Gastric Bleeding Research Articles

Prevalence, causes and management of gastric varices – a literature review

Summary: Gastric varices, although less prevalent than esophageal varices, exhibit greater morbidity and mortality. This comprehensive literature review investigates the prevalence of gastric varices, diverse classifi cation systems, and available management options. The spectrum of management modalities encompasses primary and secondary prevention, acute gastric variceal bleeding strategies, and preventive measures against rebleeding. A meticulous exploration of PubMed and Google Scholar over the past decade (2013 to 2023) shaped the inclusion criteria for adults aged 18 and above dia gnosed with gastric varices, with or without variceal bleeding. Exclusion criteria eliminated non-gastric variceal causes of upper gastrointestinal bleeding and qualitative articles, resulting in 43 relevant records from the 190 initially identified. The diverse management landscape caters to the specifi c type of gastric varix, contributing to a varied treatment approach. Notably, endoscopic ultrasound- -guided coil embolization coupled with glue injection has emerged as a promising intervention, demonstrating superior outcomes in addressing gastric varices. The evolving understanding of these varices and advancing therapeutic strategies underscore the dynamic nature of research in this critical medical domain. Key words: gastric varices – upper gastrointestinal bleeding – classifi cation – hemostasis – etiology – management options

Proton Pump Inhibitor for Gastrointestinal Bleeding in Patients with Myocardial Infarction on Dual-Antiplatelet Therapy: A Nationwide Cohort Study.

Guidelines provide various recommendations for the use of proton pump inhibitors (PPI) to prevent upper gastrointestinal (UGI) bleeding in acute myocardial infarction (MI) treatment with dual antiplatelet therapy (DAPT). We evaluated the effects of PPIs in reducing the risk of severe UGI bleeding in patients with MI receiving DAPT. This retrospective cohort study included patients admitted for acute MI between 2014 and 2018, based on a nationwide health claims database in Korea. Primary outcome was admission for severe UGI bleeding requiring transfusion within 1 year of MI diagnosis. A multivariable Cox regression model was used to calculate the association between PPI use and severe UGI bleeding risk. Of 100,556 patients with MI on DAPT (mean age, 63.7 years; 75.4% men), 37% were prescribed PPIs. Based on risk assessment for UGI bleeding, among 6,392 (6.4%) high-risk and 94,164 (93.6%) low-risk patients, 50.5% and 35.8% received PPIs, respectively. Overall, 0.5% of the patients experienced severe UGI bleeding within 1 year after MI. The use of PPI was associated with a reduced risk of severe UGI bleeding (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.47-0.70; P < 0.001). The benefits of PPIs were consistent in high-risk (HR, 0.71; 95% CI, 0.45-1.13; P = 0.147) and low-risk (HR, 0.54; 95% CI, 0.43-0.68; P < 0.001) patients (P for interaction = 0.481). Among Korean patients with MI receiving DAPT, PPIs were underutilized, even among those at high risk of severe UGI bleeding. Nonetheless, PPI use reduced severe UGI bleeding in low- and high-risk groups.

Diagnosis and Management of Upper Gastrointestinal Bleeding in Long-Term NSAID Users : Case Report

Upper gastrointestinal bleeding is one of the most frequently encountered emergency cases. For most general practitioners, diagnosing and providing initial management is a challenge in itself. Upper gastrointestinal bleeding is divided into variceal and non-variceal bleeding. Clinical symptoms that can be found include hematemesis or melena. Patients with melena tend to have lower hemoglobin (Hb) levels than hematemesis because clinical manifestations appear more slowly. Drug Induced NSAIDs are also one of the etiologies that can cause upper gastrointestinal bleeding. Endoscopy is the gold standard for diagnosis, but not all health facilities are able to perform it. This case reported a 66-years-old male patient came to the emergency room with complaints of blackish stools with a soft, sticky consistency for 6 days, accompanied by weakness, dizziness, nausea in the stomach and disruption of daily activities. The patient has a history of taking over-the-counter NSAIDs long term to relieve his knee pain. On physical examination, hepatomegaly and splenomegaly were not found and the patient’s hemodynamics is stable. On laboratory examination, Hb was found to be 3.4 g/dl. It was suspected that there was upper gastrointestinal bleeding, then received therapy in the form of PPI injections, antiemetic injections and planned PRC transfusion.

