Etiology Of Upper Gastrointestinal Bleeding Research Articles

Upper Gastrointestinal Bleeding in the Emergency Department of Ibn Sina Hospital in Rabat: Etiological, Endoscopic, Therapeutic and Evolutive Aspects

Introduction: Upper gastrointestinal bleeding (UGIB) is defined as a bleeding from a lesion in the digestive tract located upstream of the duodenojejunal angle of Treitz. It is a medical emergency with a mortality ranging from 2 to 10%. The aim of the study is to investigate the main etiologies of upper gastrointestinal bleeding in our setting, and specify the main endoscopic findings, therapeutic approaches, and evolutive aspects. Materials and methods: A prospective, descriptive study conducted over an eight month period from May 1st to December 1st, including 50 adult patients admitted for UGIB who underwent conclusive esophagogastroduodenoscopy (EGD). We collected data about patients demographics, comorbidities, clinical presentaiton, physical examination findings, laboratory data, EGD results, therapeutic procedures and patient outcomes. Results: UGD represented 0.5% of emergency admissions, with a mean age of 61.22 years and no gender predominance. The main risk factors were related to the use of anticoagulants and/or antiplatelet agents, a history of chronic liver disease, chronic gastritis, and alcohol and tobacco use. Patients presented with hematemesis, melena, or both. EGD was performed in all patients, the main etiologies were peptic ulcer disease, vatical pathology and peptic pathology. Endoscopic treatment was performed in 38% patients, surgery was required in one case. Red blood cell transfusion was necessary in 83% patients. A favorable outcome was observed in 84% patients, while 16% patients died because of hemorrhagic shock, cardiogenic shock, and one case of multiple myeloma. Conclusion: UGIB remans a common medical and surgical emergency in our setting. The etiologies are dominated by peptic ulcer disease. EGD is the key investigation, with a diagnostic, therapeutic, and prognostic interest. The outcome was generally favorable in our study, except for 16% of cases who resulted in death. Preventive measures are essential.

Age-specific causes of upper gastrointestinal bleeding in children.

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Hospital Length of Stay Independently Predicts Mortality in Patients Emergently Admitted for Esophageal Hemorrhage: Sex, Frailty, and Age as Additional Mortality Factors.

Upper gastrointestinal bleeding results in greater than $7.6 billion of in-hospital economic burden in the United States yearly. With a worldwide incidence between 40-100/100,000 individuals and a mortality rate of approximately 2-10%, upper gastrointestinal bleeding represents a major source of mortality and morbidity. The goal of this study was to describe mortality risk factors in patients emergently admitted with esophageal hemorrhage, the second most common etiology of upper gastrointestinal bleeding. Patients emergently admitted with esophageal hemorrhage between 2005-2014 were evaluated using the National Inpatient Sample database. Patient characteristics, clinical outcomes, and therapeutic trends were obtained. Relationships between morality and all other variables were determined via univariable and multivariable logistic regression analyses. In total, 4,607 patients were included, of which 2,045 (44.4%) were adults, 2,562 (55.6%) were elderly, 2,761 (59.9%) were males, and 1,846 (40.1%) were females. The average age of adult and elderly patients were 50.1 and 78.7 years, respectively. The multivariable logistic regression analysis revealed, for every additional day of hospitalization, the odds of mortality for nonoperatively treated adult and elderly patients increased by 7.5% (p=<0.001) and 6.6% (p=<0.001), respectively. Every additional year of age was associated with a 5.4% (p=0.012) increase in mortality odds for nonoperatively managed adult patients. Frailty increased the odds of mortality by 31.1% (p=0.009) in nonoperatively treated elderly patients. Undergoing invasive diagnostic procedures in conservatively treated adults reduced mortality significantly (odds ratio=0.400, p=0.021). Frailty, age, and hospital length of stay demonstrated no significant association with mortality in surgically managed adult and elderly patients. Nonoperatively managed patients emergently admitted for esophageal hemorrhage with longer hospital length of stay and higher modified frailty index exhibited higher odds of mortality. Invasive diagnostic procedures were negatively correlated with mortality in nonoperatively treated adult patients. Age is only associated with higher mortality rates in adults, while elderly patients revealed no association between age and mortality.

