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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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Saydam ŞS, Molnar M, Vora P. The global epidemiology of upper and lower gastrointestinal bleeding in general population: A systematic review. World J Gastrointest Surg 2023; 15:723-739. [PMID: 37206079 PMCID: PMC10190726 DOI: 10.4240/wjgs.v15.i4.723] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/20/2023] [Accepted: 03/08/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common and potentially life-threatening clinical event. To date, the literature on the long-term global epidemiology of GIB has not been systematically reviewed.
AIM To systematically review the published literature on the worldwide epidemiology of upper and lower GIB.
METHODS EMBASE® and MEDLINE were queried from 01 January 1965 to September 17, 2019 to identify population-based studies reporting incidence, mortality, or case-fatality rates of upper GIB (UGIB) or lower GIB (LGIB) in the general adult population, worldwide. Relevant outcome data were extracted and summarized (including data on rebleeding following initial occurrence of GIB when available). All included studies were assessed for risk of bias based upon reporting guidelines.
RESULTS Of 4203 retrieved database hits, 41 studies were included, comprising a total of around 4.1 million patients with GIB worldwide from 1980–2012. Thirty-three studies reported rates for UGIB, four for LGIB, and four presented data on both. Incidence rates ranged from 15.0 to 172.0/100000 person-years for UGIB, and from 20.5 to 87.0/100000 person-years for LGIB. Thirteen studies reported on temporal trends, generally showing an overall decline in UGIB incidence over time, although a slight increase between 2003 and 2005 followed by a decline was shown in 5/13 studies. GIB-related mortality data were available from six studies for UGIB, with rates ranging from 0.9 to 9.8/100000 person-years, and from three studies for LGIB, with rates ranging from 0.8 to 3.5/100000 person-years. Case-fatality rate ranged from 0.7% to 4.8% for UGIB and 0.5% to 8.0% for LGIB. Rates of rebleeding ranged from 7.3% to 32.5% for UGIB and from 6.7% to 13.5% for LGIB. Two main areas of potential bias were the differences in the operational GIB definition used and inadequate information on how missing data were handled.
CONCLUSION Wide variation was seen in estimates of GIB epidemiology, likely due to high heterogeneity between studies however, UGIB showed a decreasing trend over the years. Epidemiological data were more widely available for UGIB than for LGIB.
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Affiliation(s)
- Şiir Su Saydam
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
| | - Megan Molnar
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
| | - Pareen Vora
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Shung DL, Au B, Taylor RA, Tay JK, Laursen SB, Stanley AJ, Dalton HR, Ngu J, Schultz M, Laine L. Validation of a Machine Learning Model That Outperforms Clinical Risk Scoring Systems for Upper Gastrointestinal Bleeding. Gastroenterology 2020; 158:160-167. [PMID: 31562847 PMCID: PMC7004228 DOI: 10.1053/j.gastro.2019.09.009] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/02/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Scoring systems are suboptimal for determining risk in patients with upper gastrointestinal bleeding (UGIB); these might be improved by a machine learning model. We used machine learning to develop a model to calculate the risk of hospital-based intervention or death in patients with UGIB and compared its performance with other scoring systems. METHODS We analyzed data collected from consecutive unselected patients with UGIB from medical centers in 4 countries (the United States, Scotland, England, and Denmark; n = 1958) from March 2014 through March 2015. We used the data to derive and internally validate a gradient-boosting machine learning model to identify patients who met a composite endpoint of hospital-based intervention (transfusion or hemostatic intervention) or death within 30 days. We compared the performance of the machine learning prediction model with validated pre-endoscopic clinical risk scoring systems (the Glasgow-Blatchford score [GBS], admission Rockall score, and AIMS65). We externally validated the machine learning model using data from 2 Asia-Pacific sites (Singapore and New Zealand; n = 399). Performance was measured by area under receiver operating characteristic curve (AUC) analysis. RESULTS The machine learning model identified patients who met the composite endpoint with an AUC of 0.91 in the internal validation set; the clinical scoring systems identified patients who met the composite endpoint with AUC values of 0.88 for the GBS (P = .001), 0.73 for Rockall score (P < .001), and 0.78 for AIMS65 score (P < .001). In the external validation cohort, the machine learning model identified patients who met the composite endpoint with an AUC of 0.90, the GBS with an AUC of 0.87 (P = .004), the Rockall score with an AUC of 0.66 (P < .001), and the AIMS65 with an AUC of 0.64 (P < .001). At cutoff scores at which the machine learning model and GBS identified patients who met the composite endpoint with 100% sensitivity, the specificity values were 26% with the machine learning model versus 12% with GBS (P < .001). CONCLUSIONS We developed a machine learning model that identifies patients with UGIB who met a composite endpoint of hospital-based intervention or death within 30 days with a greater AUC and higher levels of specificity, at 100% sensitivity, than validated clinical risk scoring systems. This model could increase identification of low-risk patients who can be safely discharged from the emergency department for outpatient management.
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Affiliation(s)
| | | | | | | | | | | | | | - Jeffrey Ngu
- Christchurch Hospital, Christchurch, New Zealand
| | | | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
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Haddad FG, El Imad T, Nassani N, Kwok R, Al Moussawi H, Polavarapu A, Ahmed M, El Douaihy Y, Deeb L. In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem? World J Gastrointest Endosc 2019; 11:561-572. [PMID: 31839875 PMCID: PMC6885731 DOI: 10.4253/wjge.v11.i12.561] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/29/2019] [Accepted: 10/02/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Fady G Haddad
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Talal El Imad
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Najib Nassani
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, IL 60607, United States
| | - Raymond Kwok
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Hassan Al Moussawi
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Abhishek Polavarapu
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Moiz Ahmed
- Department of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Elmhurst, NY 11373, United States
| | - Youssef El Douaihy
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Liliane Deeb
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY 10305, United States
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Validation of a Machine Learning Model That Outperforms Clinical Risk Scoring Systems for Upper Gastrointestinal Bleeding. Gastroenterology 2019. [PMID: 31562847 DOI: 10.1053/j.gastro.2019.09.00] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND & AIMS Scoring systems are suboptimal for determining risk in patients with upper gastrointestinal bleeding (UGIB); these might be improved by a machine learning model. We used machine learning to develop a model to calculate the risk of hospital-based intervention or death in patients with UGIB and compared its performance with other scoring systems. METHODS We analyzed data collected from consecutive unselected patients with UGIB from medical centers in 4 countries (the United States, Scotland, England, and Denmark; n = 1958) from March 2014 through March 2015. We used the data to derive and internally validate a gradient-boosting machine learning model to identify patients who met a composite endpoint of hospital-based intervention (transfusion or hemostatic intervention) or death within 30 days. We compared the performance of the machine learning prediction model with validated pre-endoscopic clinical risk scoring systems (the Glasgow-Blatchford score [GBS], admission Rockall score, and AIMS65). We externally validated the machine learning model using data from 2 Asia-Pacific sites (Singapore and New Zealand; n = 399). Performance was measured by area under receiver operating characteristic curve (AUC) analysis. RESULTS The machine learning model identified patients who met the composite endpoint with an AUC of 0.91 in the internal validation set; the clinical scoring systems identified patients who met the composite endpoint with AUC values of 0.88 for the GBS (P = .001), 0.73 for Rockall score (P < .001), and 0.78 for AIMS65 score (P < .001). In the external validation cohort, the machine learning model identified patients who met the composite endpoint with an AUC of 0.90, the GBS with an AUC of 0.87 (P = .004), the Rockall score with an AUC of 0.66 (P < .001), and the AIMS65 with an AUC of 0.64 (P < .001). At cutoff scores at which the machine learning model and GBS identified patients who met the composite endpoint with 100% sensitivity, the specificity values were 26% with the machine learning model versus 12% with GBS (P < .001). CONCLUSIONS We developed a machine learning model that identifies patients with UGIB who met a composite endpoint of hospital-based intervention or death within 30 days with a greater AUC and higher levels of specificity, at 100% sensitivity, than validated clinical risk scoring systems. This model could increase identification of low-risk patients who can be safely discharged from the emergency department for outpatient management.
