Rates Of Gastrointestinal Bleeding Research Articles

Proton Pump Inhibitors and In-Hospital Gastrointestinal Bleeding in Patients With Acute Coronary Syndrome Receiving Dual Antiplatelet Therapy

ObjectiveTo evaluate the association between proton pump inhibitor (PPI) use and in-hospital gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) taking dual antiplatelet therapy (DAPT). Patients and MethodsThis study is based on the Improving Care for Cardiovascular Disease in China-ACS project, an ongoing collaborative registry and quality improvement project of the American Heart Association and the Chinese Society of Cardiology. A total of 25,567 patients with ACS taking DAPT from 172 hospitals from July 1, 2017, through December 31, 2018, were included. Multivariable Cox regression and propensity score–matched analyses were used to evaluate the association between PPI use and in-hospital GI bleeding. ResultsOf these patients with ACS, 63.9% (n=16,332) were prescribed PPIs within 24 hours of admission. Patients using PPIs had a higher rate of GI bleeding compared with those not using PPIs (1.0% vs 0.5%; P<.001). In the multivariable Cox regression analysis, early PPI use was associated with a 58% higher risk of GI bleeding (hazard ratio, 1.58; 95% CI, 1.15 to 2.18; P=.005). Further propensity score matching attenuated the association but still showed that patients using PPIs had a higher rate of GI bleeding (0.8% vs 0.6%; P=.04). ConclusionIn China, PPIs are widely used within 24 hours of admission in patients with ACS taking DAPT. An increased risk of GI bleeding is observed in inpatients with early PPI use. Randomized trials on early use of PPIs in patients with ACS receiving DAPT are warranted. Trial Registrationclinicaltrials.gov Identifier: NCT02306616.

Gastric emergencies in older adults: not always the same old story! A tertiary care emergency department observational cohort study

ObjectiveTo analyse and compare the clinical outcomes between patients ≥80 years and 65–79 years, who presented to our emergency department (ED) with the two most common gastric emergency (GE) clinical...

Factor Xa Inhibition for the Treatment of Venous Thromboembolism Associated With Cancer: A Meta-Analysis of the Randomised Controlled Trials

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients. Until recently, guidelines recommended the use of low-molecular weight heparin (LMWH) as standard of care for VTE in patients with cancer. Despite the proven efficacy of direct oral anticoagulants (DOACs) for treatment of VTE, there is equipoise supporting their use in cancer patients. A systematic review of PubMed, Medline and EMBASE identified four randomised controlled trials (RCTs) in patients with cancer and VTE comparing a factor Xa inhibitor (FXaI) to LMWH. A meta-analysis was performed with a primary outcome of VTE recurrence and key secondary outcomes of major bleeding, clinically relevant non-major bleeding (CRNMB) and gastrointestinal (GI) bleeding. Four RCTs with 2,907 patients were included. 1,451 patients were randomised to FXaI and 1,456 to LMWH. VTE recurrence was lower in the FXaI group (RR 0.62, 95%CI 0.44-0.87; p=0.01; I2=24.90), with an absolute risk difference of -4% equating to a number needed to treat of 25 for prevention of recurrent VTE with FXaI. No significant difference in major bleeding was noted between groups (RR 1.33, 95%CI 0.84-2.11; p=0.23). Rates of GI bleeding (RR 1.87, 95%CI 1.06-3.29; p=0.03) and CRNMB (RR 1.57, 95%CI 1.11-2.23; p=0.01) were greater with FXaIs. In patients with cancer and VTE, the rate of VTE recurrence was significantly lower with FXaI than with LMWH without an increased risk of major bleeding. Our data supports the use of FXaIs as the standard of care for the treatment of VTE in this population.

Direct oral anticoagulants are associated with potentially bleeding lesions in suspected mid-gastrointestinal bleeding