S2278 Black Esophagus: A Striking Etiology of Gastrointestinal Bleeding

Introduction: Black esophagus, or acute esophageal necrosis (AEN), is an uncommon etiology of upper gastrointestinal bleeding with incidence 0.01%-0.2% and poor prognosis. AEN is characterized by endoscopic findings of diffuse circumferential black discoloration of distal esophageal mucosa with sharp demarcation at the GEJ. The pathophysiology of AEN is unknown, however current hypotheses implicate ischemia, thromboembolic injury, critical illness, and corrosive injury. We describe a case of black esophagus in a patient with hemorrhagic shock. Case Description/Methods: An 83-year-old woman with hypertension presented to an outside hospital after a fall with lethargy, acute hypoxic respiratory failure, and shock. CT chest revealed right sided hemothorax. The patient was intubated, resuscitated with IV fluids and blood products, initiated on vasopressors, and a chest tube was placed prior to transfer to our institution. Repeat CT chest was concerning for the right thoracostomy tube traveling through the right middle lobe parenchyma and terminating within the mediastinum between the left atrium and the distal esophagus. The chest tube was removed and replaced in the operating room. Double contrast esophogram was without esophageal leak. The patient subsequently developed melena and worsening anemia. EGD demonstrated sharply demarcated circumferential black ulceration of the distal esophagus consistent with black esophagus without obvious signs of perforation. IV PPI and therapy aimed at reversing the underlying shock was pursued. Unfortunately, after a prolonged hospital course with worsening acute respiratory distress syndrome and inability to liberate from the ventilator, the patient’s family elected to pursue comfort measures and the patient expired (Figure). Discussion: In this case, AEN was most likely caused by ischemia secondary to hemorrhagic shock. Black esophagus carries a very poor prognosis, usually related to the underlying condition. Timely recognition of AEN and treatment aimed at reversing the underlying etiology can help prevent complications such as infection, esophageal stricture, and perforation. AEN is managed with aggressive IV PPI, NPO, and avoiding passage of nasogastric tubes due to risk of perforation. In rare instances, surgical intervention may be warranted. This case highlights the need to maintain a wide differential diagnosis for gastrointestinal bleeding and the importance of early recognition and treatment of this rare condition to prevent complications.Figure 1.: EGD indicating circumferential black ulceration of the distal esophagus with clear demarcation (arrow).

S2572 Bleeding Duodenal Varix Treated With Hemostatic Clips

Introduction: Duodenal varices are a rare etiology of upper gastrointestinal bleeding with a prevalence of 0.4% in patients with portal hypertension undergoing esophagogastroduodenoscopy (EGD). Ectopic varices account for 1–5% of variceal bleeding, of which 17–40% are estimated to occur within the duodenum. Definitive guidelines on the management of duodenal varices, which have an estimated mortality rate of 40%, have not been established. We report the use of hemostatic clips to achieve hemostasis in a case of a bleeding duodenal varix due to portal hypertension in an orthotopic liver transplant patient with a dysfunctional mesocaval shunt. Case Description/Methods: A 42-year-old female with advanced liver cirrhosis (MELD 17) secondary to alcohol use and primary biliary cholangitis status post orthotopic liver transplantation complicated by portal vein thrombosis and biliary stricture for which she underwent mesocaval shunting and biliary reconstruction with recurrent portal hypertension. She presented with one day of bright red blood per rectum. On admission, her vital signs were significant for hypotension (81/61 mmHg) and tachycardia (132 bpm). Her hemoglobin was 7.6 g/dL (baseline 12 g/dL). Computed tomography angiography was remarkable for prominent proximal duodenal mucosal varices, portosystemic shunting with prominent splenorenal and gastric/gastroesophageal varices, and portal vein thrombosis. EGD was significant for a large (>5 mm) actively bleeding varix in the second portion of the duodenum, for which two hemostatic clips were successfully placed with resolution of bleeding. The patient remained hemodynamically stable post-procedure and was transferred to her transplant center for further management with no further bleeding episodes. Discussion: Alcoholic-associated liver disease (ALD) is one of the most common causes of cirrhosis. As the incidence and prevalence of ALD continues to rise, it is important that management of duodenal variceal bleeding becomes more standardized. Only a few cases have reported the use of hemostatic clips in these patients. Treatment options include band ligation, coiling, cyanoacrylate injection, balloon-occluded retrograde transvenous obliteration, and transjugular intrahepatic portosystemic shunt. Standardized treatment modalities for duodenal variceal bleeds have not been well-established and further studies are required to investigate appropriate management strategies. Our case demonstrates that hemostatic clips can be effectively used to achieve hemostasis (Figure 1).Figure 1.: (A) Computed tomography angiography (CTA) revealing prominent proximal duodenal mucosal varices, likely from the superior mesenteric vein. (B) Esophagogastroduodenoscopy (EGD) demonstrating a large (>5 mm) actively bleeding varix in the second portion of the duodenum. (C) EGD demonstrating hemostatic clips placed on the duodenal varix with resolution of bleeding.