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Management of upper gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis: a prospective, multicenter, observational study. Scand J Trauma Resusc Emerg Med 2017; 25:78. [PMID: 28807040 PMCID: PMC5557479 DOI: 10.1186/s13049-017-0425-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/02/2017] [Indexed: 12/16/2022] Open
Abstract
Background Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective. We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes. Method This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included. Results In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs. Conclusion Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0425-6) contains supplementary material, which is available to authorized users.
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Acute gastrointestinal bleeding cases presenting to the emergency department are associated with age, sex and seasonal and circadian factors. Eur J Gastroenterol Hepatol 2017; 29:78-83. [PMID: 27662496 DOI: 10.1097/meg.0000000000000752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is one of the most common emergencies in gastroenterology. The aim of this study was to investigate the association between the incidence of GIB and seasonal, circadian and meteorological patterns in the emergency department (ED) of a tertiary hospital. PATIENTS AND METHODS From January 2007 until December 2012, we retrospectively evaluated patients presenting to the ED with respect to the number and location of GIB, season, time of day and weather. RESULTS Of 45 458 patients, 578 (1.3%) presented with a GIB. Of these, 62.5% were men compared with 54.7% of all patients in the ED (χ, P=0.0002). Patients with GIB were on average 4.4 years older than those without GIB (95% confidence interval 2.76-5.98, t-test, P<0.001). In addition, 304 (52.6%) patients had upper GIB and 138 (23.9%) had lower GIB. In total, 136 (23.5%) patients required no endoscopy because of initial laboratory and circulatory stability. In univariate analysis, meteorological parameters, including air temperature, cloud cover, relative humidity, vapour pressure, amount of precipitation, sunshine duration and snow height, were each associated with an increased risk of acute GIB (all P-values<0.05). In the 6-year study period, patients with GIB presented to the ED mainly during the winter months. Independent predictors of GIB on multivariate logistic regression were older age, male sex, season and daytime, all P less than 0.005. Emergency admissions during the night were associated with a 54 and 35% higher risk of GIB compared with daytime (8 a.m. to 4 p.m., P=0.0002) and late evening hours (4 p.m. to midnight, P=0.0142), respectively. CONCLUSION Presentation of patients with acute GIB in the ED is age and sex specific and shows seasonal and circadian differences in distribution, with an increased incidence in winter months and during night-time. This should be considered when determining possible emergency endoscopic interventions and the availability of emergency endoscopy services.
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Comparison of the efficacy of two combined therapies for peptic ulcer bleeding: adrenaline injection plus haemoclipping versus adrenaline injection followed by bipolar electrocoagulation. GASTROENTEROLOGY REVIEW 2015; 9:354-60. [PMID: 25653731 PMCID: PMC4300351 DOI: 10.5114/pg.2014.47898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 10/21/2014] [Accepted: 10/23/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peptic ulcer remains the most frequent cause of upper gastrointestinal bleeding. Treatment of bleeding with simultaneous combination of two endoscopic techniques has proved to be more efficient than monotherapy. None of the published comparative studies of various contact coagulation modalities have confirmed the superiority of one of these techniques over the others. AIM To compare the therapeutic outcomes of the use of a device enabling both injection of adrenaline solution and bipolar electrocoagulation (A + BE) to those of combined adrenaline injection with mechanical therapy (haemostatic clips) (A + HC) in the treatment of peptic ulcer bleeding. MATERIAL AND METHODS Fifty-two subjects with bleeding ulcers were assigned to the A + BE group, and 55 patients were treated with A + HC. RESULTS Overall, treatment failed in 20 patients (20/107, 18.7%): in 10 individuals from the A + BE group (10/52; 18.2%) and in 10 individuals from the A + HC group (10/55; 19.2%) (p > 0.05). Primary haemostasis was not obtained in 7 patients (6.5%): in 4 patients in the A + BE group and in 3 patients in the A + HC group (p > 0.05). Ten individuals (9.3%) experienced recurrent bleeding during hospitalisation: 4 patients from the A + BE group and 6 patients from the A + HC group (p > 0.05). Finally, in 96.3% of the patients (n = 103) the endoscopic treatment proved efficient with regards to obtaining haemostasis during hospitalisation. Surgical intervention was required in 4 individuals (3.7%): 2 patients in the A + BE group and 2 patients treated with A + HC (p > 0.05). Three patients (2.8%) - all from the A + HC group - died during hospitalisation. No significant intergroup differences were documented with regards to the mean number of transfused blood units and the mean length of hospital stay. CONCLUSIONS The efficacy of combined endoscopic treatment of ulcer bleeding with a probe enabling simultaneous bipolar electrocoagulation and adrenaline injection seems comparable to the widely used dual technique of adrenaline injection and haemostatic clipping.
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Bijpuria P, Thor S, Parsa L, Schlachterman A, Ahmad A. Do medicine residents triage patients with gastrointestinal bleeding appropriately? Hosp Pract (1995) 2015; 43:31-35. [PMID: 25659954 DOI: 10.1080/21548331.2015.1008379] [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] [Indexed: 06/04/2023]
Abstract
BACKGROUND Gastrointestinal specialists depend on internal medicine (IM) teams to accurately identify acute gastrointestinal bleeding (GIB). We evaluated whether IM residents' assessment of GIB correlated with the impressions of GI specialists during consultations at an inner-city university teaching hospital. METHODS A questionnaire was distributed to house staff requesting GIB consultations and to the GI fellows performing the consults between August 2011 and April 2012. Residents and fellows were asked to assess GIB, specifically melena, using a stool color card and digital rectal examination (DRE) findings. Fellow DRE findings served as controls for stool color identification. RESULTS Eighty-seven GI consults were eligible for the study. Residents and fellows completed 81 and 86 questionnaires, respectively. A total of 76 questionnaires were included for analysis. A DRE was performed by medical staff before calling a consult in 65% of cases compared with fellows (97% of cases, P = 0.0001). Residents more frequently labeled stool as melena (42%) in patients as compared with fellows (12%, P = 0.0001). Residents inaccurately identified melenic stools in 22 patients (11 based on stool color and 11 based on DRE findings). Residents were more likely to label a consult as emergent than fellows (13.5% vs 4%, P < 0.05). CONCLUSION Residents are less likely to perform DRE during an evaluation for GIB and to accurately identify melena based on stool color or DRE findings. There appears to be a need to educate residents on the appropriate terminology for stool color and the importance of DRE to accurately triage patients with acute GIBs.
