Gastrointestinal bleeding

Process of care in acute nonvariceal upper-GI hemorrhage

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

Outpatient management of “low-risk” nonvariceal upper GI hemorrhage. Are we ready to put evidence into practice?

Video capsule endoscopy for triage of patients with acute upper GI hemorrhage: Is seeing believing?

BackgroundIn patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants.ObjectiveTo analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB.MethodsRetrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality.ResultsFrom 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1–5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 – 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups.ConclusionEarly endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.

BackgroundThe findings on mortality, rebleeding rate, and hospital stay in patients who underwent early vs. late endoscopy are conflicting. We aimed to compare in-hospital outcomes and medical resource use in patients with acute non-variceal upper gastrointestinal bleeding.MethodsWe retrospectively reviewed the medical records of patients with acute non-variceal upper gastrointestinal bleeding who underwent early or late endoscopy between 2016 and 2019. The primary outcome was in-hospital mortality. The secondary outcomes were the need for packed red blood cells and number of transfusions, the proportion of lesions with high-risk stigmata, endoscopic and additional hemostasis, in-hospital rebleeding, duration of stay, and admission cost. Statistical analysis was performed using Pearson’s chi-squared or Fisher’s exact test for categorical variables, Student’s t-test, and Wilcoxon rank-sum test for continuous variables.ResultsEarly and late endoscopies were performed on 451 and 279 patients, respectively. After 1:1 propensity score matching, 278 patients from each group were included, and patients’ baseline characteristics were similar in the matched groups. Compared with the late group, the early group had a significantly increased rate of endoscopic hemostasis (22.7% vs. 13.7%, P = 0.006) and a low rate of packed red blood cell transfusion (53.6% vs. 61.9%, P = 0.048). Duration of stay and admission costs were significantly higher in the late group than in the early group (all P < 0.05). After adjusting for confounding factors, early endoscopy was positively associated with ulcers with high-risk stigmata (adjusted odds ratio = 1.83, P = 0.023) and endoscopic hemostasis (adjusted odds ratio = 1.97, P = 0.004). It was negatively associated with the need for packed red blood cell transfusion (adjusted odds ratio = 0.62, P = 0.017) and duration of stay (adjusted coefficient=-0.10, P < 0.001) with no impact on in-hospital mortality, rebleeding, or radiological interventions.ConclusionsThe timing of endoscopy does not affect in-hospital mortality or rebleeding rate. This study supports using early endoscopy in patients with acute non-variceal upper gastrointestinal bleeding based on the potential benefits and feasibility of medical resource use.

Silencing the Erupter: Over-the-Scope Clip in the Management of Nonvariceal Upper Gastrointestinal Bleeding

Glue for gastric varices: some sticky issues

IntroductionHemospray is an endoscopic haemostatic agent licensed for use in non-variceal upper gastrointestinal bleeding (UGIB). It has been shown to be effective in achieving haemostasis in bleeding peptic ulcers in...

Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3h) or following (< 3h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. A total of 68 patients (38 men, median age 69years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.

BackgroundTo evaluate the optimal endoscopy time in elderly patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) based on clinical outcomes.MethodsPatients over 65 years of age presenting with NVUGIB are three patient groups based on endoscopy timing: very early endoscopy (< 12 h), early endoscopy (12–24 h) and late endoscopy (> 24 h). Endoscopic intervention was undertaken during the first 12 h for patients who had unstable hemodynamic settings, ongoing bleeding, or a low hematocrit despite transfusion. The clinical outcomes investigated were: The primary endpoint was 30-day mortality, with the need for endoscopic intervention, rebleeding, and length of hospital stay considered as secondary endpoints.ResultsThe study population was 468, 260 of whom were ≥ 65 years. Based on the timing of endoscopy, very early endoscopy (within 12 h) was performed in 180 (69.2%) patients aged > 65 years and 150 (72.1%) younger patients (p > 0.05). Early endoscopy (12–24 h) was performed in patients aged > 65 years and younger patients 53 (20.4%) vs. 41 (19.7%), respectively, while late endoscopy (24–48 h) was performed in 27 (10.4%) vs. 17 (8.2%) patients, respectively (p > 0.05, for all parameters). The clinical results of subgroups based on endoscopy time in the ≥ 65 population and comparisons between groups. When groups were compared, it was found that the very early endoscopy group had a considerably lower likelihood of need for surgical/radiological intervention than the late endoscopy group [3 (1,7) vs. (3,7), p = 0.016], and 30-day mortality rates by the endoscopy timing were statistically significantly different in the very early group (15.6%), early endoscopy group (7.5%), and late endoscopy group (29.6%) (p < 0.05, for all groups). Endoscopy time within 24–48 h (late) (OR: 3.133, 95%Cl: 1.127–8.713, p: 0.029) was an independent predictor of rebleeding during the hospital stay.ConclusionsEarly endoscopy may benefit the management of acute UGIB, especially in the elderly population with high comorbidities and the severity of bleeding.