S2284 Black Esophagus as Cause of UGIB After a Complicated Urologic Procedure

Introduction: We report a case of upper endoscopy performed for a patient with coffee-ground emesis after a complicated urologic procedure. It showed diffuse black discoloration in mid-distal esophagus consistent with acute esophageal necrosis (AEN). Case Description/Methods: This is a 68-year-old male with diabetes mellitus (DM), chronic kidney disease, hypertension (HTN) and bladder cancer. He was admitted to intensive care after transurethral resection of bladder tumor (TURBT) was complicated by bladder perforation that required open laparotomy and bladder repair. Patient remained intubated for 48 hours. During the postoperative period, he developed ileus with nausea, vomiting and abdominal distention. He subsequently developed coffee-ground emesis and chest pain. He was not on acid suppressing medication. Upper endoscopy was performed to investigate etiology of upper gastrointestinal bleeding (UGIB), which showed diffuse areas of black discoloration in mid-distal esophagus suggestive for esophageal necrosis (Figure). Pathology showed tissue necrosis consistent with AEN. Patient was promptly treated with a proton-pump inhibitor and sucralfate. Symptoms rapidly improved without recurrence of bleeding or complication. Discussion: AEN, also known as “black esophagus” or necrotizing esophagitis, is a rare syndrome characterized by circumferential black mucosa at the distal esophagus and stops at the gastroesophageal junction. The prevalence is about 0.2% and 4 times more likely in men than women. Risk factors include DM, malignancy, HTN, alcohol abuse and coronary artery disease. The etiology is likely esophageal ischemia from a low-flow state followed by a backflow injury from chemical contents of gastric secretions. Majority of patients present with UGIB, followed by dysphagia and epigastric/chest pain. Symptoms can develop rapidly following an inciting event. With adequate resuscitation and medical therapy (proton pump inhibitors and sucralfate), patients can recover rapidly. Complications may include stricture, perforation, mediastinitis, and death. Prognosis is poor due to underlying critical illness, but mortality specific to AEN is much lower. Endoscopic appearance is suggestive, but biopsy is recommended to establish the diagnosis and exclude other diagnoses (e.g. melanoma and acanthosis nigricans). Repeat endoscopic evaluation is important to assess mucosal healing and determine duration of antacid therapy. Endoscopic balloon dilation may be necessary for stricture from AEN.Figure 1.: Diffuse circumferential black discoloration in lower esophagus.

Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department.