Background and aim Direct oral anticoagulants (DOACs) became a widespread alternative in anticoagulant therapy. Nevertheless, concerns are raised about their safety, with increased gastrointestinal bleeding rates being described. There are scarce studies regarding DOACs effect on small-bowel capsule endoscopy (SBCE) findings. We aimed to assess if the detection of lesions with high bleeding potential on SBCE was significantly different in patients treated with DOACs when compared to non-anticoagulated patients and to patients anticoagulated with other agents. Methods Cohort study including consecutive patients who underwent SBCE for suspected mid-gastrointestinal bleeding (MGIB) in 2019 and 2020. Results From 148 patients, 38 (25.7%) were anticoagulated, of which 26 (68.4%) with DOACs. P2 lesions were detected in 36.5% (n = 54) of the patients. These lesions were more frequently detected in patients under DOACs treatment when compared to non-anticoagulated patients (69.2% vs. 29.1%; p=.001), and also when compared to patients treated with other anticoagulants (69.2% vs. 33.3%; p=.037). No differences in P2 lesions detection were observed between patients treated with other anticoagulants and non-anticoagulated patients (33.3% vs. 29.1%; p=.747). In multivariate analysis, DOACs usage was significantly associated with higher detection rates of P2 lesions on SBCE, when adjusted for classical risk factors for MGIB (OR: 3.38; 95%CI = 1.23–9.26; p=.018). Conclusions Despite their undeniable cardiovascular benefits and easy applicability, DOACs should still be considered with caution. These drugs were significantly associated with higher risk of potentially bleeding lesions on SBCE when compared to other anticoagulants and represent an independent risk factor for MGIB when adjusted for other variables.

Abstract 9726: Simplified Academic Research Consortium for High Bleeding Risk Criteria Predicts Bleeding Events in Patients with Heart Failure

Introduction: It has been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in which six rare criteria are excluded are comparable to the original ARC-HBR criteria in predicting major bleeding in patients who undergo percutaneous coronary intervention. We aimed to evaluate the predictive value of the simplified ARC-HBR criteria for bleeding events in patients with heart failure (HF) including those with and without coronary artery disease (CAD). Methods and Results: A total of 2,437 patients hospitalized for HF were enrolled. Among them, 56.5%, 23.7%, 15.8%, 4.8%, 4.7%, and 3.0% presented with oral anticoagulation, anemia, renal dysfunction, thrombocytopenia, active malignancy, and stroke of major criteria. Patients were divided into two groups based on the simplified ARC-HBR criteria: patients who are at HBR (HBR group, n = 2,026, 83.1%) and those who are not (non-HBR group, n = 411, 16.9%). The HBR group was older (72.0 vs. 61.0 years old, P &amp;lt; 0.001) and had lower prevalence of CAD (31.1% vs. 36.5%, P = 0.034) than the non-HBR group. The Kaplan-Meier analysis showed that post-discharge hemorrhagic stroke and gastrointestinal bleeding rates were higher in the HBR group than in the non-HBR group ( Figure ). In the Cox proportional hazard analysis, the simplified ARC-HBR criteria predicted both hemorrhagic stroke (hazard ratio [HR] 2.827, 95% confidence interval [CI] 1.019-7.844, P = 0.046) and gastrointestinal bleeding (HR 3.565, 95% CI 1.560-8.145, P = 0.003) irrespectively of CAD (interaction P = 0.931 and 0.761, respectively). Conclusions: The simplified ARC-HBR criteria predicts high bleeding events in patients with HF.

Abstract 11839: Outcomes of Stroke and Bleeding by Class of Anticoagulant Use for Non-Valvular Atrial Fibrillation in Patients With Active Cancer

Introduction: The choice of anticoagulant for patients with non-valvular atrial fibrillation (AF) in the setting of active cancer has not been well studied given only a minority of patients with cancer included in clinical trials. Hypothesis: Cancer patients will have similar rates of stroke (CVA), gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH) when treated with direct oral anticoagulants (DOAC) compared to warfarin (VKA) for AF. Methods: A retrospective study was performed at MD Anderson Cancer Center on patients with cancer and AF being treated with VKA or DOAC. The outcomes assessed were overall mortality, CVA, GIB, or ICH and patients were censored at 5 years. 1:1 propensity score matching was conducted to select comparable patients receiving VKA versus DOAC. Multivariable Cox proportional hazards regression models were fitted for each outcome. Results: A total of 1133 patients were included in the dataset with mean age of 72 years, 42% women, and 74% received DOAC (57% received apixaban). At 5 year follow up, mortality occurred in 145, CVA in 59, GIB in 59, and ICH in 6 patients. The baseline risk scores were higher for those on VKA compared to DOAC (CHADSVASC 3.5±1.6 vs 3.3±1.7 p=0.04, HASBLED 2.0 ± 1.1 vs 1.8 ± 1.0 p&lt;0.01). After propensity score matching 210 patients were included in each anticoagulant group. Survival analysis showed higher GIB free survival in the DOAC group however no difference was observed for composite GIB, CVA, or ICH (Figure). On multivariate analysis the risk of GIB was higher in the VKA group (HR 3.1, 95% CI 1.3-7.3); however, risk of mortality (HR 1.1, 95% CI 0.7-1.8), CVA (HR 0.9, 95% CI 0.4-1.8), ICH (HR 0.3, 95% CI 0.0-2.2), and composite of GIB, CVA, or ICH (HR 1.3, 95% CI 0.8-2.3) were not different comparing VKA to the DOAC propensity matched group. Conclusion: Patients with active cancer have higher risk of GIB but similar overall survival and risk for composite stroke and bleeding when treated with VKA compared to DOAC for AF.

