Acute Nonvariceal Bleeding Research Articles

Clinical Efficacy of Transcatheter Arterial Embolization for Acute Non-Variceal Gastrointestinal Bleeding

See the article "Clinical Outcomes of Transcatheter Arterial Embolization after Failed Endoscopic Intervention for Acute Non-Variceal Bleeding Associated with Benign Upper Gastrointestinal Diseases" on page 52.

Clinical Outcomes of Transcatheter Arterial Embolization after Failed Endoscopic Intervention for Acute Non-Variceal Bleeding Associated with Benign Upper Gastrointestinal Diseases

Background/Aims: Transcatheter arterial embolization (TAE) is useful for management of uncontrolled upper gastrointestinal (UGI) bleeding. We investigated clinical outcomes of TAE for non-variceal bleeding from benign UGI diseases uncontrolled with endoscopic intervention.Methods: This retrospective study performed between 2017 and 2021 across four South Korean hospitals. Ninety-two patients (72 men, 20 women) who underwent angiography were included after the failure of endoscopic intervention for benign UGI disease- induced acute non-variceal bleeding. We investigated the factors associated with endoscopic hemostasis failure, the technical success rate of TAE, and post-TAE 30-day rebleeding and mortality rates.Results: The stomach (52/92, 56.5%) and duodenum (40/92, 43.5%) were the most common sites of bleeding. Failure of endoscopic procedures was attributable to peptic ulcer disease (81/92, 88.0%), followed by pseudo-aneurysm (5/92, 5.4%), and angiodysplasia (2/92, 2.2%). Massive bleeding that interfered with optimal visualization of the endoscopic field was the most common indication for TAE both in the stomach (22/52, 42.3%) and duodenum (14/40, 35.0%). Targeted TAE, empirical TAE, and exclusive arteriography were performed in 77 (83.7%), nine (9.8%), and six patients (6.5%), respectively. The technical success rate, the post-TAE 30-day rebleeding rate, and the overall mortality rate were 100%, 22.1%, and 5.8%, respectively. On multivariate analysis, coagulopathy (OR, 5.66; 95% CI, 1.71~18.74; <i>P</i>=0.005) and empirical embolization (OR, 5.71; 95% CI, 1.14~28.65; <i>P</i>=0.034) were independent risk factors for post-TAE 30-day rebleeding episodes.Conclusions: TAE may be useful for acute non-variceal UGI bleeding. Targeted embolization and correction of coagulopathy can improve clinical outcomes.

Факторы риска летального исхода при острых язвенных гастродуоденальных кровотечениях

The most common cause of acute nonvariceal bleeding from the upper gastrointestinal tract (GIT) is ulcerative lesions of the stomach and duodenum. The aim of the present study was to investigate the structure of mortality in acute ulcerative gastroduodenal bleeding (AUGDB) and the influence of concomitant pathology, as well as to evaluate the possibilities of prognostic systems for determining the risk of lethal outcome. The study included 374 patients, 77 (20.6%) of them died, 12 (15.6%) patients had recurrence of ulcer bleeding. The risk factors for AUGDB include severe degree of blood loss with a change in shock index (SI) >0.8 in comorbid patients, multiple gastric and duodenal ulcer defects. A separate risk factor is an episode of AUGDB during inpatient treatment as a complication of the underlying disease. Rockall, Glasgow-Blatchford and PNED scales can be used to predict the lethal outcome, with the best results demonstrated by the PNED system: sensitivity 84.4% and specificity 77.4%.

Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review.

