Hematemesis is associated with worse outcomes in upper gastrointestinal bleeding: a retrospective study

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

ACUTE UPPER GASTROINTESTINAL BLEEDING IN ELDERLY PEOPLE: PRESENTATIONS, ENDOSCOPIC FINDINGS, AND OUTCOMES

Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

Introduction: Acute upper gastrointestinal (UGI) bleeding is a common medical emergency which is associated with significant morbidity and mortality. The annual incidence of UGI bleeding varies from 48 to 160 cases per 100,000 populations in the United States of America (USA), with a mortality rate of 7% to 10%. The aetiology and outcome of UGI bleeding varies significantly in different geographic regions depending on the demographic and socioeconomic characteristics of the local population. This study was done to evaluate the clinical profile and outcome of patients presenting with acute UGI bleeding at a tertiary care centre in Lumbini zone of Nepal.Material and Methods: This was a hospital based prospective observational study. All the patients who presented with acute UGI bleeding and fulfilled the inclusion criteria from 1st August 2013 to 31st July 2014 were included in the study. The study was cleared by the ethical review committee of the institute and written informed consent was taken from all the patients.Results: During the study period, 70 patients fulfilled the inclusion criteria and were subjected to statistical analysis. The mean age of patients in the present study was 55.11 ± 19.93 years. The majority of patients (30, 43%) were elder, belonging to the age group of more than 60 years. There were 55 (79%) male and 15 (21 %) female. The patients were mostly farmers by occupation accounting 29 (41 %) cases. Ethnically, 26 (3 7%) patients of UGI bleeding were from janajati group where majority of them had esophageal varices. Overall, the peptic ulcer disease was the leading cause of UGI bleeding seen in 26 (37%) patients followed by esophageal varices seen in 23 (33%) patients. 0 positive was the commonest blood group which was found in 28 (40%) of our patients. In our study 44 (63%) patients were alcohol consumers and 37 (53%) had coexisting comorbidities that added for the UGI bleeding related complications. During admission, 7 patients expired causing 10% mortality.Conclusion: Acute UGI bleeding was commonly seen in older age group patients with male preponderance. Peptic ulcer disease was the leading cause of the UGI bleeding. The mortality rate was found to be 10%. The mortality also increased with increasing age and patients with pre-existing co morbidities. Journal of Universal College of Medical ScienceVol. 6, No. 1, 2018, Page: 3-7

Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH.To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo.We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021.We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH.We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome. MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion).We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.

Sa1136 Pre-Endoscopic Intravenous Proton Pump Inhibition and the Outcomes of Acute Upper Gastrointestinal Bleeding

Mo1164 Red Blood Cell Transfusion Is Associated With Increased Rebleeding but Fresh Frozen Plasma With Increased Mortality in Acute Non-Variceal Upper Gastrointestinal Bleeding

Transcatheter arterial embolisation (TAE) to treat acute upper gastrointestinal bleeding secondary to gastric cancer: A systematic review and meta-analysis

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

The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were attending the emergency department (ED), before hospitalization. We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls. We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients [2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77]. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients. The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. In-hospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.

Systematic reports on acute upper gastrointestinal bleeding in children/adolescents are scanty. The aim of this study is to analyze its presentation, pathology and outcome in Hong Kong. A retrospective review of the hospital database for admissions up to the age of 18 years with signs of acute upper gastrointestinal bleeding between 1 June 1996 and 31 May 2006. During the 10-year period 76 patients (55 boys) were admitted with signs of upper gastrointestinal bleeding. The median age was 13.5 (range 0.25-18) years. Melena and hematemesis were by far the most frequent presentations. Medication was implicated in 16 cases (21%) as the possible cause for the bleeding. Endoscopic findings were a duodenal ulcer in 57 (75%) patients (50 boys) and a gastric ulcer in eight (10.5%). Helicobacter pylori infection was identified in 42 (55%) patients, of which 38 were found in duodenal ulcer patients. Eleven patients (14.5%) had interventions to achieve hemostasis: six epinephrine spray only, three thermal probe and two vessel ligation. After a median follow-up time of 3.5 years six patients had a recurrent duodenal ulcer. Three patients died of unrelated illnesses. Acute upper gastrointestinal tract bleeding in children and adolescents in Hong Kong is dominated by a duodenal ulcer in 75% of the patients. Acute bleeding is more frequent in boys (boy to girl ratio 2.6:1). Medication is a predisposing factor in 20% of the bleedings. Six patients (8%) have recurrent duodenal ulcers.

Mo1165 Prediction for Mortality in Patients With Non-Variceal Upper Gastrointestinal Bleeding: Novel DGSG Score

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies. Currently, there is a paucity of data on the clinical profile and outcome of UGIB in resource-limited settings. We aim to describe the etiology and outcomes of the patients who presented to the Emergency Department (ED) of a tertiary hospital in Ghana with UGIB. This was a single-center prospective cohort study involving 195 adults who presented with symptoms of UGIB from May 2022 to April 2023. Relevant baseline demographic and clinical characteristics were obtained. The cause of UGIB was determined as per findings at endoscopy. Patients were followed up for 6 weeks from admission, looking out for rebleeding, need for transfusion, length of hospital stay, and mortality. There were 145 (74.4%) males and 50 (25.6%) females, and the mean age ± SD was 51.4 ± 17.4 years. The main clinical presentations included melena (87.2%), hematemesis (69.7%) and postural dizziness (73.8%). The commonest findings at endoscopy were esophageal and gastric varices (33.3%), erosive gastritis and duodenitis (27.7%) and peptic ulcers (21.5%). The median length of hospital stay (IQR) was 7 days (5 days). 70.8% required whole blood transfusion with a median (IQR) of 2 units (2 units). The 6-week mortality and rebleeding rates were 17.4% and 7.2%, respectively. Variceal bleeding was the most common cause of UGIB at the emergency. One out of every fourteen patients that recover from acute UGIB may rebleed within the first six weeks one out of everysix patients who present with acute UGIB may die within the succeeding six weeks.

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

Cirrhosis is a major global cause of mortality, and upper gastrointestinal (GI) bleeding significantly increases the mortality risk in these patients. Although scoring systems such as the Child-Pugh score and the Model for End-stage Liver Disease evaluate the severity of cirrhosis, none of these systems specifically target the risk of mortality in patients with upper GI bleeding. In this study, we constructed machine learning (ML) models for predicting mortality in patients with cirrhosis and upper GI bleeding, particularly in emergency settings, to achieve early intervention and improve outcomes. In this retrospective study, we analyzed the electronic health records of adult patients with cirrhosis who presented at an emergency department (ED) with GI bleeding between 2001 and 2019. Data were divided into training and testing sets at a ratio of 90:10. The ability of three ML models-a linear regression model, an XGBoost (XGB) model, and a three-layer neural network model-to predict mortality in the patients was evaluated. A total of 16,025 patients with cirrhosis and 32,826 ED visits for upper GI bleeding were included in the study. The in-hospital and ED mortality rates were 11.2% and 2.2%, respectively. The XGB model exhibited the highest performance in predicting both in-hospital and ED mortality (area under the receiver operating characteristic curve: 0.866 and 0.861, respectively). International normalized ratio, renal function, red blood cell distribution width, age, and white blood cell count were the strongest predictors in all the ML models. The median ED length of stay for the ED mortality group was 17.54 h (7.16-40.01 h). ML models can be used to predict mortality in patients with cirrhosis and upper GI bleeding. Of the three models, the XGB model exhibits the highest performance. Further research is required to determine the actual efficacy of our ML models in clinical settings.