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Hu JN, Xu F, Hao YR, Sun CY, Wu KM, Lin Y, Zhong L, Zeng X. MH-STRALP: A scoring system for prognostication in patients with upper gastrointestinal bleeding. World J Gastrointest Surg 2024; 16:790-806. [PMID: 38577095 PMCID: PMC10989336 DOI: 10.4240/wjgs.v16.i3.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/21/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common medical emergency and early assessment of its outcomes is vital for treatment decisions. AIM To develop a new scoring system to predict its prognosis. METHODS In this retrospective study, 692 patients with UGIB were enrolled from two centers and divided into a training (n = 591) and a validation cohort (n = 101). The clinical data were collected to develop new prognostic prediction models. The endpoint was compound outcome defined as (1) demand for emergency surgery or vascular intervention, (2) being transferred to the intensive care unit, or (3) death during hospitalization. The models' predictive ability was compared with previously established scores by receiver operating characteristic (ROC) curves. RESULTS Totally 22.2% (131/591) patients in the training cohort and 22.8% (23/101) in the validation cohort presented poor outcomes. Based on the stepwise-forward Logistic regression analysis, eight predictors were integrated to determine a new post-endoscopic prognostic scoring system (MH-STRALP); a nomogram was determined to present the model. Compared with the previous scores (GBS, Rockall, ABC, AIMS65, and PNED score), MH-STRALP showed the best prognostic prediction ability with area under the ROC curves (AUROCs) of 0.899 and 0.826 in the training and validation cohorts, respectively. According to the calibration curve, decision curve analysis, and internal cross-validation, the nomogram showed good calibration ability and net clinical benefit in both cohorts. After removing the endoscopic indicators, the pre-endoscopic model (pre-MH-STRALP score) was conducted. Similarly, the pre-MH-STRALP score showed better predictive value (AUROCs of 0.868 and 0.767 in the training and validation cohorts, respectively) than the other pre-endoscopic scores. CONCLUSION The MH-STRALP score and pre-MH-STRALP score are simple, convenient, and accurate tools for prognosis prediction of UGIB, and may be applied for early decision on its management strategies.
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Affiliation(s)
- Jun-Nan Hu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Fei Xu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Ya-Rong Hao
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Chun-Yan Sun
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Kai-Ming Wu
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Yong Lin
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Lan Zhong
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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Tari E, Frim L, Stolcz T, Teutsch B, Veres DS, Hegyi P, Erőss B. At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231190970. [PMID: 37655056 PMCID: PMC10467304 DOI: 10.1177/17562848231190970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI). Objectives We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB. Design A systematic search was conducted in three medical databases in October 2021. Data sources and methods Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias. Results A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies. Conclusion Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI. Registration PROSPERO registration number: CRD42021285727.
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Affiliation(s)
- Edina Tari
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Levente Frim
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tünde Stolcz
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Tömő u. 25.-29., Budapest, 1083, Hungary
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Nammour T, El Jamal L, Hosni MN, Tamim H, Kerbage A, Hashash JG, Shaib YH, Daniel F, Francis F, Mourad FH, Soweid A, Sharara AI, Makki M, Rockey DC, Barada K. Development and Validation of a Novel 1-year Mortality Risk Score That Includes the Use of Antithrombotic in Patients With Overt Gastrointestinal Bleeding. J Clin Gastroenterol 2023; 57:700-706. [PMID: 35921332 DOI: 10.1097/mcg.0000000000001736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 06/15/2022] [Indexed: 12/10/2022]
Abstract
GOALS AND BACKGROUND We aimed to develop a novel 1-year mortality risk-scoring system that includes use of antithrombotic (AT) drugs and to validate it against other scoring systems in patients with acute gastrointestinal bleeding (GIB). STUDY We developed a risk-scoring system from prospectively collected data on patients admitted with GIB between January 2013 and August 2020, who had at least 1- year of follow-up. Independent predictors of 1-year mortality were determined after adjusting for the following confounders: the age-adjusted Charlson Comorbidity Index (CCI) (divided into 4 groups: CCI-0=0, CCI-1=1 to 3, CCI-2=4 to 6, CCI-3 ≥7), need for blood transfusion, GIB severity, need for endoscopic therapy, and type of AT. The risk score was based on independent predictors. RESULTS Five hundred seventy-six patients were included and 123 (21%) died at 1-year follow-up. Our risk -score was based on the following: CCI-2 (2 points), CCI-3 (4 points), need for blood transfusion (1 point), and no use of aspirin (1 point), as aspirin use was protective (maximum score=6). Patients with higher risk scores had higher mortality. The model had a better predictive accuracy [AUC=0.82, 95% confidence interval (0.78-0.86), P <0.0001] than the Rockall score for upper GIB (Area Under the Curve (AUC)=0.68, P <<0.0001), the Oakland score for lower GIB (AUC=0.69, p =0.004), or the Shock Index for all (AUC=0.54, P <0.0001). CONCLUSION A simple and novel score that includes use of AT upon admission accurately predicts 1-year mortality in patients with GIB. This scoring system may help guide follow-up decisions and inform the prognosis of patients with GIB.
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Affiliation(s)
| | | | | | - Hani Tamim
- Biostatistics Support Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | | | | | | | | | | | | | - Maha Makki
- Biostatistics Support Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC
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Obeidat M, Teutsch B, Rancz A, Tari E, Márta K, Veres DS, Hosszúfalusi N, Mihály E, Hegyi P, Erőss B. One in four patients with gastrointestinal bleeding develops shock or hemodynamic instability: A systematic review and meta-analysis. World J Gastroenterol 2023; 29:4466-4480. [PMID: 37576706 PMCID: PMC10415974 DOI: 10.3748/wjg.v29.i28.4466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Hemodynamic instability and shock are associated with untoward outcomes in gastrointestinal bleeding. However, there are no studies in the existing literature on the proportion of patients who developed these outcomes after gastrointestinal bleeding. AIM To determine the pooled event rates in the available literature and specify them based on the bleeding source. METHODS The protocol was registered on PROSPERO in advance (CRD42021283258). A systematic search was performed in three databases (PubMed, EMBASE, and CENTRAL) on 14th October 2021. Pooled proportions with 95%CI were calculated with a random-effects model. A subgroup analysis was carried out based on the time of assessment (on admission or during hospital stay). Heterogeneity was assessed by Higgins and Thompson's I2 statistics. The Joanna Briggs Institute Prevalence Critical Appraisal Tool was used for the risk of bias assessment. The Reference Citation Analysis (https://www.referencecitationanalysis.com/) tool was applied to obtain the latest highlight articles. RESULTS We identified 11589 records, of which 220 studies were eligible for data extraction. The overall proportion of shock and hemodynamic instability in general gastrointestinal bleeding patients was 0.25 (95%CI: 0.17-0.36, I2 = 100%). In non-variceal bleeding, the proportion was 0.22 (95%CI: 0.14-0.31, I2 = 100%), whereas it was 0.25 (95%CI: 0.19-0.32, I2 = 100%) in variceal bleeding. The proportion of patients with colonic diverticular bleeding who developed shock or hemodynamic instability was 0.12 (95%CI: 0.06-0.22, I2 = 90%). The risk of bias was low, and heterogeneity was high in all analyses. CONCLUSION One in five, one in four, and one in eight patients develops shock or hemodynamic instability on admission or during hospitalization in the case of non-variceal, variceal, and colonic diverticular bleeding, respectively.