Abstract 9779: The Utility of Endoscopic Screening in Mitigating the Risk of Gastrointestinal Bleeding After Left Ventricular Assist Device Placement. A Retrospective Chart Review Study

Introduction: Left ventricular assist device (LVAD) is a lifesaving bridge to transplantation or destination therapy for patients with end-stage heart failure. More than one-third of patients suffer from gastrointestinal (GI) bleeding within one year of placement. We investigated the yield and safety of endoscopic screening for potential sources of GI bleeding before LVAD insertion. Hypothesis: Endoscopic screening prior to LVAD placement does not necessarily reduce the risk of GI bleed post LVAD. Methods: We performed a retrospective chart review study of patients at Saint Luke’s Mid America Heart Institute who underwent continuous-flow LVAD implantation from 2010 to 2020. Study participants were categorized based on whether or not they underwent screening endoscopy prior to LVAD implantation. Patients were followed for one year after implantation, and outcomes were collected to determine the yield and safety of these procedures. A multivariable logistic regression analysis was performed using SPSS® controlling for the following confounding factors: age, gender, race, and history of GI bleeding. Results: Among 205 patients with an LVAD, 169 patients were included in the study after excluding those with lack of data or those lost to follow up. 68 (40.23%) patients who received pre-LVAD screening by either upper and/or lower endoscopies, and 42 (24.85%) patients who had post-LVAD GI bleed. Patients who underwent pre-LVAD screening had similar rates of GI bleeding after LVAD compared to those who were not screened (odds ratio 1.66, 95% CI 0.648-4.264, P=0.2). Moreover, in patients with post LVAD GI bleed, endoscopy findings were typically different than those pre LVAD. No complications to the endoscopic interventions were reported. Conclusions: While endoscopic screening appears to be safe in patients before LVAD implantation, it had no association with GI bleeding risk or etiology after LVAD.

The impact of left ventricular size on outcomes after centrifugal-flow left ventricular assist device implantation.

The influence of preoperative left ventricular size in outcomes following centrifugal-flow left ventricular assist device (LVAD) implantation has not been well characterized. A cohort of 313 patients who received a centrifugal-flow LVAD at a single institution was analysed. Using a maximally selected log-rank statistic, we investigated whether a left ventricular end-diastolic dimension (LVEDD) cut-off point was associated with worse outcomes. The cohort was then divided in 2 groups based on the LVEDD cut-off point. An LVEDD cut-off point of 59 mm was found to predict worse survival. Smaller LVEDD patients (≤59 mm, N = 52) were older and more likely to have a history of coronary artery disease compared those with a larger LVEDD (>59 mm, N = 261). Smaller LVEDD patients had lower survival compared to larger LVEDD patients (71% vs 85% at 1 year and 58% vs 80% at 2 years, P = 0.003). The need for temporary right ventricular mechanical support was significantly higher in the smaller LVEDD cohort (11.5% vs 1.9%, P = 0.002). Pump flows at time of discharge were lower in the smaller LVEDD group (3.8 vs 4.2 l/min, P = 0.005), who also had a higher incidence of late right ventricular failure (23% vs 12%, P = 0.02), higher rates of gastrointestinal bleeding (0.416 vs 0.256 events per patient-year, P = 0.025) and higher readmissions secondary to low flow alarms (0.429 vs 0.240 events per patient-year, P = 0.007). Multivariable analysis demonstrated that smaller LVEDD, older age, high BUN and high bilirubin levels were independent predictors of worse survival. In patients receiving a centrifugal-flow LVAD, smaller preoperative LVEDD (≤59 mm) was associated with lower survival and higher incidence of adverse outcomes.

