortality occurred in 9% versus 12% (P = 0.63) and 6.7% versus 5.6% (P = 1.00) of patients. Median units of packed red blood cells in the combination therapy versus PPI group was 3 vs 2 units (P = 0.43). After propensity score adjustment in multivariable analyses, hospital and ICU LOS, rebleeding, and mortality all remained nonsignificant. Conclusion and Relevance: Our study observed no difference in clinical end points. This suggests that octreotide provides no additional major clinical benefit in NVUGIB, and PPI therapy alone may be sufficient.

Clinical approach to the patient with acute gastrointestinal bleeding

Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery.

Peptic Ulcer Is the Most Common Cause of Non-Variceal Upper-Gastrointestinal Bleeding (NVUGIB) in China

BACKGROUND This study aimed to discover the common cause of non-variceal upper-gastrointestinal bleeding (NVUGIB) by conducting a multi-center retrospective study from 2008 to 2012. MATERIAL AND METHODS Hospitalized patients ages ≥18 years old, from 8 hospitals in China, diagnosed with NVUGIB by endoscopy from 1 January 2008 to 31 December 2012 were enrolled. Questionnaires were developed and a data-entry graphical user interface was designed by using EpiData software. RESULTS Total of 2977 hospitalized patients from 8 medical centers were included. A total of 95.47% (2842/2977) of patients were admitted to a general ward, 3.53% (105/2977) were admitted to an emergency ward, and 1.00% (31/2977) were admitted to an intensive care unit. Peptic ulcer remained the most common cause of NVUGIB (73.26%), but there was a declining trend in its constituent ratio, from 2008 to 2012. A total of 14.41% (429/2977) of patients had co-morbid conditions, 92.85% (2764/2977) used proton-pump inhibitors (PPIs) prior to endoscopic treatment, 19.65% (585/2977) underwent emergency endoscopy, and 23.45% (698/2977) received a transfusion of red blood cell suspensions. A total of 5.34% (159/2977) underwent endoscopic therapy, with a treatment rate of 16.9% in high-risk peptic ulcer patients (96/568). A total of 7.69% (237/2977) were administered aspirin, of whom 32.50% (77/237) resumed aspirin intake after gastrointestinal bleeding was controlled. The median length of hospitalization was 8 days (IQR, 5-11) and the mortality rate was 1.71% (51/2977). CONCLUSIONS Peptic ulcer was still the most common cause of NVUGIB in China. The proportion of patients with high-risk peptic ulcer bleeding who received endoscopic therapy was 16.9%. Only 19.65% of NVUGIB patients underwent emergency endoscopy.

Evaluation and management of Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

Early esophagogastroduodenoscopy is associated with better Outcomes in upper gastrointestinal bleeding: a nationwide study

Background and study aims We analyzed NIS (National Inpatient Sample) database from 2007 - 2013 to determine if early esophagogastroduodenoscopy (EGD) (24 hours) for upper gastrointestinal bleeding improved the outcomes in terms of mortality, length of stay and costs. Patients and methods Patients were classified as having upper gastrointestinal hemorrhage by querying all diagnostic codes for the ICD-9-CM codes corresponding to upper gastrointestinal bleeding. For these patients, performance of EGD during admission was determined by querying all procedural codes for the ICD-9-CM codes corresponding to EGD; early EGD was defined as having EGD performed within 24 hours of admission and late EGD was defined as having EGD performed after 24 hours of admission. Results A total of 1,789,532 subjects with UGIH were identified. Subjects who had an early EGD were less likely to have hypovolemia, acute renal failure and acute respiratory failure. On multivariable analysis, we found that subjects without EGD were 3 times more likely to die during the admission than those with early EGD. In addition, those with late EGD had 50 % higher odds of dying than those with an early EGD. Also, after adjusting for all factors in the model, hospital stay was on average 3 and 3.7 days longer for subjects with no or late EGD, respectively, then for subjects with early EGD. Conclusion Early EGD (within 24 hours) is associated with lower in-hospital mortality, morbidity, shorter length of stay and lower total hospital costs.

Preventive transarterial embolization in upper nonvariceal gastrointestinal bleeding

Background

Transarterial embolization (TAE) is a therapeutic option for patients with a high risk of recurrent bleeding after endoscopic haemostasis. The aim of our prospective study was a preliminary assessment of the safety, efficacy, and clinical outcomes following preventive TAE in patients with non-variceal acute upper gastrointestinal bleeding (NVUGIB) with a high risk of recurrent bleeding after endoscopic haemostasis.

Methods

Preventive visceral angiography and TAE were performed after endoscopic haemostasis on patients with NVUGIB who were at a high risk of recurrent bleeding (PE+ group). The comparison group consisted of similar patients who only underwent endoscopic haemostasis, without preventive TAE (PE− group). The technical success of preventive TAE, the completeness of haemostasis, the incidence of rebleeding and the need for surgical intervention and the main outcomes were compared between the groups.

Results

The PE+ group consisted of 25 patients, and the PE− group of 50 patients, similar in age (median age 66 vs. 63 years), gender and comorbid conditions. The ulcer size at endoscopy was not significantly different (median of 152 mm vs. 127 mm). The most frequent were Forest II type ulcers, 44% in both groups. The distribution of the Forest grade was even. The median haemoglobin on admission was 8, 2 g/dl vs. 8,7 g/dl, p = 0,482, erythrocyte count was 2,7 × 10¹²/L vs. 2,9 × 10¹²/L, p = 0,727. The shock index and Rockall scores were similar, as well as and transfusion – on average, four units of packed red blood cells for the majority of patients in both groups, however, significantly more fresh frozen plasma was transfused in the PE− group, p = 0,013. The rebleeding rate was similar, while surgical treatment was needed notably more often in the PE- group, 8% vs. 35% accordingly, p = 0,012. The median ICU stay was 3 days, hospital stay – 6 days vs. 9 days, p = 0.079. The overall mortality reached 20%; in the PE+ group it was 4%, not reaching a statistically significant difference.

Conclusion

Preventive TAE is a feasible, safe and effective minimally invasive type of haemostasis decreasing the risk of repeated bleeding and preparing the patient for the definitive surgical intervention when indicated.

Gastric Ulcer Hemorrhage - a Potential Life-Threatening Complication of Intragastric Balloon Treatment of Obesity

BACKGROUND

Some morbidly obese patients do not qualify for bariatric surgery due to general health contraindications. Intragastric balloon treatment might be a therapeutic option in the above-mentioned cases. It can prime super-obese patients with end-stage disease for bariatric surgery. As a neoadjuvant therapy before surgery, it leads to a downstage of the disease by preliminary weight reduction, to an improvement in general health and, in summary, to a reduction of the perioperative risk. It is generally considered to be a safe method. However, due to the wide range of possible complications and unusual symptoms after intragastric balloon treatment, an interdisciplinary, instead of only a surgical or endoscopic, treatment and follow-up might be recommended in these patients.

CASE REPORT

We here describe a potential life-threatening complication in the form of gastric bleeding as a consequence of intragastric balloon treatment and simultaneous aspirin taking and Helicobacter pylori infection.

CONCLUSION

There have been reports of some complications of intragastric balloon treatment. However, to the best of our knowledge there were no reports concerning life-threatening hemorrhage from gastric ulcer.