Critical upper gastrointestinal bleeding secondary to pine stall shaving ingestion and mechanical gastritis in a young do

AbstractAn 8‐month‐old, male, entire Staffordshire terrier was presented for acute lethargy. The patient was severely anaemic. Diagnostic and clinical findings indicated severe upper gastrointestinal haemorrhage of unknown aetiology. Large‐volume transfusion (a total of 64.2 mL/kg of blood product) and medical management resulted in fleeting stabilisation. Serial imaging documented persistent non‐obstructive foreign material within the stomach. Due to continued gastrointestinal haemorrhage, failure to respond to medical management, and the persistent abnormal material within the stomach, surgical exploration was recommended. Exploratory laparotomy and gastrotomy resulted in the removal of a large volume of pine stall shavings. There was gross evidence of diffuse mucosal haemorrhage and mechanical gastritis. No additional blood product was required following gastrotomy. To the authors’ knowledge, this is the first case report of a dog with critical bleeding necessitating large‐volume transfusion due to mechanical gastritis from ingestion of pine stall shavings, a material which is typically considered innocuous.

Gastrohepatic Fistula Secondary to Metastatic Colon Cancer as a Rare Etiology of Upper Gastrointestinal Bleed

Gastrohepatic Fistula Secondary to Metastatic Colon Cancer as a Rare Etiology of Upper Gastrointestinal Bleed

Gastrointestinal stromal tumor of the duodenum presenting with shock and massive upper and lower gastrointestinal bleeding: a case report and review of the literature

BackgroundDue to rarity of duodenal GISTs, clinicians have few information about its clinical features, diagnosis, management and prognosis.Case reportWe report a case of promptly diagnosed duodenal GIST in a 61-year-old Egyptian man presented shocked with severe attack of hematemesis and melena. Upper gastroduodenal endoscopy was done and revealed a large ulcerating bleeding mass at first part of duodenum 4 hemo-clips were applied with good hemostasis.An exploratory laparotomy and distal gastrectomy, duodenectomy and gastrojejunostomy were performed. The morphology of the mass combined with immunohistochemistry was consistent with duodenal gastrointestinal stromal tumours (GISTs) of high risk type. The patient is on amatinib one tablet daily and he was well with no evidence of tumor recurrence.Conclusiondespite being rare, emergency presentation with sudden severe, life-threatening hemorrhagic shock duodenal GISTs might be a cause of potentially lethal massive combined upper and lower gastrointestinal bleeding which is the key feature of this rare and challenging tumor.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review

BackgroundThe rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach.Case presentationA 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma.ConclusionsWe successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding — An Updated Meta-Analysis

BackgroundThe goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients.MethodsWe included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses.ResultsTwelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty).ConclusionsHigh certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.)

Recurrence of urothelial carcinoma. An unusual cause of upper gastrointestinal bleeding.

Gastrointestinal metastases of urothelial tumors are rare, implying an advanced stage of the disease and a poor prognosis. We report the case of a patient with a history of urothelial carcinoma in remission who presents with upper gastrointestinal bleeding secondary to gastric metastases due to tumor recurrence and we review recent literature on this topic.

Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation

BackgroundWhether proton-pump inhibitors are beneficial or harmful for stress ulcer prophylaxis in critically ill patients undergoing invasive ventilation is unclear.MethodsIn this international, randomized trial, we assigned critically ill adults who were undergoing invasive ventilation to receive intravenous pantoprazole (at a dose of 40 mg daily) or matching placebo. The primary efficacy outcome was clinically important upper gastrointestinal bleeding in the intensive care unit (ICU) at 90 days, and the primary safety outcome was death from any cause at 90 days. Multiplicity-adjusted secondary outcomes included ventilator-associated pneumonia, Clostridioides difficile infection, and patient-important bleeding.ResultsA total of 4821 patients underwent randomization in 68 ICUs. Clinically important upper gastrointestinal bleeding occurred in 25 of 2385 patients (1.0%) receiving pantoprazole and in 84 of 2377 patients (3.5%) receiving placebo (hazard ratio, 0.30; 95% confidence interval [CI], 0.19 to 0.47; P<0.001). At 90 days, death was reported in 696 of 2390 patients (29.1%) in the pantoprazole group and in 734 of 2379 patients (30.9%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.85 to 1.04; P=0.25). Patient-important bleeding was reduced with pantoprazole; all other secondary outcomes were similar in the two groups.ConclusionsAmong patients undergoing invasive ventilation, pantoprazole resulted in a significantly lower risk of clinically important upper gastrointestinal bleeding than placebo, with no significant effect on mortality. (Funded by the Canadian Institutes of Health Research and others; REVISE ClinicalTrials.gov number, NCT03374800.)

Clinical and laboratory parameters as predictors of mortality in patients with chronic liver disease presenting to emergency department- a cross sectional study

BackgroundThe World Health Organization (WHO) reports that Asia and Africa have the highest Chronic Liver Disease (CLD) mortality rate. Cirrhosis, responsible for 22.2 fatalities per 100,000 people, is India’s 10th most common cause of mortality. The increasing prevalence of chronic liver disease necessitates a study to identify predictive factors for patients who visit the emergency department. Identifying elements that enhance the predictive value of mortality in unstable patients with CLD complications is important in emergency departments. This study aims to determine Clinical and Laboratory Parameters as mortality predictors in adult chronic liver disease patients.MethodologyThe study was conducted at the emergency department of a tertiary healthcare center in Northern India. Patients with chronic liver disease above 18 years of age who satisfied the inclusion criteria were clinically evaluated. Clinical and demographic details were collected, and data was analyzed.ResultsTwo hundred thirty-six patients were enrolled. The mean age was 50.77 ± 14.26 years. 78.4% of the participants were men. Abdominal distension, affecting 59.7% of patients, was the most common presenting ailment, followed by melena and hematemesis, affecting 41.9% and 32.6%, respectively. The mean stay in the emergency department was 10.29 ± 8.10 h. Refractory septic shock, the leading cause of mortality, accounts for 69.2% of all deaths, alongside grade 4 hepatic encephalopathy and massive Upper Gastrointestinal (UGI) bleeding, as identified in our study. Factors such as altered mental sensorium, high respiratory rate, low SpO2, increased heart rate, low systolic blood pressure, low diastolic blood pressure, and low Glasgow Coma Scale (GCS) on Emergency Department (ED) arrival are significantly associated with mortality.ConclusionsChronic liver disease, a prevalent condition in India, most commonly seen in middle aged men and lower socioeconomic groups. The parameters independently associated with mortality in our study were presence of altered mental sensorium, Glasgow coma scale, Child Pugh class and need for ICU admission. Understanding the presentation pattern, and mortality predictors can help ED physicians in managing acute events and follow-ups.

Continuous co-prescription of rebamipide prevents upper gastrointestinal bleeding in NSAID use for orthopaedic conditions: A nested case-control study using the LIFE Study database.

Rebamipide has been widely co-prescribed with non-steroidal anti-inflammatory drugs (NSAIDs) in Japan for decades. This study aimed to evaluate the effectiveness of rebamipide in preventing upper gastrointestinal bleeding in new users of NSAIDs without risk factors of NSAID-induced ulcers other than age. A nested case-control study was conducted using medical claims data of 1.66 million inhabitants of 17 municipalities participating in Japan's Longevity Improvement & Fair Evidence study. The cohort entry (t0) corresponded to a new user of NSAIDs for osteoarthritis or low back pain. Patients with risk factors of NSAID-induced ulcers other than age were excluded. Cases were defined as patients who underwent gastroscopy for upper gastrointestinal bleeding (occurrence date was defined as index date). A maximum of 10 controls were selected from non-cases at the index date of each case by matching sex, age, follow-up time, and type and dosage of NSAIDs. Exposure to rebamipide was defined as prescription status from t0 to index date: Non-user (rebamipide was not co-prescribed during the follow-up period), Continuous-user (rebamipide was co-prescribed from t0 with the same number of tablets as NSAIDs), and Irregular-user (neither Non-user nor Continuous-user). Conditional logistic regression analysis was conducted to estimate each category's odds ratio compared to non-users. Of 67,561 individuals who met the inclusion criteria, 215 cases and 1,516 controls were selected. Compared with that of Non-users, the odds ratios and 95% confidence interval were 0.65 (0.44-0.96) for Continuous-users and 2.57 (1.73-3.81) for Irregular-users. Continuous co-prescription of rebamipide significantly reduced the risk of upper gastrointestinal bleeding in an Asian cohort of new users of NSAIDs with osteoarthritis or low back pain without risk factors other than age.