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Affiliation(s)
- Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
| | - Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Edina Tari
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Katalin Márta
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest 1085, Hungary
| | - Nóra Hosszúfalusi
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Emese Mihály
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Department of Internal Medicine and Hematology, Semmelweis University, Faculty of Medicine, Budapest 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7623, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest 1083, Hungary
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Öhlinger T, Müllner EW, Fritz M, Werning M, Baron-Stefaniak J, Jungbauer C, Baron DM, Salzer U. Storage of packed red blood cells impairs an inherent coagulation property of erythrocytes. Front Physiol 2022; 13:1021553. [PMID: 36505041 PMCID: PMC9732456 DOI: 10.3389/fphys.2022.1021553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
Storage of packed red blood cells is associated with changes in erythrocytes that over time increasingly impair cellular function and potentially contribute to adverse effects associated with blood transfusion. Exposure of phosphatidylserine at the outer membrane leaflet of erythrocytes and shedding of microvesicles (MVs) during packed red blood cell storage are alterations assumed to increase the risk of prothrombotic events in recipients. Here, we used rotational thromboelastometry to study the coagulation process in blood samples with erythrocytes from stored PRBCs reconstituted with freshly prepared platelet-rich plasma. We explored the influence of following effects on the coagulation process: 1) PRBC storage duration, 2) differences between erythrocytes from stored PRBCs compared to freshly drawn erythrocytes, and 3) the contribution of added MVs. Interestingly, despite of a higher fraction of PS-positive cells, erythrocytes from PRBCs stored for 6 weeks revealed longer clotting times than samples with erythrocytes stored for 2 or 4 weeks. Further, clotting times and clot formation times were considerably increased in samples reconstituted with erythrocytes from stored PRBCs as compared to fresh erythrocytes. Moreover, MVs added to reconstituted samples elicited only comparably small and ambiguous effects on coagulation. Thus, this study provides no evidence for an amplified clotting process from prolonged storage of PRBCs but on the contrary implicates a loss of function, which may be of clinical significance in massive transfusion. Our observations add to the increasing body of evidence viewing erythrocytes as active players in the clotting process.
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Affiliation(s)
- Thomas Öhlinger
- Center for Medical Biochemistry, Max Perutz Labs (MPL), Medical University of Vienna, Vienna, Austria,Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ernst W. Müllner
- Center for Medical Biochemistry, Max Perutz Labs (MPL), Medical University of Vienna, Vienna, Austria
| | - Magdalena Fritz
- Center for Medical Biochemistry, Max Perutz Labs (MPL), Medical University of Vienna, Vienna, Austria
| | - Maike Werning
- Center for Medical Biochemistry, Max Perutz Labs (MPL), Medical University of Vienna, Vienna, Austria
| | - Joanna Baron-Stefaniak
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christof Jungbauer
- Blood Service for Vienna, Lower Austria and Burgenland, Austrian Red Cross, Vienna, Austria
| | - David M. Baron
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ulrich Salzer
- Center for Medical Biochemistry, Max Perutz Labs (MPL), Medical University of Vienna, Vienna, Austria,*Correspondence: Ulrich Salzer,
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Schmid B, Busch HJ, Thimme R, Bettinger D. [Preclinical and clinical management of patients with acute gastrointestinal bleeding]. Dtsch Med Wochenschr 2022; 147:1212-1220. [PMID: 36070739 DOI: 10.1055/a-1728-9137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute gastrointestinal bleeding often leads to admission to the emergency room. Especially in elderly patients and in those with significant comorbidities it is associated with increased morbidity and mortality. Approximately 2 % of the patients with gastrointestinal bleeding present with hemorrhagic shock. This review focusses on the structured preclinical and clinical management of gastrointestinal bleeding in the emergency department.
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Dixit VK, Sahu MK, Venkatesh V, Bhargav VY, Kumar V, Pateriya MB, Venkataraman J. Gastrointestinal Emergencies and the Role of Endoscopy. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1755303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractMany gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.
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Affiliation(s)
- Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Manoj Kumar Sahu
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Vybhav Venkatesh
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Varanasi Yugandhar Bhargav
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Vinod Kumar
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mayank Bhushan Pateriya
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Costa AP, Pereira CL, Garção A, Rodrigues A. Transfusion Practices in Gastrointestinal Bleeding - a Tertiary Care Single-Centre Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221087219. [PMID: 36503291 DOI: 10.1177/10760296221087219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute upper or lower Gastrointestinal bleeding (GIB) is a clinical emergency in which transfusion can be lifesaving. An individualized and restrictive transfusion strategy is recommended. This study aims to analyze and evaluate GIB transfusion practices during one year in a large tertiary hospital in Lisbon, Portugal. All patients with GIB and transfusion support during 2014 were identified and clinical data collected and statistically treated. There were 1005 GIB transfusion episodes, in a total of 494 patients. Upper GIB was more common. The median haemoglobin concentration that triggered RBC transfusion was 7,6 g/dL with a median of 2 RBC per episode. In 21,9% of episodes, RBC were used in combination with other therapies, in 70,8%, only RBC were administered and in 7,3% RBC were not used at all. In the subgroup of patients receiving FC and/or PCC there were higher median of blood products transfused: RBC (3 17 units), FFP (3 units), PC (1 unit). In a large percentage of the transfusion episodes for GIB, only RBC were used whereas only 7,3% of the GIB didn't require RBC transfusion. Patients requiring FC and/or PCC, needed more allogenic components. We observed, in accordance with the latest clinical practice guidelines and the published literature, a restrictive transfusion approach in our clinical practice.
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Affiliation(s)
- Ana Palricas Costa
- Transfusion Medicine Department, Hospital de Santa Maria, 218728Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Carla Leal Pereira
- Transfusion Medicine Department, Hospital de Santa Maria, 218728Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Garção
- Transfusion Medicine Department, Hospital de Santa Maria, 218728Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Anabela Rodrigues
- Transfusion Medicine Department, Hospital de Santa Maria, 218728Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. [Guidelines for Non-variceal Upper Gastrointestinal Bleeding]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 75:322-332. [PMID: 32581203 DOI: 10.4166/kjg.2020.75.6.322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Red Blood Cells (RBCs) have been increasingly recognized to play important roles in hemostasis and the mechanisms by which they do so continue to be elucidated. First and foremost, RBC biomechanics are the principal determinant of viscosity and flow dynamics of blood, which strongly influence all features of hemostasis. Of note, morphologic pathology, such as that found in sickle cell disease, leads to increased risk of thrombotic disease. RBC surface interactions govern signaling between platelets and RBCs and also aid in the conversion of prothrombin to thrombin. Additionally, RBCs generate microparticles which have been shown to reduce clotting time. Finally, blood clot structure and maturation are dependent on the inclusion of RBCs in forming thrombi. Here, we review the above mechanisms of RBC contribution to hemostasis.
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Affiliation(s)
- Andrea H Gillespie
- Division of Pediatric Hematology and Oncology, Oregon Health and Sciences University, Portland, OR, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, United States
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11
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Cotter J, Baldaia C, Ferreira M, Macedo G, Pedroto I. Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: A systematic review. World J Gastroenterol 2020; 26:7242-7257. [PMID: 33362380 PMCID: PMC7723662 DOI: 10.3748/wjg.v26.i45.7242] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/10/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anemia is considered a public health issue and is often caused by iron deficiency. Iron-deficiency anemia (IDA) often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women, and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%. However, few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.
AIM To review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.
METHODS Five gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites. MEDLINE (via PubMed) searches combined medical subject headings (MeSH) terms and the keywords “gastrointestinal bleeding” with “iron-deficiency anemia” and “diagnosis” or “treatment” or “management” or “prognosis” or “prevalence” or “safety” or “iron” or “transfusion” or “quality of life”, or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding; retrieved studies were published in English between January 2003 and April 2019. Worldwide professional association websites were searched for clinical practice guidelines. Reference lists from guidelines were reviewed to identify additional relevant articles. The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.