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Thorat MA, Cuzick J. Prophylactic use of aspirin: systematic review of harms and approaches to mitigation in the general population. Eur J Epidemiol 2015; 30:5-18. [PMID: 25421783 DOI: 10.1007/s10654-014-9971-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 10/30/2014] [Indexed: 12/26/2022]
Abstract
A careful assessment of benefits and harms is required to assess suitability of aspirin as a prophylactic public health measure. However, comprehensive population-level data on harms are lacking. We collected and synthesized age and sex-specific data on harms relevant to aspirin use in average-risk individuals aged 50 years or older. We conducted systematic literature searches to identify baseline rates of gastrointestinal (GI) bleeding, peptic ulcer, major extra-cranial bleeding, and case-fatality rates due to GI bleeding or peptic ulcer in general population. The magnitude of aspirin-associated increase, the prevalence and attributable risk of Helicobacter pylori infection on these events in aspirin users was also assessed. Baseline rates of major extracranial bleeding events and GI complications increase with age; an almost threefold to fourfold increase is observed from age 50-54 to 70-74 years. Low or standard-dose aspirin use increases GI bleeding events by 60% leading to an annual excess of 0.45 and 0.79 GI bleeding events per 1,000 women and men aged 50-54 years respectively. 5-10% of major GI complications are fatal; a clear age dependence--higher fatality in older individuals, is seen. Eradication of H. pylori infection before aspirin use could reduce the incidence of upper GI complications by 25-30%. GI complications are increased by about 60% due to aspirin use but are fatal only in a very small proportion of individuals younger than 70 years of age. Major bleeding events that are comparable in severity to cancer or CVD, are infrequent. Screening and eradication of H. pylori infection could substantially lower aspirin-related GI harms.
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Affiliation(s)
- Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK,
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Tjwa ETTL, Holster IL, Kuipers EJ. Endoscopic management of nonvariceal, nonulcer upper gastrointestinal bleeding. Gastroenterol Clin North Am 2014; 43:707-19. [PMID: 25440920 DOI: 10.1016/j.gtc.2014.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) is the most common emergency condition in gastroenterology. Although peptic ulcer and esophagogastric varices are the predominant causes, other conditions account for up to 50% of UGIBs. These conditions, among others, include angiodysplasia, Dieulafoy and Mallory-Weiss lesions, gastric antral vascular ectasia, and Cameron lesions. Upper GI cancer as well as lesions of the biliary tract and pancreas may also result in severe UGIB. This article provides an overview of the endoscopic management of these lesions, including the role of novel therapeutic modalities such as hemostatic powder and over-the-scope-clips.
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Affiliation(s)
- Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - I Lisanne Holster
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
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Abstract
Background Tranexamic acid reduces haemorrhage through its antifibrinolytic effects. In a previous version of the present review, we found that tranexamic acid may reduce mortality. This review includes updated searches and new trials.Objectives To assess the effects of tranexamic acid versus no intervention, placebo or other antiulcer drugs for upper gastrointestinal bleeding.Search methods We updated the review by performing electronic database searches (Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE, EMBASE, Science Citation Index) and manual searches in July 2014.Selection criteriaRandomised controlled trials, irrespective of language or publication status.Data collection and analysis We used the standard methodological procedures of the The Cochrane Collaboration. All-cause mortality, bleeding and adverse events were the primary outcome measures. We performed fixed-effect and random-effects model meta-analyses and presented results as risk ratios (RRs) with 95% confidence intervals (CIs) and used I² as a measure of between-trial heterogeneity. We analysed tranexamic acid versus placebo or no intervention and tranexamic acid versus antiulcer drugs separately. To analyse sources of heterogeneity and robustness of the overall results, we performed subgroup, sensitivity and sequential analyses.Main results We included eight randomised controlled trials on tranexamic acid for upper gastrointestinal bleeding. Additionally, we identified one large ongoing pragmatic randomised controlled trial from which data are not yet available. Control groups were randomly assigned to placebo (seven trials) or no intervention (one trial). Two trials also included a control group randomly assigned to antiulcer drugs(lansoprazole or cimetidine). The included studies were published from 1973 to 2011. The number of participants randomly assigned ranged from 47 to 216 (median 204). All trials reported mortality. In total, 42 of 851 participants randomly assigned to tranexamic acid and 71 of 850 in the control group died (RR 0.60, 95% CI 0.42 to 0.87; P value 0.007; I² = 0%). The analysis was not confirmed when all participants in the intervention group with missing outcome data were included as treatment failures, or when the analysis was limited to trials with low risk of attrition bias. Rebleeding was diagnosed for 117 of 826 participants in the tranexamic acid group and for 146 of 825 participants in the control group (RR 0.80, 95% CI 0.64 to 1.00; P value 0.07; I² = 49%).We were able to evaluate the risk of serious adverse events on the basis of only four trials. Our analyses showed 'no evidence of a difference between tranexamic acid and control interventions regarding the risk of thromboembolic events.’ Tranexamic acid appeared to reduce the risk of surgery ina fixed-effect meta-analysis (RR 0.73, 95% CI 0.56 to 0.95), but this result was no longer statistically significant in a random-effects meta-analysis (RR 0.61, 95% CI 0.35 to 1.04; P value 0.07). No difference was apparent between tranexamic acid and placebo in the assessment of transfusion (RR 1.02, 95% CI 0.94 to 1.11; I² = 0%), and meta-analyses that compared tranexamic acid versus antiulcer drugs did not identify beneficial or detrimental effects of tranexamic acid for any of the outcomes assessed.Authors' conclusions This review found that tranexamic acid appears to have a beneficial effect on mortality, but a high dropout rate in some trials means that we cannot be sure of this until the findings of additional research are published. At the time of this update in 2014, one large study(8000 participants) is in progress, so this review will be much more informative in a few years. Further examination of tranexamic acid would require inclusion of high-quality randomised controlled trials. Timing of randomisation is essential to avoid attrition bias and to limit the number of withdrawals. Future trials may use a pragmatic design and should include all participants with suspected bleeding or with endoscopically verified bleeding, as well as a tranexamic placebo arm and co-administration of pump inhibitors and endoscopic therapy. Assessment of outcome measures in such studies should be clearly defined. Endoscopic examination with appropriate control of severe bleeding should be performed, as should endoscopic verification of clinically significant rebleeding. In addition, clinical measures of rebleeding should be included. Other important outcome measures include mortality (30-day or in-hospital), need for emergency surgery or blood transfusion and adverse events (major or minor).