Annals for Educators - November 2021.

Annals for Educators - November 2021.

Gastrointestinal bleeding and endoscopic findings in critically and non-critically ill patients with corona virus disease 2019 (COVID-19): Results from Lean European Open Survey on SARS-CoV-2 (LEOSS) and COKA registries.

BackgroundCorona virus disease 2019 (COVID‐19) patients are at increased risk for thromboembolic events. It is unclear whether the risk for gastrointestinal (GI) bleeding is also increased.MethodsWe considered 4128 COVID‐19 patients enrolled in the Lean European Open Survey on SARS‐CoV‐2 (LEOSS) registry. The association between occurrence of GI bleeding and comorbidities as well as medication were examined. In addition, 1216 patients from COKA registry were analyzed focusing on endoscopy diagnostic findings.ResultsA cumulative number of 97 patients (1.8%) with GI bleeding were identified in the LEOSS registry and COKA registry. Of 4128 patients from the LEOSS registry, 66 patients (1.6%) had a GI bleeding. The rate of GI bleeding in patients with intensive care unit (ICU) admission was 4.5%. The use of therapeutic dose of anticoagulants showed a significant association with the increased incidence of bleeding in the critical phase of disease. The Charlson comorbidity index and the COVID‐19 severity index were significantly higher in the group of patients with GI bleeding than in the group of patients without GI bleeding (5.83 (SD = 2.93) vs. 3.66 (SD = 3.06), p < 0.01 and 3.26 (SD = 1.69) vs. 2.33 (SD = 1.53), p < 0.01, respectively). In the COKA registry 31 patients (2.5%) developed a GI bleeding. Of these, the source of bleeding was identified in upper GI tract in 21 patients (67.7%) with ulcer as the most frequent bleeding source (25.8%, n = 8) followed by gastroesophageal reflux (16.1%, n = 5). In three patients (9.7%) GI bleeding source was located in lower GI tract caused mainly by diverticular bleeding (6.5%, n = 2). In seven patients (22.6%) the bleeding localization remained unknown.ConclusionConsistent with previous research, comorbidities and disease severity correlate with the incidence of GI bleeding. Also, therapeutic anticoagulation seems to be associated with a higher risk of GI bleeding. Overall, the risk of GI bleeding seems not to be increased in COVID‐19 patients.

Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study.

Gastrointestinal bleeding (GIB) rates for direct oral anticoagulants (DOACs) and warfarin have been extensively compared. However, population-based studies comparing GIB rates among different DOACs are limited. To compare rates of GIB among apixaban, dabigatran, and rivaroxaban. Nationwide population-based cohort study. Landspítali-The National University Hospital of Iceland and the 4 regional hospitals in Iceland. New users of apixaban, dabigatran, and rivaroxaban from 2014 to 2019. Rates of GIB were compared using inverse probability weighting, Kaplan-Meier survival estimates, and Cox regression. In total, 2157 patients receiving apixaban, 494 patients receiving dabigatran, and 3217 patients receiving rivaroxaban were compared. For all patients, rivaroxaban had higher overall rates of GIB (3.2 vs. 2.5 events per 100 person-years; hazard ratio [HR], 1.42 [95% CI, 1.04 to 1.93]) and major GIB (1.9 vs. 1.4 events per 100 person-years; HR, 1.50 [CI, 1.00 to 2.24]) compared with apixaban. Rivaroxaban also had higher GIB rates than dabigatran, with similar point estimates, although the CIs were wider and included the possibility of a null effect. When only patients with atrial fibrillation were included, rivaroxaban was associated with higher rates of overall GIB than apixaban (HR, 1.40 [CI, 1.01 to 1.94]) or dabigatran (HR, 2.04 [CI, 1.17 to 3.55]). Dabigatran was associated with lower rates of upper GIB than rivaroxaban in both analyses. Unmeasured confounding and small subgroup analyses. Rivaroxaban was associated with higher GIB rates than apixaban and dabigatran regardless of treatment indication. Icelandic Centre for Research and Landspítali-The National University Hospital of Iceland.