RESULTS From 494 Literature citations found during the initial literature search, 17 original articles, one meta-analysis, and 13 clinical practice guidelines were analyzed. Based on the published evidence and clinical experience, the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding: (1) Evaluation of hemoglobin and iron status; (2) Laboratory testing; (3) Target treatment population identification; (4) Indications for erythrocyte transfusion; (5) Treatment targets for erythrocyte transfusion; (6) Indications for intravenous iron; (7) Dosages; (8) Monitoring; (9) Indications for intravenous ferric carboxymaltose treatment; and (10) Treatment targets and monitoring of patients. The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding, which should be implemented during the hospital stay and follow-up visits after patient discharge.
CONCLUSION These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.
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Affiliation(s)
- José Cotter
- Department of Gastroenterology, Hospital da Senhora da Oliveira-Guimarães, Guimarães 4835-044, Portugal
- Department of Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga 4710-057, Portugal
- Department of Life and Health Sciences Research Institute (ICVS)/3B’s, PT Government Associate Laboratory, Braga 4710-057, Portugal
| | - Cilénia Baldaia
- Department of Gastroenterology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon 1649-035, Portugal
- Department of University Clinic of Medicine II, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal
| | - Manuela Ferreira
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra 3000-075, Portugal
- Department of Faculty of Medicine, University of Coimbra, Coimbra 3004-504, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, Centro Hospitalar de São João, Porto 4200-319, Portugal
- Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
- Department of Gastroenterology and Hepatology Training Center, World Gastroenterology Organization, Porto 4200-319, Portugal
| | - Isabel Pedroto
- Department of Gastroenterology, Centro Hospitalar do Porto, Porto 4099-001, Portugal
- Department of Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto 4050-313, Portugal
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12
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Marmo R, Soncini M, de Franchis R. Patient's performance status should dictate transfusion strategy in nonvariceal acute upper gastrointestinal bleeding (NV-AUGIB): A prospective multicenter cohort study: Transfusion strategy in NV-AUGIB. Dig Liver Dis 2020; 52:1156-1163. [PMID: 32788141 DOI: 10.1016/j.dld.2020.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/29/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-variceal acute UGI bleeding (NV-AUGIB) is a frequent indication for transfusion, but the best hemoglobin threshold and target values for transfusion in relation to the patients' performance status are unknown. OBJECTIVE To identify threshold and target hemoglobin levels for transfusion favoring survival of patients with NV-AUGIB stratified by ASA score. DESIGN Prospective cohort study. SETTING 50 hospitals of the Italian National Health Service. PARTICIPANTS 2758 consecutive patients with NV-AUGIB admitted to 50 Italian hospitals from January 1st, 2014 to December 31st, 2015. Five hemoglobin cut-off values were evaluated. RESULTS 30-days mortality: overall: 5.4%; ASA 1-2 patients: 2.5%; ASA 3-4 patients: 10.8%. Mortality was higher when hemoglobin at admission was ≤ 7 g/dL in ASA 1-2 patients, and when it was ≤ 8 g/dL in ASA 3-4 patients. The hemoglobin levels after transfusion favouring survival were ≥ 8 g/dL in ASA 1-2, p <0.0001 and 9-10 g/dL in ASA 3-4 patients; p = 0.0002. CONCLUSIONS In patients with NV-AUGIB the physical performance status should dictate the transfusion strategy. In ASA 1-2 patients, admission hemoglobin values ≤ 7 g/dL should prompt transfusion, aiming at a target value of 8-9 g/dL; the corresponding figures for ASA 3-4 patients are: admission hemoglobin level ≤ 8 g/dL and target value of 9-10 g/dL.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Department, Presidio Ospedaliero Luigi Curto, ASL 3 Salerno, Via Luigi Curto , Polla (Salerno)
| | - Marco Soncini
- Medical Department, A. Manzoni Hospital, ASST Lecco, Via dell'Eremo, Lecco
| | - Roberto de Franchis
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy.
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13
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. Guidelines for Nonvariceal Upper Gastrointestinal Bleeding. Gut Liver 2020; 14:560-570. [PMID: 32921639 PMCID: PMC7492499 DOI: 10.5009/gnl20154] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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14
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Ferrer‐Barceló L, Sanchis Artero L, Sempere García‐Argüelles J, Canelles Gamir P, P. Gisbert J, Ferrer‐Arranz LM, Monzó Gallego A, Plana Campos L, Huguet Malavés JM, Luján Sanchis M, Ruiz Sánchez L, Barceló Cerdá S, Medina Chuliá E. Randomised clinical trial: intravenous vs oral iron for the treatment of anaemia after acute gastrointestinal bleeding. Aliment Pharmacol Ther 2019; 50:258-268. [PMID: 31197861 PMCID: PMC6771644 DOI: 10.1111/apt.15327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 01/15/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding is prevalent condition and iron deficiency anaemia is a common comorbidity, yet anaemia treatment guidelines for affected patients are lacking. AIM To compare efficacy and safety of intravenous ferric carboxymaltose (FCM) and oral ferrous sulphate (FeSulf) in patients with anaemia secondary to non-variceal gastrointestinal bleeding METHODS: A prospective 42-day study randomised 61 patients with haemoglobin <10 g/dL upon discharge (Day 0) to receive FCM (n = 29; Day 0: 1000 mg, Day 7: 500 or 1000 mg; per label) or FeSulf (n = 32; 325 mg/12 hours for 6 weeks). Outcome measures were assessed on Days 0 (baseline), 7, 21 and 42. The primary outcome was complete response (haemoglobin ≥12 g/dL [women], ≥13 g/dL [men]) after 6 weeks. RESULTS A higher proportion of complete response was observed in the FCM vs the FeSulf group at Days 21 (85.7% vs 45.2%; P = 0.001) and 42 (100% vs 61.3%; P < 0.001). Additionally, the percentage of patients with partial response (haemoglobin increment ≥2 g/dL from baseline) was significantly higher in the FCM vs the FeSulf group (Day 21:100% vs 67.7%; P = 0.001, Day 42:100% vs 74.2%; P = 0.003). At Day 42, normalisation of transferrin saturation to 25% or greater was observed in 76.9% of FCM vs 24.1% of FeSulf-treated patients (P < 0.001). No patient in the FCM group reported any adverse event vs 10 patients in the FeSulf group. CONCLUSION FCM provided greater and faster Hb increase and iron repletion, and was better tolerated than FeSulf in patients with iron deficiency anaemia secondary to non-variceal acute gastrointestinal bleeding.
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Affiliation(s)
- Luis Ferrer‐Barceló
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | - Laura Sanchis Artero
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | | | - Pilar Canelles Gamir
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | - Javier P. Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS‐IP) y Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | | | - Ana Monzó Gallego
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | - Lydia Plana Campos
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | | | - Marisol Luján Sanchis
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | - Lucía Ruiz Sánchez
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
| | - Susana Barceló Cerdá
- Departamento de Estadística e Investigación Operativa y CalidadUniversitat Politècnica de ValènciaValenciaSpain
| | - Enrique Medina Chuliá
- Hospital General Universitario de ValenciaServicio de Patología DigestivaValenciaSpain
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15
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Kherad O, Restellini S, Martel M, Sey M, Murphy MF, Oakland K, Barkun A, Jairath V. Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther 2019; 49:919-925. [PMID: 30805962 DOI: 10.1111/apt.15158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/15/2018] [Accepted: 01/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Restrictive red blood cell (RBC) transfusion reduces mortality and rebleeding after upper gastrointestinal bleeding (UGIB). However, there is no evidence to guide transfusion strategies in lower gastrointestinal bleeding (LGIB). AIM To assess the association between RBC transfusion strategies and outcomes in patients with LGIB METHODS: This was a post hoc analysis of the UK National Comparative Audit of LGIB and the Use of Blood. The relationships between liberal RBC transfusion and clinical outcomes of rebleeding, mortality and a composite outcome for safe discharge were examined. Transfusion strategy was dichotomised and defined as "liberal" when transfusion was administered for haemoglobin (Hb) ≥80 g/L (or ≥90 g/L in patients with acute coronary syndrome) or major haemorrhage, and "restrictive" otherwise. Multivariable logistic regression models were used to assess the independent association between liberal RBC transfusion and outcomes. RESULTS Of 2528 consecutive patients enrolled from 143 hospitals in the original study, 666 (26.3%) received RBC transfusion (mean age 73.3 ± 16 years, 49% female, initial mean haemoglobin 90 ± 24 g/L, 2.3% had haemodynamic instability). The rebleeding rate in transfused patients was 42.3%. After adjusting for potential confounders, there was no difference between liberal and restrictive RBC transfusion strategies for the odds of rebleeding (OR 0.89, 95% CI 0.6-1.22), in-hospital mortality (OR 0.54, 95% CI 0.3-1.1) or of achieving the composite outcome (OR 0.72, 95% CI 0.5-1.1). CONCLUSION Although these results could be due to residual confounding, they provide an important foundation for the design of randomised trials to evaluate transfusion strategies for LGIB.