BACKGROUNDAcute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.AIMTo evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.METHODSEmploying PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding. RESULTSOverall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.CONCLUSIONEndotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

Non-variceal Causes and Outcome of Acute Upper Gastro-intestinal bleeding among Cirrhotic Patients in Tropical Medicine Intensive Care Unit

Background and aim of the work: non-variceal bleeding is less common than variceal bleeding among cirrhotic patients; hence there are fewer studies that pay attention to its causes and outcomes. The aim of this study is to shed light on the causes of acute non-variceal bleeding in cirrhotic patients and the outcome of acute upper gastrointestinal bleeding in those patients. Patients and Methods: this cross sectional study included 179 patients, they were allocated into two groups according to the source of bleeding; group I: included 104 patients with variceal bleeding and group II: included 75 patients with non-variceal bleeding. Results: The frequency of non-variceal bleeding was 41.9%. The mean period of intensive care unit stay was 5.03 ± 2.65 days ranging between 1and 17 days. The overall rate of early rebleeding was 3.7% and the mortality rate in intensive care unit was 4.5%. The most common cause of non variceal bleeding is ulceration (24%), followed by portal hypertensive gastropathy (17.3%), and in 24% of cases the cause of bleeding was obscure. Mortality is significantly correlated to white blood cells count (r=0.2 p=0.002), Child’s grade and score (r=0.217 p=0.003 and r= 0.16 p=0.03 successively) as well as Glasgow-Blachford score (r=0.18 p=0.01). Conclusion: The frequency of non-variceal bleeding among cirrhotic patients admitted with acute upper gastrointestinal bleeding bleeding is 41.9%. The mortality rate in those patients is 4.5%. The degree of deterioration of liver functions and the severity of initial bleeding episode were the most important predictors of mortality.

Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: Implications for early discharge?

There is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding. Identify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death). Secondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis. Out of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoy's lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome. The "good luck score" may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.

A Risk Score to Predict the Need for Emergent Endoscopy in Patients with Non-Variceal Upper Gastrointestinal Bleeding

Purpose: To develop a scoring system to stratify the need for emergent endoscopy in patients with non-variceal upper gastrointestinal bleeding using clinical parameters available in a emergency department. Methods: We conducted a prospective observational study in all patients over 18 yrs who presented to our institution with presumed non-variceal bleed. We excluded pregnant women and variceal bleeding patients. Variables collected included age, gender, medications, aspirin use, clopidogrel use, anticoagulation use, nasogastric lavage results, CBC, SMA-7, and INR. Upper endoscopy results were reported as, (1) no lesion seen (2) lesion but no therapy and (3) lesion with the need for hemostatic therapy. The primary end points were a endoscopically treated lesion versus no endoscopic treatment. Variables with impact were incorporated into a Wilcoxon rank sum test. A risk score was then developed using six variables. Results: 31 patients were enrolled in the study (mean age 66.9 years; 58% men). 16 patients were found to have actively bleeding lesions which benefited from emergent therapy. Identified impact variables included drop in hemoglobin, INR, nasogastric lavage results, age, BUN/Cr Ratio, and aspirin use. Using these variables in our proposed scoring system (Table 1), the Treatable Lesions group was found to have a statistically significant higher mean score value than the Untreatable Lesions group (3.06 vs. 1.8, p=0.0453). Seventy-five percent of the Treatable Lesions Group had a score greater than or equal to 3 while 73.3% of the Untreatable Lesions Group had a score less than 3. When a score of 1 is used as the cut-off sensitivity and specificity value, our scoring system has a sensitivity of 93.8% but a specificity of 20%. This profile of sensitivity and specificity is comparable to the published scoring systems of the Rockall and Blatchford. Our scoring system has advantages over these others because it's simple, directed towards a practical endpoint (therapy) and derived at presentation.Table: [1836] Table 1Conclusion: We have developed a useful risk stratifying scoring system that can help identify acute non-variceal bleeding patients who truly need emergent endoscopy. It is simple and can be used at patient presentation to the emergency department. External validation is needed for our study.

Trends in acute non-variceal bleeding in Israel in 1996–2007: A significant decrease in the rates of bleeding peptic ulcers