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Affiliation(s)
- Cathy Bennett
- Coventry UniversityCentre for Technology Enabled Health Research (CTEHR)Priory StreetCoventryUKCV1 5FB
| | - Sarah Louise Klingenberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ebbe Langholz
- Gentofte University HospitalDepartment F, Gastroenterology SectionNiels Andersensvej 65HellerupDenmark2900
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards AlleHvidovreDenmark2650
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Bai Y, Du YQ, Wang D, Zou DW, Jin ZD, Zhan XB, Zhao XY, Sha WH, Wang JB, Yu WF, Jiang Y, Ye LP, Zhang ST, Zhou LY, Chen MH, Yu XF, Zheng JW, Wang RQ, Huang XJ, Chen DF, Wang HH, Tian DA, Lu NH, Hou XH, Ji F, Wang JY, Yuan YZ, Fan DM, Wu KC, Jiang B, Li ZS. Peptic ulcer bleeding in China: a multicenter endoscopic survey of 1006 patients. J Dig Dis 2014; 15:5-11. [PMID: 24118892 DOI: 10.1111/1751-2980.12104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to describe the clinical picture, management and outcomes of Chinese patients with peptic ulcer bleeding (PUB), especially in those with high risks. METHODS A multicenter endoscopic survey was conducted. All consecutive patients with endoscopy confirmed PUB from October 2010 to June 2011 were enrolled. Data including patients' gender, age, symptoms and endoscopic findings, Forrest classification, and endoscopic and medical treatment were documented. High-risk ulcer was defined as Forrest grades Ia to IIb upon endoscopy. Rates of rebleeding, surgery and mortality were recorded. RESULTS In all, 1006 patients were included. Of these 437 (43.4%) were categorized with high-risk PUB, among whom 110 (25.2%) received endoscopic treatment, and the success rate was 99.1%. Rebleeding rates 1-3 days, 4-5 days and 6-30 days after treatment in high-risk patients who did and did not receive endoscopic treatment were 10.9% versus 10.4%, 3.6% versus 3.7% and 0.9% versus 1.5%, respectively. The surgery rates of high-risk patients with or without endoscopic treatment were 1.8% (2/110) versus 1.8% (6/327). During the 9-month study period, two patients with high-risk PUB died, therefore, the overall mortality rate of high-risk PUB was 0.5% (2/437). CONCLUSION The study suggests that the proportions of high-risk PUB in China is 43.4%, while rebleeding and surgery rate after endoscopic treatment as well as the mortality rate of high-risk PUB in China are 15.6%, 1.8% and 0.5%, respectively.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48:439-47. [PMID: 23356751 PMCID: PMC3613943 DOI: 10.3109/00365521.2012.763174] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The authors aimed to investigate the incidence and outcomes of acute upper gastrointestinal bleeding (AUGIB) and to examine the role of drugs potentially associated with AUGIB. METHODS The study was prospective, population-based and consisted of all patients who underwent upper gastrointestinal endoscopy (UGE), during the year of 2010 at the National University Hospital of Iceland. Drug intake of NSAIDs, low-dose aspirin (LDA), warfarin, SSRIs and bisphosphonates prior to GIB was prospectively registered and also checked in a Pharmaceutical Database covering all prescriptions in Iceland. An age- and gender-matched control group consisted of patients who underwent UGE during the study period and were without GIB. RESULTS A total of 1731 patients underwent 2058 UGEs. Overall, 156 patients had AUGIB. The crude incidence for AUGIB was 87/100,000 inhabitants per year. The most common etiologies were duodenal (21%) and gastric ulcers (15%). Use of LDA (40% vs. 30%), NSAIDs (20% vs. 8%), warfarin (15% vs. 7%), combination of NSAIDs + LDA (8% vs. 1%) and SSRIs + LDA (8% vs. 3%) were significantly more common among bleeders than non-bleeders. Three patients (1.9%) had emergency surgery and two patients died of AUGIB. Independent predictors of clinically significant bleeding were gastric ulcer (OR 6.6, p = 0.012) and NSAIDs (OR 6.6, p = 0.004). CONCLUSIONS LDA, NSAIDs and warfarin play an important role in AUGIB etiology and particularly combinations of drugs. Gastric ulcer and NSAIDs were independent predictors of severe bleeding. Mortality and the need for surgery during hospitalization was low in this population-based setting.
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Affiliation(s)
- Jóhann P. Hreinsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
| | | | | | - Einar S. Björnsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
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Lu Y, Sverdén E, Ljung R, Söderlund C, Lagergren J. Use of non-steroidal anti-inflammatory drugs and proton pump inhibitors in correlation with incidence, recurrence and death of peptic ulcer bleeding: an ecological study. BMJ Open 2013; 3:bmjopen-2012-002056. [PMID: 23293249 PMCID: PMC3549209 DOI: 10.1136/bmjopen-2012-002056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) are regarded as two types of drugs that respectively increase and decrease the risk of peptic ulcer bleeding. However, their relation to occurrence, recurrence and death of bleeding in the population level is not clear. STUDY OBJECTIVE To clarify recent calendar-time correlations between sales of NSAIDs and PPIs and the occurrence of peptic ulcer bleeding, re-bleeding and death. DESIGN Ecological study. RESULTS The time trend of peptic ulcer bleeding did not correlate with PPI sales but did correlate with NSAIDs in mem (R(male)=0.6571, P(male)=0.05). Sales of PPIs (inverse) and NSAIDs correlated with re-bleeding in women (R(male)=-0.8754, P(male)=0.002 and R(female)=0.7161, P(female)=0.03, respectively), but not in men. An inverse correlation between PPI sales and 30-day death after bleeding was found (R(male)=-0.9392, P(male)=0.0002 and R(female)=-0.8561, P(female)=0.003), and NSAID sales were found to correlate with increased death after bleeding ((R(male)=0.7278, P(male)=0.03, R(female)=0.7858, P(female)=0.01). CONCLUSIONS The sales of NSAIDs and PPIs correlate with recurrence of peptic ulcer bleeding in women and death after peptic ulcer bleeding in both genders in the population level.
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Affiliation(s)
- Yunxia Lu
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Emma Sverdén
- Section of Upper Gastrointestinal Surgery, Department of Surgery, South General Hospital, Stockholm, Sweden
| | - Rickard Ljung
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology, The National Board of Health and Welfare, Stockholm, Sweden
| | - Claes Söderlund
- Section of Upper Gastrointestinal Surgery, Department of Surgery, South General Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- King's College London, London, UK
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Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol 2012; 18:1202-7. [PMID: 22468083 PMCID: PMC3309909 DOI: 10.3748/wjg.v18.i11.1202] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 05/30/2011] [Accepted: 06/06/2011] [Indexed: 02/06/2023] Open
Abstract
Acute upper gastrointestinal bleeding (UGIB) is a gastroenterological emergency with a mortality of 6%-13%. The vast majority of these bleeds are due to peptic ulcers. Nonsteroidal anti-inflammatory drugs and Helicobacter pylori are the main risk factors for peptic ulcer disease. Endoscopy has become the mainstay for diagnosis and treatment of acute UGIB, and is recommended within 24 h of presentation. Proton pump inhibitor (PPI) administration before endoscopy can downstage the bleeding lesion and reduce the need for endoscopic therapy, but has no effect on rebleeding, mortality and need for surgery. Endoscopic therapy should be undertaken for ulcers with high-risk stigmata, to reduce the risk of rebleeding. This can be done with a variety of modalities. High-dose PPI administration after endoscopy can prevent rebleeding and reduce the need for further intervention and mortality, particularly in patients with high-risk stigmata.