Fatty acid-arginine vesicles with prominent encapsulation efficiency and substantial transdermal delivery of sinomenine hydrochloride

In clinical practice, sinomenine hydrochloride (SH) is a valuable and promising medication for rheumatoid arthritis. However, oral administration of SH is less bioavailable with adverse reactions to the digestive system, blood circulation, and nervous system, among which rash, gastric ulcer, gastric haemorrhage and anaphylactic shock are the most common. Owing to a short half-life in the human body (0.791 h), patient compliance is greatly reduced, resulting in frequent administration for patient treatment. Therefore, SH encapsulated in vesicles with amphiphilic layers would be more stable and have fewer side effects. In this study, a transdermal drug delivery system (TDDS) for SH was designed utilizing fatty acid vesicles as carriers. The physicochemical properties and aggregate morphology of two carriers: arginine-oleic acid ([Arg][Ole]) and arginine-decanoic acid ([Arg][Dec]) were investigated, and the SH encapsulation method by the above materials was optimized and verified by single factor and central composite design (CCD) response surface methods. Notably, the encapsulation efficiency (EE) of SH in [Arg][Dec] vesicles was increased to 83.5 % and the centrifugal stability (CS) to 90.4 %. Moreover, as a result of the Conductor-like screening model for real solvents (COSMO-RS) calculation, it was found that the interaction between [Arg][Dec] and SH was stronger than that of [Arg][Ole], aligning with experimental results. In comparison to the sustained release period in water, the in vitro release experiment showed that the [Arg][Ole] and [Arg][Dec] vesicles could be prolonged to 17 hours. Importantly, the cumulative skin permeability of [Arg][Dec] vesicles reached 1665.59 μg·cm−2 after 48 h, which is much higher than the previous literature value of around 663 μg·cm−2. These results suggest that vesicles provide a viable method for transdermal delivery of SH.

Racial Differences in Non-variceal Upper Gastrointestinal (GI) Bleeding: A Nationwide Study.

Background and aims Knowledge about the impact of race on non-variceal upper GI bleeding (NVUGIB) is limited. This study explored the racial differences in the etiology and outcome of NVUGIB. Methods We conducted a study from 2009 to 2014 using the Nationwide Inpatient Sample (NIS) database. NIS is the largest publicly available all-payer inpatient database in the USA with more than seven million hospital stays each year. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for NVUGIB, esophagogastroduodenoscopy (EGD) and demographics were obtained. The outcomes of interest were in-hospital mortality, hospital length of stay (HLOS), total hospital charges, admission to the intensive care unit (ICU), and patient disposition. Analysis was conducted using Chi-square tests and Tukey multiple comparisons between groups. Results Among 1,082,516 patients with NVUGIB, African American and Native Americans had the highest proportions of hemorrhagic gastritis/duodenitis (8.2% and 4.2%, respectively) and Mallory-Weiss bleeding (10.4% and 5.4%, respectively; p<0.01). African Americans were less likely to get an EGD done within 24 hours of admission compared to Whites and Latinxs (45.9% vs 50.1% and 50.4%, respectively; p<0.001). In-hospital mortality was similar among African Americans, Latinxs, and Whites (5.8% vs 5.6% vs 5.9%, respectively; p=0.175). Asian/Pacific Islanders and African Americans were more likely to be admitted to the ICU (9.6% and 9.0%, respectively; p<0.001). Moreover, African Americans had a longer HLOS compared to Latinxs and Whites (7.5 vs 6.5 and 6.4 days, respectively; p<0.001). Conversely, Asian/Pacific Islanders and Latinx incurred the highest hospital total charges compared to African Americans and Whites ($81,821 and $69,267 vs $61,484 and $53,767, respectively; p<0.001). Conclusion African Americans are less likely to receive EGD within 24 hours of admission and are more likely to be admitted to the ICU with prolonged hospital lengths of stay. Latinxs are more likely to be uninsured and incur the highest hospital costs.

