Aortoesophageal fistula complicated by mycotic aneurysm secondary to endoscopic procedures: A case report

Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding that often receives little attention in the emergency department. The classic presentation includes the Chiari triad of central chest pain, sentinel arterial bleeding, and subsequent evacuation after an asymptomatic period. For patients suspected of having AEF, a CT scan with IV contrast is the preferred diagnostic modality. In our patient, the presence of an aortic wall outpouching, ectopic gas, periaortic fat stranding, and leukocytosis, even in the absence of fever and positive blood culture, suggested mycotic aneurysm with AEF. The unique aspect of this case report is the occurrence of AEF as a rare complication of endoscopic procedures, which should be considered. Treatment options for AEF include surgery and thoracic endovascular aortic repair (TEVAR). TEVAR is a good option for stabilizing the patient's condition and reducing mortality in the short term. Once the patient's condition is suitable for AEF repair surgery, surgical intervention can be performed.

A comprehensive review of transvenous obliteration techniques in the management of gastric varices

Bleeding gastric varices (GVs) is a life-threatening complication of portal hypertension, with higher morbidity and mortality rates compared with bleeding esophageal varices (EVs). The endovascular techniques for the management of GVs are mainly transjugular intrahepatic portosystemic shunt (TIPS) and transvenous obliteration of the GVs. Transvenous obliteration techniques can be an alternative or an adjunct to TIPS for treatment of GVs, depending on the clinical scenario, and are less invasive than TIPS. However, these procedures are associated with increased portal pressure and related complications, mainly worsening of the EVs. In this article, the different techniques of transvenous obliteration of GVs, their indications, contraindications, and outcomes are discussed.

Acute Esophageal Necrosis or Black Esophagus in the Setting of Diabetic Ketoacidosis

Acute esophageal necrosis (AEN) or black esophagus is a rare cause of mortality in patients with gastrointestinal bleeding. We present a case of a 54-year-old female who presented with diabetic ketoacidosis (DKA) and developed melena eventually attributed to AEN. The esophagogastroduodenoscopy (EGD) identified severe inflammation with black discoloration consistent with acute esophageal necrosis in the middle and lower esophagus. The patient was managed with intravenous pantoprazole and total parenteral nutrition (TPN) until she was able to tolerate an adequate diet. Black esophagus should be added to the differential diagnosis of patients with DKA who develop gastrointestinal bleeding. This need is stressed by the fact that early treatment is essential to reducing complications and mortality associated with the condition.

A Novel Prediction Tool for Endoscopic Intervention in Patients with Acute Upper Gastro-Intestinal Bleeding

(1) Background: Predicting which patients with upper gastro-intestinal bleeding (UGIB) will receive intervention during urgent endoscopy can allow for better triaging and resource utilization but remains sub-optimal. Using machine learning modelling we aimed to devise an improved endoscopic intervention predicting tool. (2) Methods: A retrospective cohort study of adult patients diagnosed with UGIB between 2012−2018 who underwent esophagogastroduodenoscopy (EGD) during hospitalization. We assessed the correlation between various parameters with endoscopic intervention and examined the prediction performance of the Glasgow-Blatchford score (GBS) and the pre-endoscopic Rockall score for endoscopic intervention. We also trained and tested a new machine learning-based model for the prediction of endoscopic intervention. (3) Results: A total of 883 patients were included. Risk factors for endoscopic intervention included cirrhosis (9.0% vs. 3.8%, p = 0.01), syncope at presentation (19.3% vs. 5.4%, p < 0.01), early EGD (6.8 h vs. 17.0 h, p < 0.01), pre-endoscopic administration of tranexamic acid (TXA) (43.4% vs. 31.0%, p < 0.01) and erythromycin (17.2% vs. 5.6%, p < 0.01). Higher GBS (11 vs. 9, p < 0.01) and pre-endoscopy Rockall score (4.7 vs. 4.1, p < 0.01) were significantly associated with endoscopic intervention; however, the predictive performance of the scores was low (AUC of 0.54, and 0.56, respectively). A combined machine learning-developed model demonstrated improved predictive ability (AUC 0.68) using parameters not included in standard GBS. (4) Conclusions: The GBS and pre-endoscopic Rockall score performed poorly in endoscopic intervention prediction. An improved predictive tool has been proposed here. Further studies are needed to examine if predicting this important triaging decision can be further optimized.