Comparison of the HAS-BLED, ORBIT and ATRIA bleeding risk scores in 399,344 patients with atrial fibrillation and cancer

Abstract Background The presence of cancer worsens the prognosis of patients with atrial fibrillation (AF). However, the association between cancer type and specific bleeding events has been scarcely investigated. Furthermore, the performance of bleeding risk scores, such HAS-BLED, ORBIT and ATRIA, in this high-risk subgroup of AF patients is unclear. Purpose To investigate the incidence rate (IR) of major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH) according to cancer types. We also investigated the performance of HAS-BLED, ATRIA and ORBIT scores. HASBLED ≥3, ATRIA ≥5 and ORBIT ≥4 were defined as high-risk. Methods Observational retrospective cohort study including 399,344 patients with AF and cancer. Results Mean age was 77.9±10.2 years and 63.2% were men. During a mean follow-up of 2.0 years, the IR of major bleeding was as high as 8.41%/year, GI bleeding was 3.61%/year and ICH 1.33%/year. Major bleedings were more frequent in liver (12.68%/year), leukaemia (12.39%/year), pancreas (11.71%/year), bladder (11.67%/year) and myeloma (11.64%/year). GI bleeding were highest in liver (7.54%/year), pancreas (7.42%/year) and gastric (5.51%/year). The highest IR of ICH was found in leukaemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year) and pancreas cancer (1.41%/year). Figure 1 shows the hazard ratios and AUC values for the three scores against each endpoint. All the three scores were significantly associated with major, GI and ICH. The HAS-BLED score performed better than others for ICH prediction, while the ORBIT score showed the best predictivity for major and GI bleedings (p&amp;lt;0.0001 for all AUC comparisons) Conclusions Cancer increases the risk of bleeding in patients with cancer, with specific differences according to each cancer type. HAS-BLED score identified patients at highest risk for ICH and the ORBIT score for major and GI bleeding. Funding Acknowledgement Type of funding sources: None. Figure 1

Predictors for major bleeding in elderly (75 years and over) patients with non-valvular atrial fibrillation at high risk of bleeding: sub-analysis of the ANAFIE Registry

Abstract Background In patients with atrial fibrillation (AF) receiving anticoagulant therapy, bleeding events are associated with reduced survival. Previous studies showed that bleeding events during anticoagulant therapy were more frequent in elderly AF patients than in younger patients. HAS-BLED score has been used to assess the risk of bleeding in AF patients. In patients at high bleeding risk (HAS-BLED score ≥3), we sought to identify other risk factors associated with major bleeding not included in HAS-BLED score in elderly non-valvular AF (NVAF) patients. Purpose The All Nippon Atrial Fibrillation In the Elderly (ANAFIE) Registry is a prospective, multicenter, observational study to collect real-world data on clinical status and prognosis in more than 30,000 Japanese patients (aged ≥75 y) with NVAF. This sub-analysis of the ANAFIE Registry assessed the 2-year outcomes and identified predictors for major bleeding in elderly NVAF patients with a high bleeding risk. Methods A total of 32,275 patients from the ANAFIE Registry were divided into 2 groups according to HAS-BLED score (≥3 [high-risk group] and ≤2 [reference group]). The annualized incidence rate, hazard ratio (HR) for clinical outcomes, and independent predictors for major bleeding were analyzed using Kaplan-Meier analysis and the Cox proportional-hazards model. Results A total of 6,826 patients constituted the high-risk group: mean age, 81.8 years old (75–80 years, 37.8%; 81–84 years, 33.9%; ≥85 years, 28.3%); male ratio, 72.2%; mean creatinine clearance (CrCL), 42.7 mL/min; history of major bleeding, 14.2%; presence of non-paroxysmal AF, 62.2%; mean total number of medicines used, 7.8. Anticoagulants were used in 91.2% (warfarin [WF], 29.9%; direct oral anticoagulants [DOACs], 61.2%). Proton-pump inhibitors (PPI) were administered in 46.5%. Compared to the reference group, the high-risk group had higher annualized incidence rates (/100 patient-year) of major bleeding (1.49 vs 0.97), intracranial hemorrhage (0.95 vs 0.70), gastrointestinal (GI) bleeding (2.63 vs 1.73), and all-cause mortality (5.50 vs 3.24). All-cause mortality more frequently occurred in patients aged ≥85 years compared to 75–79 years and those with CrCL &amp;lt;50 mL/min compared to CrCL ≥50 mL/min. In the high-risk group, DOAC subgroup had lower incidences of the above-mentioned outcomes other than GI bleeding than WF subgroup. The following relevant factors for major bleeding not included in HAS-BLED score were identified in the high-risk group: Body mass index (BMI) ≥25.0 kg/m2 (HR, 0.40), heart failure (HF) with reduced left ventricular ejection fraction (LVEF) (HR, 1.38), a fall within 1 year (HR, 2.29), and use of PPI (HR, 0.65). Conclusions Among elderly (≥75 years) Japanese NVAF patients in the high bleeding risk group (HAS-BLED score ≥3), HF with reduced LVEF, and a fall within 1 year were identified as independent predictors of major bleeding. BMI ≥25.0 kg/m2 and PPI use were protective for major bleeding. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