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Affiliation(s)
- Omar Kherad
- Department of Internal Medicine, La Tour Hospital and University of Geneva, Geneva, Switzerland
| | - Sophie Restellini
- Division of Gastroenterology, Geneva University Hospital and University of Geneva, Geneva, Switzerland.,Division of Gastroenterology, McGill University, Montreal, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University, Montreal, Canada
| | - Michael Sey
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | | | - Kathryn Oakland
- Division of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada.,Division of Epidemiology and Biostatistics, Western University, London, ON, Canada
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16
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Affiliation(s)
- Ali S Taha
- Gastroenterology Unit, University Hospital Crosshouse & University of Glasgow, Scotland, UK.,Department of Medicine & Gastroenterology, Baylor College of Medicine, Houston, Texas.,Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, China
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17
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Hajiagha Mohammadi AA, Reza Azizi M. Prognostic factors in patients with active non-variceal upper gastrointestinal bleeding. Arab J Gastroenterol 2019; 20:23-27. [PMID: 30770260 DOI: 10.1016/j.ajg.2019.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/22/2018] [Accepted: 01/08/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND STUDY AIMS Acute upper gastrointestinal bleeding is one of the main causes of hospitalisation. The purpose of this study was to determine the prognostic factors in non-variceal upper gastrointestinal bleeding. PATIENTS AND METHODS Clinical outcomes, demographic and laboratory variables of the subjects were collected from the HIS software and national code with the SQL format from three hospitals in Qazvin. The data were linked to the database software designed by the author. Clinical and upper endoscopic findings of patients' records were collected through a questionnaire form in the designed software database. RESULTS In this study, 29.2% of patients with favourable outcome and 64.2% of patients with unfavourable clinical outcomes had a history of anticoagulant drug use before hospitalisation (p < 0.001). The prevalence of chronic cardiovascular disease, chronic liver disease, chronic lung disease, diabetes and dialysis was higher in subjects with poor clinical outcomes than those with a favourable clinical outcome. 53.1% of subjects with favourable clinical outcome and 90.5% of subjects with undesirable clinical outcomes received packed red blood cell transfusion (p < 0.001). 16.1% of subjects with desirable clinical outcome and 86.3% of subjects with undesirable clinical outcomes received endoscopic haemostatic treatment which was statistically significant (p < 0.001). CONCLUSION Undesirable clinical outcome in patients with acute non-variceal upper gastrointestinal bleeding has a significant statistical association with longer hospitalisation, chronic underlying disease, anticoagulant administration, packed red blood cell infusion, higher Forrest stage, low systolic blood pressure, higher age, low haemoglobin, low platelet count, high INR and high BUN at the onset of diagnosis.
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Affiliation(s)
- Ali Akbar Hajiagha Mohammadi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mohammad Reza Azizi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.
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18
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Park SK. Clinical assessment and treatment algorithm for lower gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Soo-Kyung Park
- Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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19
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Lu M, Sun G, Zhang XM, Xv YQ, Chen SY, Song Y, Li XL, Lv B, Ren JL, Chen XQ, Zhang H, Mo C, Wang YZ, Yang YS. Peptic Ulcer Is the Most Common Cause of Non-Variceal Upper-Gastrointestinal Bleeding (NVUGIB) in China. Med Sci Monit 2018; 24:7119-7129. [PMID: 30291716 PMCID: PMC6187964 DOI: 10.12659/msm.909560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This study aimed to discover the common cause of non-variceal upper-gastrointestinal bleeding (NVUGIB) by conducting a multi-center retrospective study from 2008 to 2012. MATERIAL AND METHODS Hospitalized patients ages ≥18 years old, from 8 hospitals in China, diagnosed with NVUGIB by endoscopy from 1 January 2008 to 31 December 2012 were enrolled. Questionnaires were developed and a data-entry graphical user interface was designed by using EpiData software. RESULTS Total of 2977 hospitalized patients from 8 medical centers were included. A total of 95.47% (2842/2977) of patients were admitted to a general ward, 3.53% (105/2977) were admitted to an emergency ward, and 1.00% (31/2977) were admitted to an intensive care unit. Peptic ulcer remained the most common cause of NVUGIB (73.26%), but there was a declining trend in its constituent ratio, from 2008 to 2012. A total of 14.41% (429/2977) of patients had co-morbid conditions, 92.85% (2764/2977) used proton-pump inhibitors (PPIs) prior to endoscopic treatment, 19.65% (585/2977) underwent emergency endoscopy, and 23.45% (698/2977) received a transfusion of red blood cell suspensions. A total of 5.34% (159/2977) underwent endoscopic therapy, with a treatment rate of 16.9% in high-risk peptic ulcer patients (96/568). A total of 7.69% (237/2977) were administered aspirin, of whom 32.50% (77/237) resumed aspirin intake after gastrointestinal bleeding was controlled. The median length of hospitalization was 8 days (IQR, 5-11) and the mortality rate was 1.71% (51/2977). CONCLUSIONS Peptic ulcer was still the most common cause of NVUGIB in China. The proportion of patients with high-risk peptic ulcer bleeding who received endoscopic therapy was 16.9%. Only 19.65% of NVUGIB patients underwent emergency endoscopy.