Prognosis of variceal and non-variceal upper gastrointestinal bleeding in already hospitalised patients: Results from a French prospective cohort

OBJECTIVES

Patients who develop upper gastrointestinal bleeding (UGIB) while in hospital appear to have a poor prognosis. Our study aims at analysing the difference in outcome between in-patients (IPs) and out-patients presenting with variceal and non-variceal UGIB.

METHODS

We conducted a multicentre prospective study by collecting data about variceal and non-variceal UGIB cases through 46 hospitals in France between November 2017 and October 2018. We then compared baseline demographic features, endoscopic findings and outcome between patients who developed variceal and non-variceal UGIB on admission (OPs) and those at least 24 h after hospitalisation (IPs). Our primary end-point was mortality and re-bleeding rates at 6 weeks of bleeding onset.

RESULTS

A total of 2498 UGIB cases were identified, of whom 634 (25.4%) occurred in IPs. IPs were older than OPs (72.5 vs. 67.2 years old, p < 0.001) and had a higher rate of comorbidities (38.9% vs. 26.6%, p < 0.0001). Their bleeding was more severe with a Rockall score of >5 present in 40.9% (vs. 30.3% in OPs, p < 0.0001). The 6-week mortality rate was significantly higher in IPs when compared to OPs (21.7% vs. 8%, p < 0.0001). Prothrombin time <50% and rebleeding were the only independent predictors of mortality (p = 0.001 and 0.003, respectively). Six-week rebleeding occurred more frequently among IPs (18.6% vs. 14.4%, p = 0.015) and predictors included female sex, active bleeding upon endoscopy and a Blatchford score >11 (p = 0.017, 0.011 and 0.008, respectively).

CONCLUSION

IPs who develop variceal and non-variceal UGIB are more likely to be elderly with more comorbidities. They have a higher rate of mortality and rebleeding. Independent predictors of mortality were underlying coagulopathy and bleeding recurrence. An optimal bleeding management and efficient rebleeding prevention may improve outcome in these patients.

Life-threatening Upper Gastrointestinal Bleeding Due to Ruptured Gastroduodenal Artery Aneurysm in a Child

Gastroduodenal artery (GDA) aneurysm is a rare cause of massive life-threatening upper gastrointestinal (UGI) bleeding in children. Prompt resuscitation with fluids, administration of large amount of blood products (massive transfusion), prompt diagnostic evaluation using computed tomography (CT) angiography or digital subtraction angiography (DSA), and therapeutic endovascular or catheter-based interventions are life-saving. In cases with failed endovascular interventions, open surgical approach to ligate aneurysm is required. We report a 10-year-male with life-threatening UGI bleed due to ruptured GDA aneurysm possibly secondary to sepsis requiring resuscitation, massive transfusion, CT angiography and DSA, endovascular intervention, and ultimately surgical management with good outcome.

Upper Gastrointestinal Bleeding as the First Presentation of Eosinophilic Gastrointestinal Disease

Gastrointestinal bleeding is a rare but potentially life-threatening manifestation of eosinophilic gastrointestinal disorders (EGIDs). Here, we describe a case series comprising 5 pediatric patients between 7 and 12 years of age, who presented to the emergency department with hematemesis and were subsequently diagnosed with EGID. Accompanying allergic history, peripheral eosinophilia, and total IgE elevation were common. Despite a more severe presentation, response to medical and dietary therapy was favorable. A comprehensive review of the literature revealed 26 other cases with similar findings that reinforced the importance of prompt recognition and early dietary and immunomodulating therapy in the control of this disease.

Esophageal arteriovenous malformation, a rare cause of significant upper gastrointestinal bleeding: Case report and review of literature

Gastrointestinal (GI) arteriovenous malformations (AVMs) are a well-known source of bleeding with colon being the most common site, but they can also occur in rare locations like the esophagus which may present with life threatening bleeding. We report the case of a 51-year-old male with end stage renal disease (ESRD) presenting with hematemesis and acute on chronic anemia. Further investigation showed an esophageal AVM which is an unusual location and it was successfully treated with an endoscopic clip instead of argon plasma coagulation (APC) due to its challenging location and esophageal wall motion from breathing. The patient continued to be asymptomatic without any upper and lower GI bleeding during his 20 months follow up period after the endoscopic management. Review of literature showed only 10 cases of AVMs involving esophagus and the average age of presentation was 52 years with a male predominance. We also provide an overview of those cases in the discussion section below.

Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure.

METHODS

Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I² statistics and χ² Q-test.

RESULTS

Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32-6.79; P < .00001; I² = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24-0.56; P < .00001; I² = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44-2.38; P < .00001; I² = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66-6.55; P < .00001; I² = 0%). RE: OR = 0.43 (95% CI = 0.25-0.72; P < .001; I² = 0%). SU: OR = 1.85 (95% CI = 1.44-2.38, P < .00001; I² = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68-1.08; P = .19; I² = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63-1.32, P = .63; I² = 0%).

CONCLUSIONS

CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.

Upper Gastrointestinal Bleeding in Chronic Kidney Disease Patients

Aim: To investigate upper GI bleeding as a particular complication in chronic kidney disease patients. Material and methhod: 30 chronic kidney disease patients admitted to the Nephrology Department for upper gastrointestinal bleeding over a period of 5 years. Results: 16 patients were undergoing hemodialysis (53.3%) and 14 patients were not in a hemodialysis program. There were no patients undergoing peritoneal dialysis. Very high comorbidity rate for all patients, most important being cardiovascular diseases. Only 10% of patients had oral anticoagulant treatment prior to GI bleeding. Conservative treatment was successful for all patients; no endoscopic or surgical haemostasis was needed. Conclusion: Although chronic disease kidney patients have a high risk of upper GI bleeding compared to the general population, the conservative treatment applied has a very high rate of success in stopping the bleeding without the need for endoscopic or surgical haemostasis treatment.

BUDGET IMPACT ANALYSIS OF USING OMEPRAZOLE IMMEDIATE-RELEASE ORAL SUSPENSION IN REPLACE OF INTRAVENOUS PANTOPRAZOLE IN CRITICALLY ILL PATIENTS

OBJECTIVES

The aim of the present study was to estimate the financial consequence of using omeprazole immediate-release (IR) oral suspension versus pantoprazole intravenous infusion for preventing stress-related upper gastrointestinal bleeding in critically ill patients from the perspective of the health care system.

METHODS

An Excel-based model was developed to compare the cost of prevention of upper gastrointestinal bleeding early after intensive care admission using the current intravenous (IV) pantoprazole formulation versus omeprazole IR oral suspension. Total costs included the cost of acid suppressive drugs and related clinical outcomes. Inputs were obtained from a local clinical trial, the Ministry of Health database, insurance organizations, hospital and pharmacy registries, the relevant literature, and expert opinion. The robustness of the input data was investigated by one-way sensitivity analysis. The model was developed based on the results of a randomized control trial (RCT), in which experimental and control groups received omeprazole and pantoprazole, respectively.

RESULTS

According to the proposed model, the cost of gastrointestinal (GI) bleeding prevention using pantoprazole IV was US$ 950,000 while US$ 750,000 was spent on receiving omeprazole oral suspension. These costs led to the annual cost-saving of almost US$ 200,000 (US$4 per member, per month) for the health care system.

CONCLUSIONS

In the present study, a budget impact analysis was performed to assess the financial consequences of using omeprazole IR oral suspension in place of pantoprazole IV for prevention of upper gastrointestinal bleeding. The better preventive effect of omeprazole IR oral suspension when compared with conventional therapy using pantoprazole IV was the major reason for the final comparative budgetary savings.

Upper gastrointestinal bleeding - state of the art

Upper gastrointestinal (GI) bleeding is a condition requiring immediate medical intervention, with high associated mortality exceeding 10%. The most common cause of upper GI bleeding is peptic ulcer disease, which largely corresponds to the intake of NSAIDs and Helicobacter pylori infection. Endoscopy is the essential tool for the diagnosis and treatment of active upper GI hemorrhage. Endoscopic therapy together with proton pump inhibitors and eradication of Helicobacter pylori significantly reduces rebleeding rates, mortality and number of emergency surgical interventions. This paper presents contemporary data on the diagnosis and treatment of upper gastrointestinal bleeding.