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Abstract
BACKGROUND Tranexamic acid reduces haemorrhage through its antifibrinolytic effects. In a previous version of the present review, we found that tranexamic acid may reduce mortality. The present review includes updated searches of randomised trials on tranexamic acid versus placebo, cimetidine or lansoprazole. OBJECTIVES To assess the effects of tranexamic acid for upper gastrointestinal bleeding. SEARCH METHODS Electronic searches (The Cochrane Library, MEDLINE, EMBASE, Science Citation Index) and manual searches were combined. The last search update was in October 2011. SELECTION CRITERIA Trials in which patients with upper gastrointestinal bleeding were randomised to receive either tranexamic acid or placebo, or any anti-ulcer drug, were included. DATA COLLECTION AND ANALYSIS Two authors independently extracted data. All-cause mortality was the primary outcome measure. Random-effects model meta-analyses were performed and results presented as relative risks (RR) with 95% confidence intervals (CI). Subgroup, sensitivity, regression and sequential analyses were performed to analyse sources of intertrial heterogeneity and the robustness of the overall result. MAIN RESULTS Seven double blind randomised trials on tranexamic acid versus placebo, cimetidine, or lanzoprazole were included. One trial offered endoscopic treatment to all patients that were randomised. Random-effects model meta-analysis found that tranexmic acid reduced mortality compared with placebo (41 of 829 versus 68 of 825 patients; RR: 0.61, 95% CI 0.42 to 0.89). The beneficial effect was not confirmed in subgroup analysis stratified for the quality of bias control, in worst case scenario analyses (in which 21% of the randomised patients were excluded), or in sequential analyses. No significant differences were found between tranexamic acid and placebo on bleeding, surgery, or transfusion requirements. No clear effects of tranexamic acid were identified in trials using endoscopic therapy or in the trials comparing tranexamic acid with cimetidine or lansoprazole. In the tranexamic acid group, five cases of serious thromboembolic events occurred (myocardial infarction, pulmonary embolism, and cerebral infarction). Overall, the number of patients with any thrombotic event was not significantly increased in the tranexamic acid group (RR 1.87, 95% CI 0.60 to 5.85). AUTHORS' CONCLUSIONS Considering the internal and external validity of the evidence, tranexamic acid cannot be recommended for routine use. Additional trials in which tranexamic acid is used in combination with the currently recommended interventions are required.
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Affiliation(s)
- Lise Lotte Gluud
- Department of InternalMedicine, Gentofte UniversityHospital, Hellerup,
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20
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Changing trends in acute upper gastrointestinal bleeding in Crete, Greece: a population-based study. Eur J Gastroenterol Hepatol 2012; 24:102-3. [PMID: 22129774 DOI: 10.1097/meg.0b013e32834c3a02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Gomes SIM, de Campos FPF, Martines BMR, Martines JADS, Tafner E, Maruta LM. Primary aortoesophageal fistula: a rare cause of acute upper gastrointestinal bleeding. AUTOPSY AND CASE REPORTS 2011; 1:57-63. [PMID: 31528554 PMCID: PMC6735559 DOI: 10.4322/acr.2011.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/03/2011] [Indexed: 01/01/2023] Open
Abstract
Acute upper gastrointestinal bleeding is a potentially life-threatening emergency, especially in the elderly. This condition accounts for approximately 1% of all emergency room admissions. Among the causes of such bleeding is aortoesophageal fistula, a dreaded but apparently rare condition, first recognized in 1818. The great majority of cases are of primary aortoesophageal fistula, caused by atheromatous aortic aneurysms or, less frequently, by penetrating aortic ulcer. The clinical presentation of aortoesophageal fistula is typically characterized by the so-called Chiari’s triad, consisting of thoracic pain followed by herald bleeding, a variable, short symptom-free interval, and fatal exsanguinating hemorrhage. The prognosis is poor, the in-hospital mortality rate being 60%. Conservative treatment does not prolong survival, and the in-hospital mortality rate is 40% for patients submitted to conventional surgical treatment. Here, we report the case of a 93-year-old woman who presented to the emergency room with a history of hematemesis. The patient was first submitted to upper gastrointestinal endoscopy, the findings of which were suggestive of aortoesophageal fistula. The diagnosis was confirmed by multidetector computed tomography of the chest. Surgery was indicated. However, on the way to the operating room, the patient presented with massive bleeding and went into cardiac arrest, which resulted in her death.
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Affiliation(s)
- Samira Ineida Morais Gomes
- Heart Institute - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | | | | | - Edmar Tafner
- Endoscopy Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Luis Masuo Maruta
- Endoscopy Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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Abstract
Upper gastrointestinal bleeding is the most common gastrointestinal emergency, with peptic ulcer as the most common cause. Appropriate resuscitation followed by early endoscopy for diagnosis and treatment are of major importance in these patients. Endoscopy is recommended within 24 h of presentation. Endoscopic therapy is indicated for patients with high-risk stigmata, in particular those with active bleeding and visible vessels. The role of endoscopic therapy for ulcers with adherent clots remains to be elucidated. Ablative or mechanical therapies are superior to epinephrine injection alone in terms of prevention of rebleeding. The application of an ulcer-covering hemospray is a new promising tool. High dose proton pump inhibitors should be administered intravenously for 72 h after endoscopy in high-risk patients. Helicobacter pylori should be tested for in all patients with peptic ulcer bleeding and eradicated if positive. These recommendations have been captured in a recent international guideline.
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Affiliation(s)
- Ingrid Lisanne Holster
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Ernst Johan Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality. Gastrointest Endosc Clin N Am 2011; 21:567-81. [PMID: 21944411 DOI: 10.1016/j.giec.2011.07.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.
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Pateron D, Vicaut E, Debuc E, Sahraoui K, Carbonell N, Bobbia X, Thabut D, Adnet F, Nahon P, Amathieu R, Aout M, Javaud N, Ray P, Trinchet JC. Erythromycin Infusion or Gastric Lavage for Upper Gastrointestinal Bleeding: A Multicenter Randomized Controlled Trial. Ann Emerg Med 2011; 57:582-9. [DOI: 10.1016/j.annemergmed.2011.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 12/15/2010] [Accepted: 01/03/2011] [Indexed: 10/18/2022]
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Kaviani MJ, Pirastehfar M, Azari A, Saberifiroozi M. Etiology and outcome of patients with upper gastrointestinal bleeding: a study from South of Iran. Saudi J Gastroenterol 2010; 16:253-9. [PMID: 20871188 PMCID: PMC2995092 DOI: 10.4103/1319-3767.70608] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/AIM The prevalence of acute upper gastrointestinal bleeding (AUGIB) has undergone a change after implementation of eradication therapy for Helicobacter pylori in peptic ulcers effective prevention of esophageal variceal bleeding and eventually, progressive use of low dose aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs). To evaluate this subject, we performed a prospective study in two main University Hospitals of Shiraz (the largest city of southern Iran). MATERIALS AND METHODS All adults who were admitted in emergency room with impression of AUGIB and existing patients who developed AUGIB were included in the study. Gastroscopy was done with a follow-up for the next 15 days. RESULTS 572 patients (mean age: 54.9 years) entered in the study. The most common presenting symptom was hematemesis or coffee-ground vomits (68%). 75% of patients gave history of consumption of low dose aspirin or other NSAIDs regularly. Gastric and/or duodenal ulcers were the most common causes (252/572, 44%) of AUGIB (Gastric ulcer: 173/572, 30% and duodenal ulcer: 93/572, 16%, respectively). Esophageal varices were the third common cause (64/572, 11%). 36 (6%) of the patients died. Mean age of these patients was higher than the patients who were alive (64.8 vs. 54.2 years, P = 0.001). Other than age, orthostatic hypotension on arrival (267/536 vs. 24/36, P = 0.018) and consumption of steroids (43/536 vs. 10/36, P = 0.001) were significant factors for increasing mortality. CONCLUSION The most common cause of AUGIB, secondary only to NSAIDs consumption, is gastric ulcer. Mortality of older patients, patients who consumed NSAIDs and steroids concomitantly, and patients with hemodynamic instability on arrival were higher.