S686 Gastrointestinal Bleeding Risk and Endoscopy Utilization in COVID-19 Patients on Therapeutic Anticoagulation: A Multicentric Study

Introduction: Patients affected with coronavirus disease 2019 (COVID-19) can lead to severe hypercoagulability. Many of these patients receive therapeutic anticoagulation because of a very high risk of thromboembolism. However, data about the risk of gastrointestinal bleeding (GIB) in these patients on therapeutic anticoagulation is scarce. Additionally, endoscopy utilization among these GIB patients need further studies. This study aims to evaluate the rates of GIB bleeding in COVID-19 patients and the endoscopy utilization for the same from a national research network database. Methods: We used a federated cloud-based network database named TriNetX, comprising of 50 healthcare organizations (HCOs) across the US to identify all adults patients who were on therapeutic anticoagulation (warfarin, therapeutic dose-heparin [enoxaparin, unfractionated heparin], direct thrombin inhibitors, direct-acting factor Xa inhibitors 3-months prior to COVID-19 diagnosis. Patients with the use of anticoagulants for thromboprophylaxis were excluded. Patients with the above characteristics were studied from January 1, 2020, to June 15, 2021, were divided into the anticoagulation (COVID with AC) and without anticoagulation (COVID w/o AC) groups. The primary outcomes were rates of GIB (melena/hematemesis), inpatient hospitalizations, endoscopy (EGD/colonoscopy) utilization, number of packed red blood cell (PRBC) transfusions, and 30-day all-cause mortality. The outcomes were measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results: A total of 104,946 patients in COVID with AC and 591,273 patients in COVID w/o AC groups were compared. The patient comorbidities at presentation, laboratory findings, and clinical outcomes are noted in Table 1. After matching, COVID with AC patients had a higher risk of GIB (risk ratio [RR]- 1.62 (CI- 1.45 - 1.82)), inpatient hospitalization rates (RR- 4.53 (CI- 4.42 - 4.65)), PRBC transfusions (RR 3.67 (CI-3.35 - 4.02)), overall mortality (RR 3.93 (3.75 - 4.12)). Despite the increased presence of GIB, endoscopy utilization was lower (RR- 0.85 (0.78 - 0.93)). Conclusion: Rates of GIB, inpatient hospitalization, and overall mortality increased in COVID-19 patients on therapeutic anticoagulation. However, endoscopy utilization remained low, probably due to fear of infection transmission. If the increased mortality is related to the underlying severity of COVID-19 or unidentified comorbidities need to be further evaluated.Table 1.: Mortality in MDS patients with GI bleed (OR).Figure 1.: Risk of UGIB with and without SSRI Use Footnote: Forest Plot depicting OR of having UGIB with and without SSRI use in patients on NSAIDs.

