Cause Of Nonvariceal Bleeding Research Articles

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.

Impact of Helicobacter pylori Infection on Gastric Variceal Bleeding among Patients with Liver Cirrhosis.

Background and Aims Currently, it is well known that Helicobacter pylori- (H. pylori-) related peptic ulcer is one of the main causes of nonvariceal bleeding in cirrhotic patients. However, there is a lack of data to identify the exact effect of H. pylori infection on variceal bleeding. This study was conducted to identify the impact of H. pylori infection on gastric variceal bleeding in cirrhotic patients. Patients and Methods 76 cirrhotic patients with gastric varices were included in this prospective study and divided into 2 groups: nonbleeding gastric varices (32 patients) and bleeding gastric varices (44 patients). The fasting serum gastrin level was measured. Mucosal biopsies from the gastric body and antrum were examined to determine the patterns of gastritis and the presence of H. pylori. Results The frequency of H. pylori infection in the studied patients was 59.2%. There were significant differences between both groups regarding liver decompensation (P = 0.001), red color sign over gastric varices (P = 0.0011), prevalence of H. pylori infection (P = 0.0049), histological patterns of gastritis (P = 0.0069), and serum gastrin level (P = 0.0200). By multivariate analysis, Child C cirrhosis, red color sign over gastric varices, and H. pylori-induced follicular gastritis were independent risk factors for bleeding from gastric varices. Conclusion H. pylori-induced follicular gastritis is considered as an additional risk factor for bleeding from gastric varices.

Treat the Patient, not Just the Source of Bleeding

Marmo, Riccardo MD1; Bucci, Cristina MD1; Rea, Matilde MD1; Rotondano, Gianluca MD, FACG1, 2 Author Information

Upper GI bleeding – Has mortality changed with advancements in therapy?

Upper gastrointestinal bleeding (UGIB) is one of the most common GI medical emergencies, which all GI units deal with everyday. UGIB is broadly categorized into variceal and non variceal bleeding .This distinction becomes crucial as the management strategies are different for variceal and nonvariceal bleeding .There has been tremendous advancement in pharmacological and endoscopic interventions in management of upper GI bleeding over the past decade. However, it still carries considerable morbidity, mortality and health economic burden. Peptic ulcer bleeding is the predominant cause of nonvariceal bleeding in the US and Europe. Recent data indicate a decline in the incidence of peptic ulcer disease and peptic ulcer bleeding in both the United States and Europe, which can be attributed to a decrease in H. pylori infection. Numerous studies from US, Europe and some Asian countries have reported peptic ulcer bleeding mortality 5-12%. Furthermore, these peptic ulcer bleeding linked deaths are not a direct result of bleeding ulcers. Instead, death occurs due to multi organ failure and other associated co morbidities. These studies have also shown that endoscopic interventions and pharmacological treatments have reduced rebleeding rates, rates of surgical interventions, days of hospitalization and number of blood units transfused. However, none of these therapeutic approaches have reduced the overall mortality associated with the bleed event. Hence, there is a need to relook at factors associated with mortality and revise management strategies accordingly. Foremost, reasons for failure to reduce mortality rates despite major advances in endoscopic hemostatic modalities needs to be explored . A number of factors have been proposed as possible causes of persistently high mortality associated with peptic ulcer bleeding .Age and the presence of associated comorbidities are the most important factors for high mortality in a bleeding event. Sung et al reported an overall mortality of 6.2% in patients with peptic ulcer bleeding in a large cohort of 9,375 patients. 80% of these deaths were not related to ulcer bleed as opposed to 20% of mortality directly relatedto peptic ulcer bleed. Among those who died of non-bleeding related causes, multi-organ failure (24%), pulmonary causes (23.5%) and terminal malignancies were the most common causes, while bleeding related deaths occurred when immediate control of bleed could not be achieved or failure of endoscopic therapy within 48 hrs. The mean age of patients who died of bleeding related causes was higher than those who died of non-bleeding related causes. (75.4 years Vs 71.7 years, p=0.01). The survivors were younger with less severe comorbid diseases than non survivors. (61years vs 72.5years).This data clearly indicate that pharmacological or endoscopic intervention will have little impact on overall mortality. Hence, the efforts should be focused on identifying non GI factors associated with poor outcomes and reduce the risk of multi organ failure, especially in elderly population. How relevant is the above-mentioned scenario in the Indian context? Can we extrapolate the Western experience in India? What are the most common causes of UGI bleeding in India? What is overall prevalence of peptic ulcer bleeding? Do these patients have access to a high

THERAPEUTIC ENDOSCOPY FOR NONVARICEAL GASTROINTESTINAL BLEEDING

This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.