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Affiliation(s)
- Mohammad J. Kaviani
- Internal Medicine Department and Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Address for correspondence: Dr. Mohsen Pirastehfar, Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. E-mail:
| | - Mohsen Pirastehfar
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Azari
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Saberifiroozi
- Internal Medicine Department and Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Kohn A, Ancona C, Belleudi V, Davoli M, Giglio L, Fusco D, Andreoli A, Perucci C, Prantera C. The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal hemorrhage: an Italian population-based study. Dig Liver Dis 2010; 42:629-34. [PMID: 20646973 DOI: 10.1016/j.dld.2010.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 03/10/2010] [Accepted: 03/16/2010] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyze the effects of endoscopy and care in a gastroenterology ward on 30-day mortality among Italian patients hospitalized for acute non-variceal upper gastrointestinal hemorrhage (UGIH). METHODS We conducted a population-based study based on administrative data contained in the Regional Hospital Information System (RHIS) for the Lazio Region (Italy). We identified all hospitalizations with a main diagnosis of UGIH during period 2000-2005. Discharge data were analyzed for procedures performed, ward where the patient was cared for, comorbidities, vital status at discharge. Vital status 30 days after admission was cross-checked with the Regional Registry of Causes of Death. Logistic regression models were performed taking into account patients' risk factors (OR and C.I. 95%). RESULTS A total of 13,427 hospitalizations for UGIH (mean patient age, 68 years; 60% males) were identified. The 30-day mortality was 6.9%. Significantly lower rates were observed among hospitalizations that included endoscopy (OR 0.30, 95% C.I. 0.26-0.34), specialist care (OR 0.55, 95% C.I. 0.37-0.82), or both (OR 0.12, 95% C.I. 0.07-0.22). The protective effects of endoscopy and specialist care remained strong after adjustment for potential risk factors. CONCLUSIONS Endoscopy, per se, reduces mortality among patients hospitalized for UGIH, and care in a gastroenterology ward may offer additional protective effects.
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Affiliation(s)
- Anna Kohn
- Division of Gastroenterology AO San Camillo Forlanini, Circonvallazione gianicolense 87, 00152 Rome, Italy.
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Hussey S, Kelleher KT, Ling SC. Emergency Management of Major Upper Gastrointestinal Hemorrhage in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc 2009; 70:212-24. [PMID: 19409558 DOI: 10.1016/j.gie.2008.10.051] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 10/27/2008] [Indexed: 01/05/2023]
Abstract
BACKGROUND Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear. OBJECTIVE To analyze the time trends of UGIB in 2 different management eras. DESIGN Prospective observational study. SETTING General university-affiliated hospital. PATIENTS AND INTERVENTIONS A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period. RESULTS The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%). LIMITATIONS A single-center study and a potential lack of generalizability. CONCLUSIONS From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.
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Acute upper gastrointestinal bleeding in central Greece: the role of clinical and endoscopic variables in bleeding outcome. Dig Dis Sci 2009; 54:333-41. [PMID: 18618256 DOI: 10.1007/s10620-008-0364-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 06/03/2008] [Indexed: 12/19/2022]
Abstract
The objectives of this work were to portray the incidence of upper gastrointestinal bleeding in central Greece and to define subsets at higher risk of poor outcome or death. Two hundred and sixty-four cases were recorded. The incidence was 116 per 100,000 per year (95% CI: 102-130). Re-bleeding was noted in 7.9% of patients. The case fatality was 7.2% and population mortality 8 per 100,000 per year (95% CI: 4-12). Independently significant risk factors for re-bleeding were stigmata of bleeding at endoscopy (OR: 3.11; 95% CI: 1.06-9.13, P = 0.04), smoking (OR: 3.39; 95% CI: 1.08-10.62, P = 0.03), and the use of anti-coagulant drugs (OR: 2.64; 95% CI: 1.00-7.13, P = 0.05), while the independently significant risk factor for death was re-bleeding (OR: 5.74; 95% CI: 1.40-23.52, P = 0.03). We conclude that patients with stigmata of bleeding at endoscopy and on anti-coagulant therapy should be under close surveillance because of the higher risk of re-bleeding. Smoking also increases the risk of re-bleeding. Patients with re-bleeding episodes must be managed intensively because of the higher risk of death.
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Gluud LL, Klingenberg SL, Langholz SE. Systematic review: tranexamic acid for upper gastrointestinal bleeding. Aliment Pharmacol Ther 2008; 27:752-8. [PMID: 18248659 DOI: 10.1111/j.1365-2036.2008.03638.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tranexamic acid may reduce upper gastrointestinal bleeding and stabilize patients before endoscopic treatments. AIM To review randomized trials on tranexamic acid for upper gastrointestinal bleeding. METHODS Manual and electronic searches of The Cochrane Library, MEDLINE, EMBASE and Science Citation Index were combined. Intention-to-treat random effect meta-analyses were performed and results presented as RRs with 95% confidence intervals. RESULTS Seven double-blind randomized trials on tranexamic acid vs. placebo were included. Of 1754 patients randomized, 21% were excluded. Only one trial included endoscopic treatments or proton pump inhibitors. Five per cent of patients on tranexamic acid and 8% of controls died (RR: 0.61, 95% CI: 0.42-0.89). No significant differences were found on bleeding, bleeding-related mortality, surgery or transfusion requirements. Adverse events were unclearly reported. Data from three of the included trials suggested that tranexamic acid did not significantly increase the risk of thromboembolic disease. CONCLUSIONS The present review suggests that tranexamic acid may reduce all-cause mortality. However, because of limitations in the internal and external validity of included trials, additional evidence is needed before treatment recommendations can be made.
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Affiliation(s)
- L L Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark.
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Abstract
Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.
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Tsesmeli NE, Kotsaftis PS, Savopoulos CG, Hatzitolios AI, Kaiafa GD, Kounanis AD, Karamitsos DT. Incidence and etiology of acute non-malignant upper gastrointestinal bleeding in northern Greece. J Gastroenterol Hepatol 2007; 22:1009-13. [PMID: 17608846 DOI: 10.1111/j.1440-1746.2006.04775.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM To evaluate the incidence and etiology of acute non-malignant upper gastrointestinal bleeding (ANMUGIB) in northern Greece due to increased use of non-steroidal anti-inflammatory drugs (NSAIDs), including low-dose aspirin (L-A), exposure and geographical variability of Helicobacter pylori (Hp) seroprevalence. METHODS A retrospective study of 110 patients admitted for hematemesis or melena during a 6-month period. All patients had undergone a gastrointestinal (GI) endoscopy during hospitalization. The presence of Hp was identified by biopsies and a (13)C-urea breath test in the case of Hp(-) biopsy bleeding peptic ulcer (BPU). The activity of ANMUGIB was assessed according to Forrest's classification. Statistical analysis was made by the chi(2)-test and Yates' correction. RESULTS Most patients were in the two medium age groups with no significant difference between them (P < 0.001). NSAID or L-A (100 mg/day) use was reported in 42.73% of patients in a ratio 1:1 (P > 0.1) and Hp infection was found in 29.09% of patients. BPU, with approximately two-thirds in the bulb, erosions and varices were the most frequent sources. Hp infection was found in 60.65% of BPU, 65.57% were related to NSAIDs or L-A and 8.19% were non-Hp non-NSAID/L-A BPU. Flat spots were most commonly found with a significant difference (P < 0.001) to other stigmata of recent bleeding, except for clean base. CONCLUSIONS In northern Greece, persons aged over 40 years are prone to ANMUGIB with a non-significant relationship to males. Hp infection and medication use, such as NSAIDS and L-A, are deeply involved in its etiology. Non-Hp non-NSAID/L-A BPU are a small proportion. ANMUGIB seems to have a generally good prognosis.