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Affiliation(s)
- Mingliang Lu
- Department of Gastroenterology, The 2nd Affiliated Hospital, Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Gang Sun
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Xiao-Mei Zhang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China (mainland)
| | - You-Qing Xv
- Department of Gastroenterology, Beijing Tian Tan Hospital, Beijing, China (mainland)
| | - Shi-Yao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Ying Song
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, Shanxi, China (mainland)
| | - Xue-Liang Li
- Department of Gastroenterology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Bin Lv
- Department of Gastroenterology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland)
| | - Jian-Lin Ren
- Department of Gastroenterology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China (mainland)
| | - Xue-Qing Chen
- Department of Gastroenterology, First People's Hospital of Foshan, Foshan, Guangdong, China (mainland)
| | - Hui Zhang
- Department of Gastroenterology, Beijing Tian Tan Hospital, Beijing, China (mainland)
| | - Chen Mo
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Yan-Zhi Wang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Yun-Sheng Yang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China (mainland)
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20
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Sung JJY, Chiu PCY, Chan FKL, Lau JYW, Goh KL, Ho LHY, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67:1757-1768. [PMID: 29691276 PMCID: PMC6145289 DOI: 10.1136/gutjnl-2018-316276] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
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Affiliation(s)
- Joseph JY Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Philip CY Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James YW Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Khean-lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Lawrence HY Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jose D Sollano
- UST Hospital, University of Santo Tomas, Manila, Philippines
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Asian Healthcare Foundation, Hyderabad, India
| | - Rajvinder Singh
- Department of Medicine, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Shimotsuke, Japan
| | - Kai-chun Wu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Xi’an, China
| | | | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- Department of Gastroenterology, University Hospital, Zaragoza, Spain
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Abstract
Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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22
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The association between red blood cell transfusion and outcomes in patients with upper gastrointestinal bleeding. Clin Transl Gastroenterol 2018; 9:138. [PMID: 29599508 PMCID: PMC5876358 DOI: 10.1038/s41424-018-0004-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/02/2018] [Accepted: 01/07/2018] [Indexed: 12/26/2022] Open
Abstract
Background The benefits of transfusion for acute upper gastrointestinal bleeding (UGIB) have not been well established; however, previous studies suggest that transfusion is associated with adverse outcomes. We performed an observational study using a 10-year database to analyze the association between red blood cell (RBC) transfusion and outcomes in patients with UGIB in the emergency department (ED). Method and findings All adult patients with UGIB were identified through diagnostic codes. Hospital mortality was the primary outcome; further bleeding was the secondary outcome. Logistic regression, propensity analyses, and conditional logistic regression were performed to determine factors associated with outcomes. Of 59,188 enrolled patients, 31.6% (n = 18,705) received RBC transfusions within 24 h following presentation to the ED. Hospital mortality was noted in 3.9 and 10.6% of the patients in the non-RBC transfusion and RBC transfusion groups, respectively (P < 0.001). RBC transfusion was associated with increased mortality risk (unadjusted odds ratio (OR) 2.95, 95% confidence interval (CI) 2.75–3.16; P < 0.001) among all patients and in the propensity-matched cohort (unadjusted OR 1.55, 95% CI 1.39–1.72; P < 0.001). Further bleeding was noted in 5.6 and 33.8% of the patients in the non-RBC transfusion and RBC transfusion groups, respectively (P < 0.001). RBC transfusion was associated with increased risk of further bleeding (unadjusted OR 8.60, 95% CI 8.16–9.06; P < 0.001) among all patients and in the propensity-matched cohort (unadjusted OR 2.58, 95% CI 2.37–2.79; P < 0.001). Conclusion RBC transfusion was significantly associated with increased rates of hospital mortality and further bleeding in patients with UGIB. Although our findings have strengths, these results are not generalizable to all patients presenting with UGIB, especially patients presenting with exsanguinating bleeding. Additional prospective trials to guide optimal transfusion strategies in UGIB patients are needed.
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23
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Werner DJ, Manner H, Nguyen-Tat M, Kloeckner R, Kiesslich R, Abusalim N, Rey JW. Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature. United European Gastroenterol J 2017; 6:337-342. [PMID: 29774146 DOI: 10.1177/2050640617746299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
Abstract
Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.
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Affiliation(s)
- David J Werner
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Hendrik Manner
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Marc Nguyen-Tat
- First Department of Internal Medicine, University Medical Center, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz, Germany
| | - Ralf Kiesslich
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Nael Abusalim
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Johannes W Rey
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
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Prehospital Transfusion for Gastrointestinal Bleeding. Air Med J 2017; 36:315-319. [PMID: 29122112 DOI: 10.1016/j.amj.2017.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. METHODS We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. RESULTS A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. CONCLUSION Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.
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Gombotz H, Schreier G, Neubauer S, Kastner P, Hofmann A. Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study. BMJ Open 2016; 6:e012210. [PMID: 27965248 PMCID: PMC5168603 DOI: 10.1136/bmjopen-2016-012210] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery. SETTINGS 23 Austrian centres randomly selected and stratified by region and level of care. PARTICIPANTS We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR). MAIN OUTCOME MEASURES Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5. RESULTS In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories. CONCLUSIONS The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.
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Affiliation(s)
- Hans Gombotz
- Department of Anaesthesiology and Intensive Care,General Hospital Linz, Vienna, Austria
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Günter Schreier
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Sandra Neubauer
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Peter Kastner
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Axel Hofmann
- Department of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, School of Surgery, Dentistry and Health Sciences, University of Western Australia, Western Australia, Australia
- Faculty of Health Sciences, Curtin University, Western Australia, Australia
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Long B, Koyfman A. Red Blood Cell Transfusion in the Emergency Department. J Emerg Med 2016; 51:120-30. [PMID: 27262735 DOI: 10.1016/j.jemermed.2016.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/09/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of red blood cells (RBCs) is the primary management of anemia, which affects 90% of critically ill patients. Anemia has been associated with a poor prognosis in various settings, including critical illness. Recent literature has shown a hemoglobin transfusion threshold of 7 g/dL to be safe. This review examines several aspects of transfusion. OBJECTIVE We sought to provide emergency physicians with an updated review of indications for RBC transfusion in the emergency department. DISCUSSION The standard hemoglobin transfusion threshold was 10 g/dL. However, the body shows physiologic compensatory adaptations to chronic anemia. Transfusion reactions and infections are rare but can have significant morbidity and mortality. Products stored for <21 days have the lowest risk of reaction and infection. A restrictive threshold of 7 g/dL is recommended in the new American Association of Blood Banks guidelines and multiple meta-analyses and supported in gastrointestinal bleeding, sepsis, critical illness, and trauma. Patients with active ischemia in acute coronary syndrome and neurologic injury require additional study. The physician must consider the patient's hemodynamic status, comorbidities, risks and benefits of transfusion, and clinical setting in determining the need for transfusion. CONCLUSIONS RBC transfusion is not without risks, including transfusion reaction, infection, and potentially increased mortality. The age of transfusion products likely has no effect on products before 21 days of storage. A hemoglobin level of 7 g/dL is safe in the setting of critical illness, sepsis, gastrointestinal bleeding, and trauma. The clinician must evaluate and transfuse based on the clinical setting and patient hemodynamic status rather than using a specific threshold.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 287] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
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Subramaniam K, Spilsbury K, Ayonrinde OT, Latchmiah F, Mukhtar SA, Semmens JB, Leahy MF, Olynyk JK. Red blood cell transfusion is associated with further bleeding and fresh-frozen plasma with mortality in nonvariceal upper gastrointestinal bleeding. Transfusion 2015; 56:816-26. [PMID: 26718025 DOI: 10.1111/trf.13446] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 10/23/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Blood products are commonly transfused for patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). While concerns exist about further bleeding and mortality in subsets of patients receiving red blood cell (RBC) transfusion, the impact of non-RBC blood products has not previously been systematically investigated. The aim of the study was to investigate the associations between blood products transfusion, further bleeding, and mortality after acute NVUGIB. STUDY DESIGN AND METHODS A retrospective cohort study examined further bleeding and 30-day and 1-year mortality in adult patients who underwent gastroscopy for suspected acute NVUGIB between 2008 and 2010 in three tertiary hospitals in Western Australia. Survival analysis was performed. RESULTS A total of 2228 adults (63% male) with 2360 hospital admissions for NVUGIB met the inclusion criteria. Median age at presentation was 70 years (range, 19-99 years). Thirty-day mortality was 4.9% and 1-year mortality was 13.9%. Transfusion of 4 or more units of RBCs was associated with greater than 10 times the odds of further bleeding in patients with a hemoglobin level of more than 90 g/L (odds ratio, 11.9; 95% confidence interval [CI], 3.1-45.7; p ≤ 0.001), but was not associated with mortality. Administration of 5 or more units of fresh-frozen plasma (FFP) was associated with increased 30-day (hazard ratio, 2.8; 95% CI, 1.3-5.9; p = 0.008) and 1-year (hazard ratio, 2.6; 95% CI, 1.3-5.0; p = 0.005) mortality after adjusting for coagulopathy, comorbidity, Rockall score, and other covariates. CONCLUSION In this large, multicenter study of NVUGIB, RBC transfusion was associated with further bleeding but not mortality, while FFP transfusion was associated with increased mortality in a subset of patients.