Upper gastrointestinal bleeding (UGIB) is a major cause of clinical deterioration worldwide. A large number of patients with UGIB cannot be diagnosed through endoscopy, which is normally the diagnostic method of choice. Therefore, this study aimed to investigate the diagnostic value of multi-detector computed tomography (MDCT) for patients with suspected UGIB. In this retrospective observational study of 386 patients, we compared contrast-enhanced abdominopelvic MDCT to endoscopy to analyze the performance of MDCT in identifying the status, location of origin, and etiology of UGIB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were examined. In the assessment of bleeding status, MDCT was able to accurately identify 32.9% (21.9–43.9, 95% confidence interval [CI]) of patients with active bleeding, 27.4% (18.9–35.9, 95% CI) of patients with recent bleeding, and 94.8% (91.8–97.8, 95% CI) of patients without bleeding evidence (P<0.001). MDCT showed an accuracy of 60.9%, 60.6%, and 50.9% in identifying bleeding in the esophagus, stomach, and duodenum, respectively (P = 0.4028). The accuracy in differentiating ulcerative, cancerous, and variceal bleeding was 58.3%, 65.9%, and 56.6%, respectively (P = 0.6193). MDCT has limited use as a supportive screening method to identify the presence of gastrointestinal bleeding.

Predictive Role of Admission Venous Lactate Level in Patients with Upper Gastrointestinal Bleeding: A Prospective Observational Study.

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies. Risk stratification is essential in patients with this potentially life-threatening condition. The aim of this prospective study was to evaluate the usefulness of the admission venous lactate level in predicting clinical outcomes in patients with UGIB. All consecutive adult patients hospitalized due to UGIB were included in the study. The clinical data included the demographic characteristics of the observed population, etiology of UGIB, need for surgical intervention and intensive care, bleeding recurrence, and mortality rates. Venous lactate was measured in all patients on admission. Logistic regression analyses were used to calculate the odds ratios (OR) of lactate levels for all outcomes. The receiver operating characteristic (ROC) curve was used to determine the accuracy of lactate levels in measuring clinical outcomes, while Youden index was used to calculate the best cut-off points. A total of 221 patients were included in the study (151M; 70F). There were 24 cases of UGIB recurrence (10.8%), 19 patients (8.6%) required surgery, and 37 individuals (16.7%) required intensive care. Mortality rate was 11.3% (25 cases). The logistic regression analysis showed statistically significant association between admission venous lactate and all clinical outcomes: mortality (OR = 1.39, 95%CI: 1.22–1.58, p < 0.001), recurrence of bleeding (OR = 1.16, 95%CI: 1.06; 1.28, p = 0.002), surgical intervention (OR = 1.17, 95%CI: 1.06–1.3, p = 0.002) and intensive care (OR = 1.33, 95%CI: 1.19–1.5, p < 0.001). The ROC curve analysis showed a high predictive value of lactate levels for all outcomes, especially mortality: cut-off point 4.3 (AUC = 0.82, 95%CI: 0.72–0.92, p < 0.001) and intensive care: cut-off point 4.2 (AUC = 0.76, 95%CI: 0.66–0.85, p < 0.001). Admission venous lactate level may be a useful predictive factor of clinical outcomes in patients with UGIB.

Etiology of Upper Gastrointestinal Bleeding in the Children Admitted to Besat Hospital in Sanandaj

Etiology of Upper Gastrointestinal Bleeding in the Children Admitted to Besat Hospital in Sanandaj

COVID-19 Pandemisinde Acil Servise Başvuran Üst Gastrointestinal Kanamalı Hastaların Sayısı Azaldı mı?: Tek Merkez Deneyimi

Objective: In the period of the coronavirus disease-19 (COVID-19) pandemic, upper gastrointestinal endoscopy was either postponed or canceled, except for emergencies, due to the high risk of transmission. Our study aimed to evaluate the effect of the COVID-19 pandemic on patients with upper gastrointestinal bleeding presenting to the emergency department and to compare it with the data before the pandemic. Material and Methods: In this single-center, retrospective study, patients were divided into 2 groups: pre-COVID-19 (pre-C) (March 2019-March 2020) and post-COVID-19 (post-C) (March 2020- March 2021). Patients who presented to the emergency department with upper gastrointestinal bleeding during these periods and underwent endoscopic examination were included in the study. Results: Endoscopy for upper gastrointestinal bleeding was urgently performed in 125 patients in the pre-C period and in 89 (29% decrease) patients in the post- C period. The Glasgow-Blatchford Score was higher in the pre-C period (p=0.02). Peptic ulcers were the most common cause of bleeding in both groups. High-risk peptic ulcer (forrest 1a/1b/2a/2b), and malignancy were observed more frequently in the post-C period (p=0.003, p=0.04; respectively). Endoscopic combined treatment rate was higher in the post-C group (p<0.001). Re-bleeding ratios were similar for both the groups (p=0.48). Conclusion: During the post-C period, the number of upper gastrointestinal bleeding cases admitted to the emergency department decreased significantly. However, the rate of high-risk peptic ulcer and malignancy in the etiology of upper gastrointestinal bleeding increased in the post-C period.