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Affiliation(s)
- Niki E Tsesmeli
- First Medical Propedeutic Department, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Enns RA, Gagnon YM, Barkun AN, Armstrong D, Gregor JC, Fedorak RN. Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting. World J Gastroenterol 2006; 12:7779-85. [PMID: 17203520 PMCID: PMC4087542 DOI: 10.3748/wjg.v12.i48.7779] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death.
METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ2 goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system.
RESULTS: For rebleeding, the χ2 goodness-of-fit test indicated an acceptable fit for the model [χ2 (8) = 12.83, P = 0.12]. For surgical procedures [χ2 (8) = 5.3, P = 0.73] and death [χ2 (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing a poor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability.
CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.
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Affiliation(s)
- Robert-A Enns
- Division of Gastroenterology, Department of Medicine, St. Paul's Hospital, University of British Columbia, 300-1144 Burrard Street, Vancouver, BC, V6Z 2A5, Canada.
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Dincer D, Duman A, Dikici H, Arici C, Suleymanlar I, Isitan F. NSAID-related upper gastrointestinal bleeding: are risk factors considered during prophylaxis? Int J Clin Pract 2006; 60:546-8. [PMID: 16700851 DOI: 10.1111/j.1742-1241.2006.00794.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The purposes of this study were to evaluate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on acute nonvaricose upper gastrointestinal bleeding (ANUGIB) and establish whether the NSAID-prescribing physicians take precautions to prevent or reduce GI ulcerations. Clinical characteristics, causes of bleeding and clinical outcomes of patients hospitalised in our gastroenterology clinic with ANUGIB were recorded prospectively over a 1.5-year period. NSAIDs, including aspirin, were used by 127 of 168 patients (73%). Among the NSAID users, 100 patients (78%) had at least one risk factor for serious adverse GI events related to NSAIDs. Only two patients were using proton pump inhibitors and one patient was using H2 receptor blocker of the high-risk group for GI side effects of NSAIDs. NSAIDs have an important effect on GI bleeding, and it seems that risk factors are underestimated by physicians.
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Affiliation(s)
- D Dincer
- Division of Gastroenterology, Medical Faculty, Akdeniz University, Antalya, Turkey.
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Gallerani M, Simonato M, Manfredini R, Volpato S, Vigna GB, Fellin R. Risk of hospitalization for upper gastrointestinal tract bleeding. J Clin Epidemiol 2004; 57:103-10. [PMID: 15019017 DOI: 10.1016/s0895-4356(03)00255-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2003] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study evaluates the hospitalization risk for upper gastrointestinal bleeding (UGIB) with reference to the clinical characteristics of patients and drugs taken before admission. METHODS This study is based on the GIFA (Italian Group for the Pharmacosurveillance in the Elderly) database. Cases with an ICD-9 code of esophagus, stomach or duodenum bleeding, or acute esophago-gastroduodenal disease associated with anemia have been classified as UGIB. Sex, age, year of observation, drugs taken at home, comorbidity, smoking, alcohol, and use of gastroprotectants have been also taken into account. Statistical analysis has been conducted using multivariate logistic regression models. RESULTS 32,388 patients have been enrolled, 940 of which presented UGIB. Age, comorbidity, use of smoke and alcohol, hospitalization duration, and mortality during hospitalization were significantly higher in UGIB than nonUGIB patients. Increased UGIB risk has been found in patients taking NSAIDs (both when aspirin was included or excluded), acetaminophen, constipating agents, iron, ethacrynic acid, propranolol. Reduced UGIB risk has been found in patients taking nitrates. CONCLUSIONS UGIB risk appears to correlate with clinical characteristics of the patient: it increases with age, comorbidity, and smoke and alcohol consumption. Among drugs, NSAIDs are associated with the highest UGIB risk, while nitrates with a reduction of risk.
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Affiliation(s)
- M Gallerani
- Department of Clinical and Experimental Medicine, Section of Internal Medicine, University of Ferrara, 44100 Ferrara, Italy.
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Thomopoulos KC, Vagenas KA, Vagianos CE, Margaritis VG, Blikas AP, Katsakoulis EC, Nikolopoulou VN. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004; 16:177-82. [PMID: 15075991 DOI: 10.1097/00042737-200402000-00009] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The diagnostic and therapeutic approaches to patients with acute upper gastrointestinal bleeding have been improved during the last decades. The aim of this study was to compare the aetiology and clinical outcome of acute upper gastrointestinal bleeding (AUGIB) between two distinct periods during the last 15 years. METHODS The causes of AUGIB and clinical outcome of 668 patients hospitalised with the problem in 1986-1987 were compared to 636 patients with AUGIB in 2000-2001. Patients were admitted to our hospital or they bled while they were inpatients for other reasons. No patient was excluded because of age or concurrent diseases. Endoscopic haemostasis with adrenaline injection for bleeding peptic ulcers was performed in the second period while no endoscopic method of haemostasis was performed in the first period. RESULTS We observed an increase in the age of patients (56.5 +/- 16.9 vs 62.9 +/- 17.5 years, P < 0.0001) and the percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) before bleeding (from 44% to 63.5%, P < 0.0001). An increase in the diagnosis rate of gastric ulcer (12% vs 19.2%, P = 0.005) and varices (13.2% vs 3.3%, P < 0.001) with a simultaneous decrease in that of erosive gastroduodenitis (18.4% vs 7.2%, P < 0.0001) and duodenal ulcer (48.7% vs 33.3%, P < 0.0001) as a cause of bleeding was also observed. In peptic ulcer bleeding, emergency surgical haemostasis was reduced from 14% to 5.3%, P < 0.001. Overall mortality was also reduced from 5.2% to 3.1% and in peptic ulcer bleeding patients from 3.3% to 2.4%, respectively, but the differences are not statistically significant. CONCLUSION The aetiology of AUGIB has changed during the last 15 years probably due to the better therapeutic approach to chronic duodenal ulcers and increasing use of NSAIDs in the elderly. Emergency surgical haemostasis has been reduced but the reduction of mortality was not significant.