Sarcopenia in cirrhosis: Unraveling the prevalence and relationships with liver disease severity and complications.

Sarcopenia in cirrhosis is associated with poor survival and adverse pre and post-transplant outcomes. The study aimed at determining the prevalence of sarcopenia and its association with the severity, complications and etiology of liver disease. As many as 416 cirrhotic patients who met the inclusion criteria underwent muscle strength testing using a dynamometer. As many as 109 probable sarcopenia patients underwent computed tomography (CT) scan to measure skeletal muscle index (SMI) at the L3 vertebral level and gait-speed testing. The gender-specific cut-offs used to define sarcopenia were an SMI of 36.54 cm2/m2 in males and 30.21 cm2/m2 in females. A gait speed ≤ 0.8m/s was taken as a cut-off to define severe sarcopenia in both genders. The mean age was 54.7 ± 9.51years and male:female ratio was 2.2:1.The mean body mass index (BMI) was 24.2 ± 1.34kg/m2. Alcohol and non-alcoholic steatohepatitis (NASH) were the two most common etiologies (45.9% and 31.2%). The proportion of patients belonging to Child-Pugh class A, B and C was 26.6%, 48.6% and 24.8%, respectively. Forty out of 109 (36.7%) patients had a model for end-stage liver disease (MELD) > 14. Ascites, upper gastrointestinal bleeding and hepatic encephalopathy (HE) were present in 59 (54.1%), 60 (55.0%) and 24 (22.0%) patients, respectively. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was found to be 26.20%, 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia were associated with Child-Pugh class (p < 0.001, p < 0.001), MELD (p = 0.007, 0.002), upper gastrointestinal bleed (p = 0.007, 0.004), ascites (p = 0.038, 0.025) and HE (0.001, < 0.001). The prevalence of sarcopenia and severe sarcopenia was found to be 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia had a significant association with the severity and complications of cirrhosis. However, no association was observed with etiology of liver disease.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices: Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies. Moreover, the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

An update on management of Acute Upper GI bleeding

An update on management of Acute Upper GI bleeding

A case report of non hodgkin lymphoma presenting with upper gastrointestinal tract bleeding

Abstract: Initial evaluation of patients with acute gastrointestinal (GI) tract bleeding includes assessment of hemodynamic stability and resuscitation if necessary Case Report: A 48-year-old male patient was admitted to the emergency department with complaints of dizziness, intense weakness, vomiting in the form of coffee grounds and black diarrhea Conclusion: Aggressive non-hodgkin lymphoma may be among the etiologies of upper gastrointestinal bleeding. In cases where endoscopic and surgical methods are inadequate, chemotherapy may be a life-saving option considering the possible risks.

Outcomes of Upper Gastrointestinal Bleeding at United States Teaching and Non-teaching Hospitals: A National Inpatient Sample Analysis.