Coronavirus Associated Bleeding Esophageal Ulcerations

A 95-year-old woman developed hematemesis during her hospitalization for severe coronavirus disease 2019 (COVID-19) infection. She had been diagnosed 16 days prior and treated with remdesivir, dexamethasone, and tocilizumab. Her comorbidities included chronic kidney disease stage 4, atrial fibrillation (not on anticoagulation), and chronic systolic heart failure. Patient was hypotensive (96/45 mmHg) and tachycardic (110 bpm). Laboratory studies demonstrated hemoglobin 8.5 g/dL (normal, 11.6–15.0 g/dL), compared with 11.2 g/dL 2 days prior. An esophagogastroduodenoscopy was performed and showed a 7-cm hiatal hernia and multiple cratered ulcers in the upper and middle esophagus, with the largest lesion measuring 15 mm. One of the ulcerations had an adherent clot (Figures A and B) with an underlying bleeding visible vessel (Figure C), which was treated with epinephrine injection and bipolar cauterization (Figure D). Biopsies taken from the center and periphery of esophageal ulcerations were negative for cytomegalovirus and herpes simplex virus but had detectable severe acute respiratory syndrome–associated coronavirus RNA. She had no recurrence of gastrointestinal bleeding. This case highlights that esophageal ulcerations should be considered as a possible etiology of upper gastrointestinal bleeding in patients with COVID-19 infection.

S683 Trend Analysis of Upper Gastrointestinal Bleeding in the Last 15 Years: A Population-Based Study

Introduction: Upper Gastrointestinal Bleeding (UGIB) is defined as the bleeding originating from the gastrointestinal tract above the ligament of Treitz. UGIB is commonly caused by peptic ulcer disease (PUD), Mallory-Weiss tears, esophageal varices, and esophagitis. Although the diagnosis and management of UGIB have largely evolved with recent advancements, the incidence and trends of UGIB are unclear. Therefore, we sought to look at the incidence and trends of UGIB 2006-2020 using a population-level database. Methods: Retrospective analysis of individuals ≥ 18 years who were hospitalized with UGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of UGIB were identified. The trend in the rates of hospitalization and annual percentage change (APC) due to various etiologies of UGIB were analyzed between 2006-2020 using Excel, 2016. Results: Among a cohort of 63,000,000 unique patients, 7.63% of hospitalizations in 2020 were due to UGIB. The most common diagnosis associated with UGIB was gastritis (70.92%), followed by esophagitis (38.20%), PUD (24.67%), esophageal/gastric varices (7.73%), angiodysplasia/dieulafoy lesions (6.26%), Mallory-Weiss tears (4.18%), and esophageal and gastric tumors (2.63%). The hospitalization rates due to UGIB increased from 4.90% in 2006 to 7.63% in 2020 (Table 1). The trend in the rates of hospitalizations due to UGIB and the APC of UGIB based on etiology is depicted in Figure 1. Conclusion: The rates of upper gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last two decades. Among UGIB hospitalizations, the proportion of PUD and Mallory-Weiss tears have decreased while that of gastritis/duodenitis and esophageal/gastric varices have increased over 5-year intervals (Table 1). Patient awareness, improved diagnostic techniques, an increase in the use of anticoagulants and non-steroidal anti-inflammatory agents, and an aging population probably contribute to the rise in the rates of UGIB.Table 1.: Mortality in post-bariatric surgery patients that had UGIB (OR).Figure 1.: A. Demographics and mean ago of the study population. B. Group comparisons using a post hoc test.