Outcomes of Weekend Admissions for Upper Gastrointestinal Hemorrhage: A Nationwide Analysis

Objective:To explore the efficacy and safety of endoscopic submucosal dissection (ESD) in patients with early gastrointestinal (GI) cancer and precancerous lesion.Methods:A total of 132 patients with early GI cancer or precancerous lesion who underwent surgery at Zunhua People’s Hospital between March 2021 and June 2023 were retrospectively analyzed. Among them, 65 patients underwent endoscopic mucosal resection (EMR) (Control group), and 67 underwent ESD (ESD group). Perioperative information, treatment outcomes, stress response indicators, miR-146a and miR-199a levels, and incidence of postoperative complications were compared between the two groups.Results:Surgery duration in the ESD group was significantly longer than that in the Control group. However, the intraoperative blood loss in the ESD group was lower, and the duration of anal ventilation and hospitalization was longer than in the Control group (P<0.05). Total treatment efficacy of the ESD group was significantly higher compared to the Control group (P<0.05). After the surgery, levels of serum cortisol (Cor), norepinephrine (NE), epinephrine (E), and aldosterone (ALD) in both groups significantly increased compared to those before the surgery, and were significantly lower in the ESD group compared to the Control group (P<0.05). After the surgery, expression levels of miR-146a in both groups significantly decreased, while miR-199a levels significantly increased compared to the preoperative levels, and the difference in the ESD group was more significant than in the Control group (P<0.05). There was no statistically significant difference in the incidence of complications between the two groups (P>0.05).Conclusions:In patients with early GI cancer or precancerous lesion, ESD can reduce surgical trauma, improve the expression of miR-146a and miR-199a, and alleviate the degree of surgical stress response. ESD is safe and is associated with improved treatment effectiveness and reduce occurrence of complications.

Severe submucosal fibrosis is a crucial technical difficulty encountered during endoscopic submucosal dissection (ESD) in patients with ulcerative colitis (UC). We aimed to identify predictors of severe submucosal fibrosis in patients with UC. We retrospectively included 55 tumors resected using ESD from 48 consecutive patients with UC. We analyzed the clinicopathological characteristics and treatment outcomes between the F0/1 (none to mild submucosal fibrosis) group (n = 28) and F2 (severe submucosal fibrosis) group (n = 27). No significant difference was found between the F0/1 and F2 groups in en bloc resection rate (100% vs. 96%, P = 0.49), the R0 resection rate (100% vs. 93%, P = 0.24), and the dissection speed (0.18 vs. 0.13 cm2 /min, P = 0.07). Intraoperative perforation was more common in the F2 group (30%) than in the F0/1 group (8%; P = 0.01). Multivariable analysis showed that a longer duration of UC (≥10 years; odds ratio [OR] 6.11; 95% confidence interval [CI] 1.20-31.03; P = 0.03) and scarring of background mucosa of the tumor (OR 39.61; 95% CI 3.91-400.78; P < 0.01) were independent predictors of severe submucosal fibrosis. Long UC duration and scarring background mucosa were predictors of severe submucosal fibrosis associated with perforation during ESD.

The risk of bleeding after endoscopic submucosal dissection (ESD) in patients with early gastric neoplasms who do not discontinue aspirin for the procedure has not been established. We aimed to investigate whether post-ESD gastric bleeding is increased in patients who take aspirin. Patients who underwent ESD for early gastric neoplasms at the National Cancer Center Hospital, Korea, between November 2008 and January 2011 were enrolled. The risk of post-ESD bleeding was evaluated using Poisson regression analysis. We categorized 514 patients into three groups according to aspirin intake at the time of the procedure: patients who never used aspirin (n=439), patients who interrupted aspirin use for 7 days or more (n=56), and patients who continuously used aspirin (n=19). Post-ESD bleeding occurred in 4.1% (21/514) overall, and was more frequent in continuous aspirin users (4/19 [21.1%]) than in those who never used aspirin (15/439 [3.4%]) (P=0.006) and those with interrupted aspirin use (2/56 [3.6%]) (P=0.033). Multivariate analysis showed that use of aspirin by itself was associated with post-ESD bleeding (relative risk [RR] 4.49; 95% confidence interval [95%CI] 1.09-18.38). The resumption of clopidogrel combined with aspirin use (RR 26.71, 95%CI 7.09-100.53), and increased iatrogenic ulcer size (RR 1.52, 95%CI 1.14-2.02), were significantly associated with post-ESD bleeding. Continuous aspirin use increases the risk of bleeding after gastric ESD. Aspirin use should be stopped in patients with a low risk for thromboembolic disease to minimize bleeding complications.