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Affiliation(s)
- Kavitha Subramaniam
- Gastroenterology and Hepatology Unit, The Canberra Hospital.,Australian National University Medical School, Canberra, ACT, Australia
| | | | - Oyekoya T Ayonrinde
- Centre for Population Health Research.,Department of Gastroenterology, Fremantle Hospital.,School of Medicine and Pharmacology (Fremantle Hospital Campus), The University of Western Australia, Fremantle, WA, Australia.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital
| | - Faye Latchmiah
- Department of Gastroenterology, Fremantle Hospital.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital
| | | | | | - Michael F Leahy
- School of Medicine and Pharmacology (Fremantle Hospital Campus), The University of Western Australia, Fremantle, WA, Australia.,Department of Haematology, Royal Perth Hospital, Perth, WA, Australia
| | - John K Olynyk
- Department of Gastroenterology, Fremantle Hospital.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital.,Curtin Health Innovation Research Institute and School of Biomedical Sciences, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia.,School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA, Australia
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30
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Jairath V, Desborough MJR. Modern-day management of upper gastrointestinal haemorrhage. Transfus Med 2015; 25:351-7. [DOI: 10.1111/tme.12266] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/08/2015] [Accepted: 11/16/2015] [Indexed: 12/12/2022]
Affiliation(s)
- V. Jairath
- Gastroenterology Unit; Oxford University Hospitals Foundation Trust; Oxford UK
- Nuffield Department of Medicine; University of Oxford; Oxford UK
- Department of Medicine; Western University; London Canada
| | - M. J. R. Desborough
- NHS Blood and Transplant; John Radcliffe Hospital; Oxford UK
- Department of Haematology; Oxford University Hospitals Foundation Trust; Oxford UK
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
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31
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Stokes A, Thompson C, Clegg A, Snook J. The influence of a simple blood transfusion policy on overtransfusion in acute upper gastrointestinal haemorrhage. Clin Med (Lond) 2015; 15:325-9. [PMID: 26407379 PMCID: PMC4952792 DOI: 10.7861/clinmedicine.15-4-325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Blood transfusion is widely used in the management of acute upper gastrointestinal haemorrhage (AUGIH). Trial data suggests that excessive transfusion may be detrimental, yet overtransfusion remains commonplace. This study reports the impact of introducing a simple cross-match policy in a district general hospital, which resulted in a substantial fall in the prevalence of overtransfusion (odds ratio 0.43; 95% confidence interval 0.19-0.98), with potential patient benefits in terms of rebleeding, and a reduction in the total blood transfused from 162 to 121 units per 100 patients with AUGIH. For the cost of blood alone, this corresponds to projected savings across the NHS in England in excess of £2 million per annum.
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Affiliation(s)
- Adam Stokes
- Poole Hospital NHS Foundation Trust, Poole, UK
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32
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Jairath V, Kahan BC, Gray A, Doré CJ, Mora A, James MW, Stanley AJ, Everett SM, Bailey AA, Dallal H, Greenaway J, Le Jeune I, Darwent M, Church N, Reckless I, Hodge R, Dyer C, Meredith S, Llewelyn C, Palmer KR, Logan RF, Travis SP, Walsh TS, Murphy MF. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial. Lancet 2015; 386:137-44. [PMID: 25956718 DOI: 10.1016/s0140-6736(14)61999-1] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transfusion thresholds for acute upper gastrointestinal bleeding are controversial. So far, only three small, underpowered studies and one single-centre trial have been done. Findings from the single-centre trial showed reduced mortality with restrictive red blood cell (RBC) transfusion. We aimed to assess whether a multicentre, cluster randomised trial is a feasible method to substantiate or refute this finding. METHODS In this pragmatic, open-label, cluster randomised feasibility trial, done in six university hospitals in the UK, we enrolled all patients aged 18 years or older with new presentations of acute upper gastrointestinal bleeding, irrespective of comorbidity, except for exsanguinating haemorrhage. We randomly assigned hospitals (1:1) with a computer-generated randomisation sequence (random permuted block size of 6, without stratification or matching) to either a restrictive (transfusion when haemoglobin concentration fell below 80 g/L) or liberal (transfusion when haemoglobin concentration fell below 100 g/L) RBC transfusion policy. Neither patients nor investigators were masked to treatment allocation. Feasibility outcomes were recruitment rate, protocol adherence, haemoglobin concentration, RBC exposure, selection bias, and information to guide design and economic evaluation of the phase 3 trial. Main exploratory clinical outcomes were further bleeding and mortality at day 28. We did analyses on all enrolled patients for whom an outcome was available. This trial is registered, ISRCTN85757829 and NCT02105532. FINDINGS Between Sept 3, 2012, and March 1, 2013, we enrolled 936 patients across six hospitals (403 patients in three hospitals with a restrictive policy and 533 patients in three hospitals with a liberal policy). Recruitment rate was significantly higher for the liberal than for the restrictive policy (62% vs 55%; p=0·04). Despite some baseline imbalances, Rockall and Blatchford risk scores were identical between policies. Protocol adherence was 96% (SD 10) in the restrictive policy vs 83% (25) in the liberal policy (difference 14%; 95% CI 7-21; p=0·005). Mean last recorded haemoglobin concentration was 116 (SD 24) g/L for patients on the restrictive policy and 118 (20) g/L for those on the liberal policy (difference -2·0 [95% CI -12·0 to 7·0]; p=0·50). Fewer patients received RBCs on the restrictive policy than on the liberal policy (restrictive policy 133 [33%] vs liberal policy 247 [46%]; difference -12% [95% CI -35 to 11]; p=0·23), with fewer RBC units transfused (mean 1·2 [SD 2·1] vs 1·9 [2·8]; difference -0·7 [-1·6 to 0·3]; p=0·12), although these differences were not significant. We noted no significant difference in clinical outcomes. INTERPRETATION A cluster randomised design led to rapid recruitment, high protocol adherence, separation in degree of anaemia between groups, and non-significant reduction in RBC transfusion in the restrictive policy. A large cluster randomised trial to assess the effectiveness of transfusion strategies for acute upper gastrointestinal bleeding is both feasible and essential before clinical practice guidelines change to recommend restrictive transfusion for all patients with acute upper gastrointestinal bleeding. FUNDING NHS Blood and Transplant Research and Development.
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Affiliation(s)
- Vipul Jairath
- NHS Blood and Transplant, Oxford, UK; Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Brennan C Kahan
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Alasdair Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Caroline J Doré
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Ana Mora
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Martin W James
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Simon M Everett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - Adam A Bailey
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Helen Dallal
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - John Greenaway
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - Ivan Le Jeune
- Department of Research and Education in Emergency Medicine, Acute Medicine and Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Melanie Darwent
- Department of Emergency Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Nicholas Church
- Department of Gastroenterology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ian Reckless
- Department of Acute General Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Renate Hodge
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Dyer
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Sarah Meredith
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | | | - Richard F Logan
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon P Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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Abstract
Overt or occult gastrointestinal bleeding is a frequently observed condition in routine gastroenterological practice. Occult gastrointestinal bleeding is usually a purely incidental finding, based on the discovery of iron deficiency anemia in the laboratory or blood in stool (a positive Hemoccult test). However, overt bleeding accompanied by the clinical features of tarry stool, hematemesis, or hematochezia may be a life-threatening condition, calling for immediate emergency management. In contrast to traumatology, algorithms of emergency and intensive medicine are not sufficiently validated yet for acute life-threatening bleeding. The purpose of this review was to present all established and new endoscopic hemostasis techniques and to evaluate their efficacy, as well as to provide the treating endoscopist with practical advice on how he/she could incorporate these procedures into acute medical management. The recommendations are based on inspection of the study results in the recent published literature, as well as emergency medicine algorithms in traumatology.