Luminal Clinical

Background and Aim: Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency and carries high morbidity and mortality. There are multiple risk factors for poorer outcomes, including malnutrition. Ascorbic acid is a water-soluble vitamin present in most plant foods. Dietary deficiency leads to scurvy, which may alter the natural history of UGIB through impaired tissue and mucosal integrity. Traditionally thought to be rare in developed countries, vitamin C deficiency (VCD) is now well described in patients with pneumonia, sepsis, and coronavirus disease 2019. There is a paucity of literature investigating the prevalence and clinical significance of VCD in patients with UGIB;interim findings reported by our group suggested a prevalence of >30%. The aim of this study was to establish the prevalence of VCD in patients presenting with UGIB and its association with clinical outcomes. Methods: We conducted a prospective cohort study of adult patients presenting with UGIB to two metropolitan tertiary hospitals in Melbourne, Australia, over a 12-month period (March 2020 to March 2021). Fasting vitamin C levels were obtained on admission. Patients were risk-stratified using the AIMS65 score, and baseline demographic data and outcomes were recorded. The primary outcome was the prevalence of VCD (serum vitamin C level < 23 μmol/L) and severe VCD (<12 μmol/L). Secondary outcomes included a composite endpoint of adverse events (AE), comprising inpatient death, intensive care unit (ICU) admission, rebleeding, surgery, angioembolization, or massive transfusion (≥4 units of red cells). Multivariate logistic regression was used to determine the association between vitamin C levels and the secondary endpoints. Subgroup analyses were performed in variceal and non-variceal UGIB and high-risk (AIMS65, ≥2) and low-risk (AIMS65, 0-2) UGIB. Results: A total of 227 patients were included. The median age was 65 years (IQR, 54-78), 145 (63.9%) were male, and the median AIMS65 score was 1 (IQR, 1-2). The etiology of UGIB was variceal bleeding in 20.3%, peptic ulcer disease in 44.1%, and other causes in 35.7%. The mean vitamin C level was 40 ± 26 μmol/L. In terms of patient outcomes, inpatient mortality was 4%, ICU admission occurred for 11.9%, and mean length of stay (LOS) was 7.7 ± 9.7 days. Red cell transfusion was required in 63.4% of patients, with a mean requirement of 2.2 ± 2.8 units. VCD was identified in 74 patients (32.6%), with severe deficiency in 32 (14.1%). VCD was associated with significantly higher in-hospital mortality (9.5% vs 1.3%, P = 0.01), prolonged LOS (10.8 vs 6.2 days, P < 0.01), rebleeding (17.6% vs 7.88%, P = 0.05), and a higher composite endpoint of AE (77% vs 54.9%, P < 0.01). On multivariate logistic regression, high-risk UGIB (odds ratio [OR], 3.24;95% CI, 1.42-7.42), VCD (OR, 2.28;95% CI, 1.11-4.71), and chronic liver disease (OR, 11.66;95% CI, 2.92-46.64) were all independently associated with the composite endpoint of AE. In subgroup analysis, VCD was associated with a significantly increased composite endpoint of AE in patients with non-variceal (74% vs 51%, P < 0.01) and low-risk (66% vs 44%, P = 0.04) UGIB. Conclusion: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding, and LOS. Interventional studies are required to determine the impact of early vitamin C supplementation on clinical outcomes.

Unique meteorological characteristics in the upper gastrointestinal bleeding by different etiologies in Beijing Area, China.

Unique meteorological characteristics in the upper gastrointestinal bleeding by different etiologies in Beijing Area, China.