Studies have varied results regarding the impact of the teaching and non-teaching status of hospitals on the outcomes for hospitalized patients with upper gastrointestinal bleeding (UGIB). To evaluate these outcomes, we conducted a retrospective cohort study using the 2014 National Inpatient Sample (NIS) database. We included all adult patients who were admitted with the principal diagnosis of UGIB. Patients admitted to rural and urban non-teaching hospitals were classified as non-teaching, whereas those admitted to urban teaching hospitals were classified as teaching. The main outcomes of interest were in-hospital mortality, percentage of patients requiring inpatient endoscopy, and endoscopic therapy, packed red blood cell (PRBC) transfusion, length of stay (LOS), and total hospitalization charges. The study included 132,085 (97%) with nonvariceal UGIB (NVUGIB) and 4,200 (3%) with variceal UGIB (VUGIB). Of them, 62% were managed at teaching hospitals. Compared with admitted patients at non-teaching hospitals, patients with nonvariceal UGIB admitted at teaching hospitals had similar adjusted in-hospital mortality rates (adjusted odds ratio (OR): 0.97, 95% confidence interval (CI): 0.79-1.19), inpatient endoscopy rates (OR: 0.98, 95% CI: 0.91-1.1), and early endoscopy rates (within 24 hours) (OR: 0.98, 95% CI: 0.91-1.1) and lower PRBC transfusionrates (OR: 0.87, 95% CI: 0.79-0.97) but higher endoscopic therapyrates (OR: 1.3, 95% CI: 1.2-1.4), length of stay (mean increase of 0.43 days) (P<0.01), and total hospital charges (mean increase of $4,369) (P<0.01). Patients with variceal UGIBhad similar adjusted in-hospital mortality rates (OR: 1.2, 95% CI: 0.61-2.3), inpatientendoscopy rates (OR: 0.97, 95% CI: 0.67-1.4), early endoscopy rates (within 24 hours) (OR: 0.97, 95% CI: 0.67-1.4), endoscopic therapy rates (OR: 2.5, 95% CI: 0.54- 11.2), and total hospital charges (P=0.45), and lower PRBC transfusionrates (OR: 0.63, 95% CI: 0.45-0.88) but higher length of stay (mean increase of 0.69 days) (P=0.02). Patients with nonvariceal UGIB treated at US teaching hospitals and non-teaching hospitals have similar mortality, rates of in-hospital endoscopy, and early endoscopy, but teaching hospitals have higher rates of in-hospital therapeutic endoscopy, length of stay, and total hospital charges. There was no difference in any of the outcomes for varicealgastrointestinal (GI) bleeding treated at teaching hospitals compared with those treated at non-teaching hospitals, except for length of stay, which was higher among patients admitted to teaching hospitals compared to those admitted tonon-teaching hospitals.

Ketosis-prone Diabetes Presenting with Acute Esophageal Necrosis or “Black Esophagus”: An Intriguing New Clinical Association

Background:: Ketosis-prone diabetes (KPD) is an intermediate subtype of diabetes mellitus, usually affecting Afro-American adults, presenting with diabetic ketoacidosis (DKA), without the classic phenotype of autoimmune type 1 diabetes. Patients require insulin therapy at onset for the acute decompensation, then usually remain insulin-free for prolonged periods with diet alone or with other antidiabetic drugs. DKA can be rarely complicated by upper gastrointestinal bleeding and mucosal necrosis, a severe complication named acute esophageal necrosis (AEN) burdened by high mortality. The association of KPD presenting with DKA complicated by AEN is here reported for the first time, to the knowledge of the authors, in the medical literature. Case Presentation:: Here we report an interesting case of middle-aged African woman, newly diagnosed with KPD, presenting with DKA hematemesis. The patient was first treated at Intensive Care Unit for the ketoacidosis with intravenous fluids combined with continuous insulin infusion, and then switched to subcutaneous regimen. At the same time, esophagogastroduodenoscopy (EGD) was performed to diagnose acute esophageal necrosis, which was promptly managed with proton pump inhibitors infusion, fasting, and parenteral nutrition. After the correct clinical evaluation, the patient was switched to oral antidiabetic and basal insulin at discharge and an EGD follow-up was scheduled. Conclusions:: KPD remains an under-recognized and under-diagnosed type of diabetes which can present as DKA. Since DKA could be a possible trigger of AEN, a rare but potentially lifethreatening condition, that clinicians should be aware of, in patients presenting with upper gastrointestinal bleeding and ketoacidosis. The prompt management and classification of DKA, combined with the EGD execution for early AEN diagnosis and follow-up, is essential.