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Laursen SB, Hansen JM, Hallas J, Schaffalitzky de Muckadell OB. The excess long-term mortality in peptic ulcer bleeding is explained by nonspecific comorbidity. Scand J Gastroenterol 2015; 50:145-52. [PMID: 25540986 DOI: 10.3109/00365521.2014.992365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Previous studies have concluded that peptic ulcer bleeding (PUB) is associated with increased long-term mortality. The underlying mechanism of this excess mortality is poorly understood. The aim of the present study was to examine if PUB patients have an increased long-term mortality compared to a matched control group when adjusting for comorbidity and socioeconomic status. Additionally, we identified predictive factors for mortality and examined causes of death. MATERIAL AND METHODS We performed an observational study, comparing consecutive patients admitted with PUB with a matched control cohort from the source population. Predictors of mortality were identified using proportional hazards models. Causes of death were retrieved from death certificates. Long-term mortality was analyzed with adjustment for Charlson comorbidity index (CCI) and average income in residence municipality using proportional hazards models. RESULTS We included 455 PUB cases and 2224 control subjects. Median follow up was 9.7 years, and median survival for the PUB and control cohorts was 7 and 12 years, respectively (p < 0.001). PUB patients had a higher level of comorbidity (mean CCI: 0.92 vs. 0.49; p < 0.0001). After adjustments, PUB patients had an excess mortality lasting at least 10 years after presentation. Age, comorbidity, male sex, anemia, and smoking were predictors for long-term mortality. The distribution of causes of death was similar in the two cohorts. CONCLUSION PUB patients have an increased long-term mortality that is explained by nonspecific comorbidity.
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Affiliation(s)
- Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital , Odense C , Denmark
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35
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Hong MJ, Lee SY, Kim JH, Sung IK, Park HS, Shim CS, Jin CJ. Rebleeding after initial endoscopic hemostasis in peptic ulcer disease. J Korean Med Sci 2014; 29:1411-5. [PMID: 25368496 PMCID: PMC4214943 DOI: 10.3346/jkms.2014.29.10.1411] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/07/2014] [Indexed: 12/12/2022] Open
Abstract
Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.
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Affiliation(s)
- Mi Jin Hong
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - In-Kyung Sung
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Chan Sup Shim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Choon Jo Jin
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Duggan J. Transfusion in gastrointestinal haemorrhage: time to change? Intern Med J 2014; 44:427-8. [DOI: 10.1111/imj.12392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 11/22/2013] [Indexed: 11/30/2022]
Affiliation(s)
- J. Duggan
- School of Medical Practice and Population Health; University of Newcastle; Newcastle New South Wales Australia
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Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Y Lu
- Division of Gastroenterology and
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Predictors of early rebleeding after endoscopic therapy in patients with nonvariceal upper gastrointestinal bleeding secondary to high-risk lesions. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:454-8. [PMID: 23936874 DOI: 10.1155/2013/128760] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In an era of increasingly shortened admissions, data regarding predictors of early rebleeding among patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) exhibiting high-risk stigmata (HRS) having undergone endoscopic hemostasis are lacking. OBJECTIVES To determine predictors of early rebleeding, defined as rebleeding before completion of recommended 72 h intravenous proton pump inhibitor infusion postendoscopic hemostasis. METHODS Data from a national registry of patients with upper gastrointestinal bleeding (the REASON registry) were accessed. Univariable and multivariable analyses were sequentially performed to identify significant independent predictors among a comprehensive list of clinical and laboratory characteristics. RESULTS Overall, 393 patients underwent endoscopic hemostasis for NVUGIB with HRS. Forty patients rebled ≤72 h thereafter (32.5% female, mean [± SD] age 70.2 ± 11.8 years, 2.88 ± 2.11 comorbidities), while 21 rebled later (38.1% female, mean 70.5 ± 14.1 years of age, 2.62 ± 2.06 comorbidities). Hematemesis or bright red blood per nasogastric tube aspirate was identified as the sole independent significant predictor of early rebleeding versus later among both NVUGIB and, more specifically, patients with peptic ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P<0.01, and OR 8.41 [95% CI 1.54 to 46.10]; P=0.014, respectively). CONCLUSIONS When attempting to determine the optimal duration of pharmacotherapy and timing of discharge for patients following endoscopic hemostasis for NVUGIB with HRS, it is noteworthy that individuals who present with hematemesis or bright red blood per nasogastric tube aspirate are at particularly high risk for rebleeding within the first 72 h.
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Wang J, Bao YX, Bai M, Zhang YG, Xu WD, Qi XS. Restrictive vs liberal transfusion for upper gastrointestinal bleeding: A meta-analysis of randomized controlled trials. World J Gastroenterol 2013; 19:6919-6927. [PMID: 24187470 PMCID: PMC3812494 DOI: 10.3748/wjg.v19.i40.6919] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/16/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of upper gastrointestinal bleeding (UGIB) between patients receiving restrictive and liberal transfusion.
METHODS: PubMed, EMBASE, and Cochrane Library databases were employed to identify all relevant randomized controlled trials regarding the outcome of UGIB after restrictive or liberal transfusion. Primary outcomes were death and rebleeding. Secondary outcomes were length of hospitalization, amount of blood transfused, and hematocrit and hemoglobin at discharge or after expansion.
RESULTS: Overall, 4 papers were included in this meta-analysis. The incidence of death was significantly lower in patients receiving restrictive transfusion than those receiving liberal transfusion (OR: 0.52, 95%CI: 0.31-0.87, P = 0.01). The incidence of rebleeding was lower in patients receiving restrictive transfusion than those receiving liberal transfusion, but this difference did not reach any statistical significance (OR: 0.26, 95%CI: 0.03-2.10, P = 0.21). Compared with those receiving liberal transfusion, patients receiving restrictive transfusion had a significantly shorter length of hospitalization (standard mean difference: -0.17, 95%CI: -0.30--0.04, P = 0.009) and a significantly smaller amount of blood transfused (standard mean difference: -0.74, 95%CI: -1.15--0.32, P = 0.0005) with a lower hematocrit and hemoglobin level at discharge or after expansion.
CONCLUSION: Restrictive transfusion should be employed in patients with UGIB.
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Bryant RV, Kuo P, Williamson K, Yam C, Schoeman MN, Holloway RH, Nguyen NQ. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013; 78:576-83. [PMID: 23790755 DOI: 10.1016/j.gie.2013.05.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 05/06/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data regarding the utility of the Glasgow-Blatchford bleeding score (GBS) in hospitalized patients with upper GI hemorrhage are limited. OBJECTIVE To evaluate the performance of the GBS in predicting clinical outcomes and the need for interventions in patients with upper GI hemorrhage. DESIGN Prospective observational study. SETTING Single, tertiary-care endoscopic center. PATIENTS Between July 2010 and July 2012, 888 consecutive hospitalized patients managed for upper GI hemorrhage were entered into the study. INTERVENTION GBS and Rockall scores. MAIN OUTCOME MEASUREMENTS GBS and Rockall scores were prospectively calculated. The performance of these scores to predict the need for interventions and outcomes was assessed by using a receiver operating characteristic curve. RESULTS Endoscopy was performed in 708 patients (80%). A total of 286 patients (40.3%) required endoscopic therapy, and 29 patients (3.8%) underwent surgery. GBS and post-endoscopy Rockall scores (post-E RS) were superior to pre-endoscopy Rockall scores in predicting the need for endoscopic therapy (area under the curve [AUC] 0.76 vs 0.76 vs 0.66, respectively) and rebleeding (AUC 0.71 vs 0.64 vs 0.57). The GBS was superior to Rockall scores in predicting the need for blood transfusion (AUC 0.81 vs 0.70 vs 0.68) and surgery (AUC 0.71 vs 0.64 vs 0.51). Patients with GBS scores ≤ 3 did not require intervention. LIMITATIONS Subjective decision making as to need for endoscopic therapy and blood transfusion. CONCLUSION Compared with post-E RS, the GBS was superior in predicting the need for blood transfusion and surgery in hospitalized patients with upper GI hemorrhage and was equivalent in predicting the need for endoscopic therapy, rebleeding, and death. There are potential cutoff GBS scores that allow risk stratification for upper GI hemorrhage, which warrant further evaluation.