The Role of Aspartate Aminotransferase to Platelet Ratio Index as a Non-Invasive Predictor of Variceal Etiology of Upper Gastrointestinal Bleeding

Introduction: Non-invasive strategies to predict variceal from non-variceal bleeding will be highly beneficialfor preemptive management of Upper Gastrointestinal Bleeding (UGIB). This study aimed to assess the roleof aspartate aminotransferase (AST) to platelet ratio index (APRI) as a non-invasive predictor of varicealetiology of UGIB. Methods: This was a retrospective descriptive study conducted at Endoscopy Departmentof Dhulikhel Hospital between January 2017 and December 2019 in patients presenting with acute UGIB.We assessed the diagnostic utility of the APRI score relative to other objective measures by Area Under theReceiver Operating Characteristic (AUROC) curve analysis. Results: A total of 158 patients with historyof UGIB were included in the study. There were total 123 males (77.8%) and the mean age of the patientswas 50.3±16.1 years. The APRI score performed well in predicting a variceal etiology of acute UGIB, withAUROC 0.9. When APRI was used at cut-off of 1.3, it had a sensitivity of 84.1% and specificity of 76.8%,a positive predictive value of 70.7% and a negative predictive value of 89.9% while predicting varicealetiology of UGIB at presentation. The relative risk of varices at an APRI cut-off of 1.3 is 17.5 with a p-valueof <0.0001. Conclusion: The present study highlighted that APRI score can be used as an objective metricthat helps to predict a variceal etiology of acute UGIB.

Efficacy of Hemospray in Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Hemospray is a non-contact modality of endoscopic hemostasis that has been used in the management of upper gastrointestinal bleeding (UGIB) with varying success. Our aim was to evaluate the efficacy of Hemospray in the management of UGIB. An electronic bibliographic search of digital dissertation databases was performed from inception till October 2019. All prospective studies, including randomized controlled trials evaluating the efficacy of Hemospray in the management of UGIB were analysed. The primary outcome was immediate haemostasis and the secondary outcome was rebleeding rate. Subgroup analyses based on etiology of UGIB (tumour-related, variceal, etc) were also performed. A total of 11 prospective studies, including 4 randomized trials were included for the analysis. The pooled immediate haemostasis rate with Hemospray was 93% (95% CI 90.3-95%, p<0.001). Rebleeding occurred in 14.4% (95% CI 8.8-22.8%, p<0.001) of patients. For the subgroup of tumour-related bleeding, the immediate haemostasis rate was 95.3% (95% CI 89.6-97.3%; p <0.001) and rebleeding rate was 21.9% (95% CI 13.9-32.7%, p <0.001). In patients with variceal bleeding, immediate haemostasis was achieved in 92.7% (95% CI 83.6-96.9%; p<0.001) of patients, with a rebleeding rate of 3.1% (95% CI 0.9-10.2%, p <0.001). Hemospray shows high immediate haemostasis and low bleeding percentages. The odds were in its favour compared to conventional endoscopic modalities, but not statistically significant. The results are undermined by the risk of bias in the studies. Nevertheless, it is an easy technique that should be further investigated with better studies.

A174 RARE BUT DEADLY: AN APPROACH TO MANAGEMENT OF DUODENAL VARICEAL HEMORRHAGE

Abstract Background Common etiologies of upper gastrointestinal bleeding (UGIB) in cirrhotic patients with portal hypertension include gastroesophageal varices (GOV), portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE). Less commonly, patients with portal hypertension develop varices in ectopic sites, including the rectum, biliary tree and duodenum. Ectopic varices are rare, contributing to 1–5% of all variceal bleeding, of which 17% is from duodenal varices. Aims To describe the management of duodenal variceal hemorrhage. Methods A case report and literature review was performed. Results Case report: We present a case of recurrent UGIB in a 59-year-old male with decompensated cirrhosis due to non-alcoholic steatohepatitis (CP-C; Meld 14). Initial endoscopy was negative for GOV, peptic ulcer, PHG, and GAVE, but an erosion over a mucosal bulge in the third segment of the duodenum was identified, raising possibility of vascular malformation versus ectopic varix. There was active bleeding after water provocation, so clips were deployed for hemostasis. CT imaging showed mesenteric venous collaterals abutting the duodenum, again raising possibility of duodenal varix, which was ultimately confirmed by endoscopic ultrasound (EUS). Patient had recurrent overt bleeding despite beta-blockage for prophylaxis, endoscopic clipping on four separate occasions, attempted angioembolization by interventional radiology, and cyanoacrylate glue. Transjugular intrahepatic porto-systemic shunt (TIPS) was not possible due to portal vein occlusion, so he underwent EUS-guided cyanoacrylate glue a second time. Literature review: Ectopic varices are rare, contributing to 1–5% of all variceal bleeding, of which 17% is from duodenal varices. Duodenal variceal hemorrhage can lead to hemorrhagic shock, and is potentially life threatening, with quoted mortality rates of 40%. Unfortunately, duodenal varices can be difficult to identify. Diagnosis is often delayed due to a combination of lower awareness and endoscopic challenges given the unusual serosal and submucosal location. Evidence-based guidelines for the management of ectopic varices are limited. For this reason, our current management strategies rely heavily on local expertise. Splanchnic vasoconstrictor medication, endoscopic ligation, EUS guided gluing, interventional radiology guided embolization, TIPS, balloon retrograde transvenous obliteration and surgical shunts are potential therapeutic options to manage the acutely bleeding varix. Following a variceal bleed, liver transplantation should be considered in eligible patients with no other contraindications. Conclusions Duodenal varices are a rare, potentially fatal, and underrecognized cause of gastrointestinal bleeding in patients with portal hypertension. Definitive therapy currently relies upon local expertise in the absence of clear guideline-based therapy. Funding Agencies None