Background A decrease in the incidence of hospital admissions for acute non-variceal upper GI bleeding (AUGIB) has been reported in regions with a low prevalence of Helicobacter pylori (HP) infection. Aim To investigate trends in hospital admissions for AUGIB in Israel, where the prevalence of HP infection is intermediate. Methods We have searched the National Hospital Discharge Database of the Israeli Ministry of Health, where all admissions to acute care hospitals for the period January 1, 1996 through December 31, 2007 are compiled. Using a validated strategy, we identified all admissions for AUGIB according to ICD-9-CM codes. Incidence rates were calculated and adjusted to reflect the age and gender distribution of the Israeli population. Results The overall rates of hospital admissions for AUGIB decreased significantly from 29.3 to 16.8 cases/10 5 population/year ( p < 0.0001). The decreases were similar in both genders. This decrease was due to decreased rates of bleeding from duodenal ulcers (from 13.6 to 5 cases/10 5 population/year) and gastric ulcers (from 4.3 to 2.4 cases/10 5 population/year). The rates of bleeding from other causes remained unchanged. The rates of surgical interventions bleeding control decreased significantly (overall from 11 to 4%). The in-hospital mortality rate varied between 7.6 and 7%, did not change significantly in both genders but increased significantly with age during the study period. Conclusions A decline in the overall incidence of AUGIB during the study period was due to a significant decrease in the rate of bleeding peptic ulcers.

Aplicaciones de los clips en la terapéutica endoscópica actual

The applications of clips in current therapeutics are increasingly numerous. Endoscopic hemoclipping for acute nonvariceal bleeding is a highly effective and safe modality for hemostasis with initial hemostatic rates of between 85 and 98% and a rebleeding rate of approximately 5-10% both in patients with peptic ulcer bleeding and signs of endoscopic risk (Forrest Ia-IIb) and in bleeding secondary to submucosal lesions, diverticular bleeding, Mallory-Weiss tear, bleeding Dieulafoy's lesions, and postpolypectomy bleeding. In addition to the effectiveness of this technique as a hemostatic mechanism, many publications have demonstrated the utility of these clips to close perforations and fistulas, to serve as a radiopaque marker and as a tool to fix accessories (feeding tubes or prostheses). However, endoscopic clipping has certain limitations depending on the nature of the injury and the type of patient, as well as high economic cost and some technical limitations.

Application of endoscopic hemoclips for nonvariceal bleeding in the upper gastrointestinal tract

To investigate acute nonvariceal bleeding in the upper gastrointestinal (GI) tract and evaluate the effects of endoscopic hemoclipping. Sixty-eight cases of acute nonvariceal bleeding in the upper GI tract were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated. The 68 cases (male:female = 42:26, age from 9 to 70 years, average 54.4) presented with hematemesis in 26 cases (38.2%), melena in nine cases (13.3%), and both in 33 cases (48.5%). The causes of the bleeding included gastric ulcer (29 cases), duodenal ulcer (11 cases), Dieulafoy's lesion (11 cases), Mallory-Weiss syndrome (six cases), post-operative (three cases), post-polypectomy bleeding (five cases), and post-sphincterotomy bleeding (three cases); 42 cases had active bleeding. The mean number of hemoclips applied was four. Permanent hemostasis was obtained by hemoclip application in 59 cases; 6 cases required emergent surgery (three cases had peptic ulcers, one had Dieulafoy's lesion, and two were caused by sphincterotomy); three patients died (two had Dieulafoy's lesion and one was caused by sphincterotomy); and one had recurrent bleeding with Dieulafoy's lesion 10 mo later, but in a different location. Endoscopic hemoclip application was an effective and safe method for acute nonvariceal bleeding in the upper GI tract with satisfactory outcomes.

Therapeutic Endoscopy for Nonvariceal Gastrointestinal Bleeding

The evaluation and management of acute gastrointestinal bleeding in infants, children, and adolescents is a reason for emergency consultation frequently cited by pediatric gastroenterologists. After stabilization of the patient's condition, endoscopic evaluation remains the most rapid and accurate method to identify the origin of acute bleeding in the majority of lesions in the pediatric age group. Several endoscopic techniques may be applied to bleeding lesions to achieve hemostasis. Familiarity with the various techniques and with the specifics of their use is essential for the pediatric endoscopist. This review focuses on the endoscopic management of acute nonvariceal bleeding in infants and children.

Apache II and endoscopy in acute non-variceal bleeding. A useful clinical method to predict treatment and outcome

Apache II and endoscopy in acute non-variceal bleeding. A useful clinical method to predict treatment and outcome