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Affiliation(s)
- Robert V Bryant
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia
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Al-Jaghbeer M, Yende S. Blood transfusion for upper gastrointestinal bleeding: is less more again? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:325. [PMID: 24063362 PMCID: PMC4056793 DOI: 10.1186/cc13020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background The hemoglobin threshold for transfusion of red blood cells in patients with
acute gastrointestinal (GI) bleeding is controversial. We compared the
efficacy and safety of a restrictive transfusion strategy with those of a
liberal transfusion strategy. Methods Objective: The objective was to prove that the restrictive
threshold for red blood cell transfusion in patients with acute upper GI
bleeding (UGIB) was safer and more effective than a liberal transfusion
strategy. Design: A single-center, randomized controlled trial was
conducted. Setting: Patients with GI bleeding were admitted to the de la Santa
Creu i Sant Pau hospital in Barcelona, Spain. Subjects: The subjects were adult intensive care unit patients
admitted with high clinical suspicion of UGIB (hematomemesis, melena, or
both). Patients were excluded if they had massive exsanguinating bleeding,
acute coronary syndrome, symptomatic peripheral vascular disease,
stroke/transient ischemic attack, transfusion within the previous 90 days,
recent trauma or surgery, lower GI bleeding, or a clinical Rockall score of
0 with hemoglobin higher than 12 g/dL. Intervention: A total of 921 patients with severe acute UGIB were
enrolled. Of these, 461 were randomly assigned to a restrictive strategy
(transfusion when the hemoglobin level fell to below 7 g/dL) and 460 to a
liberal strategy (transfusion when the hemoglobin fell to below 9 g/dL).
Random assignment was stratified according to the presence or absence of
liver cirrhosis. Outcomes: The primary outcome was rate of death from any cause
within the first 45 days. Secondary outcomes were further bleeding, defined
as hematemesis or melena with hemodynamic instability or hemoglobin decrease
of 2 g/dL or more, and in-hospital complications. Results In total, 225 patients assigned to the restrictive strategy (51%) and 65
assigned to the liberal strategy (15%) did not receive transfusions
(P <0.001). The probability of survival at 6 weeks was
higher in the restrictive-strategy group than in the liberal-strategy group
(95% versus 91%; hazard ratio (HR) for death with restrictive strategy,
0.55; 95% confidence interval (CI) 0.33 to 0.92; P = 0.02). Further
bleeding occurred in 10% of the patients in the restrictive-strategy group
and in 16% of the patients in the liberal-strategy group (P =
0.01), and adverse events occurred in 40% and 48%, respectively (P
= 0.02). The probability of survival was slightly higher with the
restrictive strategy than with the liberal strategy in the subgroup of
patients who had bleeding associated with a peptic ulcer (HR 0.70, 95% CI
0.26 to 1.25) and was significantly higher in the subgroup of patients with
cirrhosis and Child-Pugh class A or B disease (HR 0.30, 95% CI 0.11 to 0.85)
but not in those with cirrhosis and Child-Pugh class C disease (HR 1.04, 95%
CI 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient
increased significantly in patients assigned to the liberal strategy
(P = 0.03) but not in those assigned to the restrictive
strategy. Conclusions Compared with a liberal transfusion strategy, a restrictive strategy
significantly improved outcomes in patients with acute UGIB.
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Kahan BC, Jairath V, Murphy MF, Doré CJ. Update on the transfusion in gastrointestinal bleeding (TRIGGER) trial: statistical analysis plan for a cluster-randomised feasibility trial. Trials 2013; 14:206. [PMID: 23837630 PMCID: PMC3716978 DOI: 10.1186/1745-6215-14-206] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/27/2013] [Indexed: 01/14/2023] Open
Abstract
Background Previous research has suggested an association between more liberal red blood cell (RBC) transfusion and greater risk of further bleeding and mortality following acute upper gastrointestinal bleeding (AUGIB). Methods and design The Transfusion in Gastrointestinal Bleeding (TRIGGER) trial is a pragmatic cluster-randomised feasibility trial which aims to evaluate the feasibility of implementing a restrictive vs. liberal RBC transfusion policy for adult patients admitted to hospital with AUGIB in the UK. This trial will help to inform the design and methodology of a phase III trial. The protocol for TRIGGER has been published in Transfusion Medicine Reviews. Recruitment began in September 2012 and was completed in March 2013. This update presents the statistical analysis plan, detailing how analysis of the TRIGGER trial will be performed. It is hoped that prospective publication of the full statistical analysis plan will increase transparency and give readers a clear overview of how TRIGGER will be analysed. Trial registration ISRCTN85757829
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Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit, Aviation House 125 Kingsway, London WC2B 6NH, UK.
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Restrictive vs liberal blood transfusion for acute upper gastrointestinal bleeding: rationale and protocol for a cluster randomized feasibility trial. Transfus Med Rev 2013; 27:146-53. [PMID: 23706959 PMCID: PMC4046243 DOI: 10.1016/j.tmrv.2013.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 12/13/2022]
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is the commonest reason for hospitalization with hemorrhage in the UK and the leading indication for transfusion of red blood cells (RBCs). Observational studies suggest an association between more liberal RBC transfusion and adverse patient outcomes, and a recent randomised trial reported increased further bleeding and mortality with a liberal transfusion policy. TRIGGER (Transfusion in Gastrointestinal Bleeding) is a pragmatic, cluster randomized trial which aims to evaluate the feasibility and safety of implementing a restrictive versus liberal RBC transfusion policy in adult patients admitted with AUGIB. The trial will take place in 6 UK hospitals, and each centre will be randomly allocated to a transfusion policy. Clinicians throughout each hospital will manage all eligible patients according to the transfusion policy for the 6-month trial recruitment period. In the restrictive centers, patients become eligible for RBC transfusion when their hemoglobin is < 8 g/dL. In the liberal centers patients become eligible for transfusion once their hemoglobin is < 10 g/dL. All clinicians will have the discretion to transfuse outside of the policy but will be asked to document the reasons for doing so. Feasibility outcome measures include protocol adherence, recruitment rate, and evidence of selection bias. Clinical outcome measures include further bleeding, mortality, thromboembolic events, and infections. Quality of life will be measured using the EuroQol EQ-5D at day 28, and the costs associated with hospitalization for AUGIB in the UK will be estimated. Consent will be sought from participants or their representatives according to patient capacity for use of routine hospital data and day 28 follow up. The study has ethical approval for conduct in England and Scotland. Results will be analysed according to a pre-defined statistical analysis plan and disseminated in peer reviewed publications to relevant stakeholders. The results of this study will inform the feasibility and design of a phase III randomized trial.
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Jairath V. Acute upper gastrointestinal bleeding-time for some new triggers? Transfus Med 2013; 23:139-41. [DOI: 10.1111/tme.12048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Indexed: 01/19/2023]
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Lin HJ. Letter: is blood transfusion really a risk factor for rebleeding in nonvariceal gastrointestinal bleeding? Aliment Pharmacol Ther 2013; 37:838-9. [PMID: 23496314 DOI: 10.1111/apt.12253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 01/28/2013] [Indexed: 12/08/2022]
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Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Letter: is blood transfusion really a risk factor for rebleeding in nonvariceal gastrointestinal bleeding? Authors' reply. Aliment Pharmacol Ther 2013; 37:839-40. [PMID: 23496316 DOI: 10.1111/apt.12257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 01/31/2013] [Indexed: 12/08/2022]
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