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Paspatis GA, Charoniti I, Papanikolaou N, Vardas E, Chlouverakis G. A prospective, randomized comparison of 10-Fr versus 7-Fr bipolar electrocoagulation catheter in combination with adrenaline injection in the endoscopic treatment of bleeding peptic ulcers. Am J Gastroenterol 2003; 98:2192-7. [PMID: 14572567 DOI: 10.1111/j.1572-0241.2003.07691.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Our study compared the efficacy of bipolar electrocoagulation (gold probe) with 10-Fr (group A) versus 7-Fr (group B) catheter after adrenaline injection in the treatment of bleeding peptic ulcers. METHODS A total of 77 consecutive patients with endoscopic evidence of peptic ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to one of the above protocols. Thirty-nine patients (31 male, eight female, mean age 62 yr) were included in group A and 38 (28 male, 10 female, mean age 61 yr) in group B. RESULTS The initial hemostasis rate, rebleeding rate, duration of hospital stay, volume of blood transfused, number of operations needed, and number of deaths were not significantly different between the two groups. The mean number of electrocoagulations and the subsequent mean duration of electrocoagulations were significantly higher in group B patients (7.0 +/- 3.8 and 14.1 +/- 7.6 s, respectively) compared with those of group A (4.6 +/- 2.6 and 9.3 +/- 5.3 s, respectively) (p < 0.01). Multivariate stepwise logistic regression analysis revealed that among sex, age, location of bleeding, ulcer size, endoscopic severity of bleeding, and the size of the gold probes, lesser endoscopic severity of bleeding (chi(2) = 31.1, p < 0.01), large size of the gold probe (chi(2) = 23.9, p < 0.01), and small ulcer size (chi(2) = 13.4, p < 0.01) were the only factors significantly associated with a smaller number of electrocoagulations. CONCLUSIONS In this study, the use of large-size gold probes was significantly associated with a lower number of electrocoagulations, resulting in the reduction of electrocoagulation duration. However, the clinical relevance of these findings is questionable because the efficacy of both sizes of gold probe after adrenaline injection in the treatment of bleeding peptic ulcers was similar.
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Affiliation(s)
- Gregorios A Paspatis
- Department of Gastroenterology, Benizelion General Hospital, and School of Education, University of Crete, Heraklion, Crete, Greece
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Wasse H, Gillen DL, Ball AM, Kestenbaum BR, Seliger SL, Sherrard D, Stehman-Breen CO. Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients. Kidney Int 2003; 64:1455-61. [PMID: 12969166 DOI: 10.1046/j.1523-1755.2003.00225.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The risk of upper gastrointestinal bleeding (UGIB) is increased among end-stage renal disease (ESRD) patients compared to the general population. However, correlates of UGIB among ESRD patients remain unknown. We conducted a cohort study of dialysis patients to ascertain risk factors for UGIB. METHODS Data from the United States Renal Data System Dialysis Morbidity and Mortality Studies, Waves 2-4 were used to identify risk factors for incident UGIB among ESRD patients. First hospitalizations for UGIB were identified using hospital diagnosis codes between 12/31/93 and 12/31/99. Cox regression was used to estimate the association between predictors of interest and first diagnosis of UGIB. RESULTS Cases of UGIB (698) were observed over 30648 patient years of follow-up. Before adjustment for confounding factors, increasing age, diabetes, former and current smoking, cardiovascular disease (CVD), lower serum albumin, malnutrition, and inability to ambulate independently were associated with an increased risk of UGIB, while African Americans and transplant patients had a lower risk of UGIB. After adjustment, African American race was associated with a lower risk of UGIB (RR = 0.90; 0.82, 0.98), while current smoking (RR = 1.11; confidence interval 1.03, 1.19), history of CVD (RR = 1.32; 1.10, 1.59), and inability to ambulate independently (RR = 1.32; 1.07, 1.63) were associated with a higher risk of UGIB. Age, gender, diabetes, lower serum albumin, nourishment, treatment modality, aspirin use, nonsteroidal anti-inflammatory drug (NSAID) use, and antiplatelet or anticoagulant medication use were not found to be significantly related to the risk of UGIB after adjustment for potential confounding factors. CONCLUSION CVD, current smoking, and risk factors suggesting more disability are associated with a greater risk of UGIB among patients with ESRD.
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Affiliation(s)
- Haimanot Wasse
- University of Washington, Division of Nephrology, Seattle, Washington, USA.
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Abstract
In this overview, medical advice for routine clinical practice regarding peptic ulcer haemorrhage (PUH) is given, based on the extensive literature about Helicobacter pylori and the controversial results about the interaction of H. pylori infection and nonsteriodal anti-inflammatory drug (NSAID) use. PUH remains an important emergency situation with an incidence between 32 and 51/100 000 persons per year. There is a high association between H. pylori infection and peptic ulcer disease. The association between H. pylori infection and PUH is less clear, but a strong argument for the aetiological role is the fact that eradication of H. pylori decreases recurrence of bleeding. NSAID use is another important risk factor for PUH. H. pylori infection and NSAID use seem to act independently, although some studies show a synergistic interaction while other studies report that H. pylori is protective against the development of PUH in NSAID users. All patients with PUH should be tested for H. pylori infection, regardless of the use of NSAIDs. Because invasive tests are less sensitive in PUH patients, negative tests in patients with no other risk factors should be confirmed by serology or urea breath test (UBT). Eradication therapy with a proton pump inhibitor or ranitidine bismuth citrate-based triple therapy should be given to all H. pylori-positive patients. Only for nonaspirin-NSAID users does the effect of eradication therapy on the healing of gastric ulcers remain controversial, but currently we also advise eradication of H. pylori in this subgroup. After eradication therapy, acid-suppressant therapy is advised to heal the ulcer. The success of eradication should always be confirmed because of the risk of recurrence of peptic ulcer disease and bleeding in H. pylori-infected patients.
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Affiliation(s)
- M E van Leerdam
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands.
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Hernández-Díaz S, Rodríguez LAG. Incidence of serious upper gastrointestinal bleeding/perforation in the general population: review of epidemiologic studies. J Clin Epidemiol 2002; 55:157-63. [PMID: 11809354 DOI: 10.1016/s0895-4356(01)00461-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The object of this study was to quantify the incidence of serious upper gastrointestinal complications among nonusers of nonsteroidal anti-inflammatory drugs (NSAIDs). Systematic review of epidemiologic studies published between 1980 and 2000 that provided data on the incidence of upper gastrointestinal bleeding, perforation, or other upper gastrointestinal tract event resulting in death, hospitalization, or visit to a specialist among nonusers of nonsteroidal anti-inflammatory drugs. The authors calculated summary incidence rates and analyzed heterogeneity among results according to outcome definition, population characteristics, and methodology of primary studies. Forty-one population-based studies were reviewed, and 12 were included in the final analysis. Differences in outcome definitions accounted for much of the variability in incidence rate estimates reported in original studies. The pooled incidence rate estimate among nonusers of prescription NSAIDs per 1,000 person-years was 0.1 (95% confidence interval: 0.04-0.23) for perforations alone, 0.8 (0.58-0.68) for bleeding lesions alone, 0.9 (0.66-1.27) for bleeding or perforated lesions, and 1.0 (0.83-1.15) for serious gastrointestinal ulcer (complicated or without bleeding). Rates increased with age, and were approximately twice as high in men than in women. Epidemiologic studies based on automated data may slightly under- or overestimate the true incidence rate among nonusers of NSAIDs. Overall, the incidence rate of serious upper gastrointestinal complications was in the order of 1 per 1,000 person-years among nonusers of prescription NSAIDs.
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Affiliation(s)
- Sonia Hernández-Díaz
- Slone Epidemiology Unit, Boston University School of Public Health, Boston, MA, USA
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