Demographic profile and endoscopic findings among patients with upper gastrointestinal bleeding in Ahmadu Bello University Teaching Hospital, Zaria, North-Western Nigeria.

Upper gastrointestinal bleeding (UGIB) is a common medical emergency that can result in significant morbidity and mortality. The aim of this study was to determine the demographic profile and etiology of UGIB in patients seen at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, North-Western Nigeria. This descriptive retrospective study was carried out at the Gastroenterology Unit of ABUTH Zaria. Data of patients referred for upper gastrointestinal endoscopy with UGIB from June 2017 to December 2019 were extracted from the endoscopy register and analyzed. One hundred and forty-four patients had upper gastrointestinal (UGI) endoscopy done for UGIB during the period under review. Of these, 105 (72.9%) were males while 39 (27.1%) were females with male-to-female ratio of 2.7:1. The mean age of the patients was 43.5 ± 17.3 and their age ranges from 11 to 89 years. The modal age group was 40-49 years. The most common cause of UGIB was esophageal varices (67 [46.5%]) followed by erosive mucosal diseases: gastritis/duodenitis 43 (29.9%), esophagitis 12 (8.3%). Less common causes were peptic ulcer disease (PUD) in five (3.5%) patients, gastric tumor in two (1.4%), hiatus hernia in one (0.7%), and portal hypertensive gastropathy in one (0.7%). Thirteen patients (9.0%) had normal findings. Esophageal varices are the most common cause of UGIB among our patients and middle-aged male patients were the most commonly affected group.

Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report

BackgroundPrimary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate.Case presentationWe report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta.ConclusionsA timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

Should Vasoconstrictors be Considered in a Cirrhotic Patient with Acute Non-variceal Upper Gastrointestinal Bleeding?

Varices manifest as a major etiology of upper gastrointestinal bleeding in patients with chronic liver diseases, such as liver cirrhosis and hepatocellular carcinoma. By contrast, non-variceal upper gastrointestinal bleeding is rare. Pharmacological treatment differs between patients with variceal and non-variceal bleeding. Vasoconstrictors are recommended for the treatment of variceal bleeding, rather than non-variceal bleeding. In contrast, pump proton inhibitors are recommended for the treatment of non-variceal bleeding, rather than variceal bleeding. Herein, we present a case with liver cirrhosis and acute upper gastrointestinal bleeding who had a high risk of rebleeding (i.e., Child-Pugh class C, hepatocellular carcinoma, portal vein thrombosis, low albumin, and high international normalized ratio and D-dimer). As the source of bleeding was obscure, only terlipressin without pump proton inhibitors was initially administered. Acute bleeding episode was effectively controlled. After that, an elective endoscopic examination confirmed that the source of bleeding was attributed to peptic ulcer, rather than varices. Based on this preliminary case report, we further discussed the potential role of vasoconstrictors in a patient with cirrhosis with acute non-variceal upper gastrointestinal bleeding.