S1160 Role of Aspirin in the Prevention of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Introduction: Hepatocellular carcinoma is the sixth most prevalent cancer worldwide. Vaccination for hepatitis B and treatment of viral hepatitis are the most important preventive therapies against hepatocellular carcinoma. Recent studies have suggested that regular use of aspirin may play a role in the prevention of hepatocellular carcinoma, but its use remains controversial because of the paucity of studies. Methods: We conducted a systematic review and meta-analysis of studies that described the association between aspirin use and the incidence of hepatocellular carcinoma. We performed a comprehensive search in the databases of PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials through Nov 16, 2020. We considered randomized controlled trials, cohort studies, and case-control studies. We excluded abstracts, animal studies, case reports, reviews, editorials, and letters to editors. Our outcomes were the incidence of hepatocellular carcinoma and major gastrointestinal bleeding during the follow-up period. The random-effects model was used to calculate the hazard ratios (HR), risk ratio (RR), and confidence intervals (CI). A P-value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index. Results: Twelve studies involving 2,666,799 subjects were included in the meta-analysis. Subjects were either healthy individuals or diagnosed with hepatitis (alcoholic or viral). Pooled results of the included studies showed a significant decrease in hepatocellular carcinoma in patients who received aspirin therapy compared to those who did not (HR 0.56, 95% CI 0.46-0.67, P <0.01, I2 90.92%). Three studies assessed the risk of major gastrointestinal bleeding while on aspirin therapy. Pooled results of these studies showed no significant difference in the rates of major gastrointestinal bleeding between patients who consumed aspirin and controls (RR 1.1, 95% CI 0.97-1.27, P 0.14, I2 49.47%). Conclusion: Our meta-analysis demonstrated a significant reduction in the risk of hepatocellular carcinoma in individuals who consumed aspirin. Moreover, aspirin use did not increase the risk of developing major gastrointestinal bleeding. This suggests that the daily use of aspirin can be utilized as a primary preventive strategy for hepatocellular carcinoma. However, further randomized clinical trials with a large sample size are needed before implementing any strategies.Figure 1.: Aspirin usage and risk of liver cancer.

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.

S648 Emergent Endoscopy for Acute Gastrointestinal Bleeding and Readmission Rates in Patients With and Without Cirrhosis

S648 Emergent Endoscopy for Acute Gastrointestinal Bleeding and Readmission Rates in Patients With and Without Cirrhosis

Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review with Meta-Analysis.

The novel coronavirus disease 2019 (COVID-19) has been reported to affect the gastrointestinal system with a variety of symptoms, including bleeding. The prevalence of bleeding in these patients remains unclear. The aim of this meta-analysis is to estimate the rate of gastrointestinal bleeding in COVID-19 patients and its association with mortality. MEDLINE and Embase were searched through December 20, 2020. Studies reporting COVID-19 patients with and without gastrointestinal bleeding were included. Estimated prevalence with 95% confidence intervals (CI) was pooled; heterogeneity was expressed as I2. Metaregression analysis was performed to assess the impact of confounding covariates. Ten studies met the inclusion criteria and were included in the analysis. A total of 91887 COVID-19 patients were considered, of whom 534 reported gastrointestinal bleeding (0.6%) [409 (76.6%) upper and 121 (22.7%) lower gastrointestinal bleeding (UGIB and LGIB, resp.)]. The overall pooled gastrointestinal bleeding rate was 5% [95% CI 2–8], with high heterogeneity (I2 99.2%); “small study effect” was observed using the Egger test (p=0.049). After removing two outlier studies, the pooled bleeding rate was 2% [95% CI 0–4], with high heterogeneity (I2 99.2%), and no “small study effect” (p=0.257). The pooled UGIB rate was 1% (95% CI 0–3, I2 98.6%, p=0.214), whereas the pooled LGIB rate was 1% (95% CI 0–2, I2 64.7%, p=0.919). Metaregression analysis showed that overall estimates on gastrointestinal bleeding were affected by studies reporting different sources of bleeding. No significant association between gastrointestinal bleeding and mortality was found. In this meta-analysis of published studies, individuals with COVID-19 were found to be at risk for gastrointestinal bleeding, especially upper gastrointestinal bleeding.

Influence of portal vein thrombosis on the prognosis of patients with liver cirrhosis based on propensity score matching

Objective To investigate the influence of portal vein thrombosis (PVT) on the short-term prognosis of patients with liver cirrhosis and the risk factors for the prognosis of patients with liver cirrhosis. Methods A retrospective analysis was performed for the clinical data of the patients with liver cirrhosis who were hospitalized in our hospital from September 2018 to March 2020, among whom 58 patients with PVT were enrolled as PVT group and 116 patients without PVT were enrolled as non-PVT group, and 44 patients were selected from each group based on propensity score matching (PSM) at a ratio of 1∶ 1 to balance the covariates between groups. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. The Kaplan-Meier method and the log-rank method were used to analyze survival status and bleeding before and after PSM, and the Cox risk model was used to analyze the risk factors for the prognosis of patients with liver cirrhosis. Results Before PSM, the non-PVT group had a significantly higher overall survival rate than the PVT group (P=0.008), while after PSM, there was no significant difference in overall survival rate between the two groups (P=0.076). Before PSM, the non-PVT group had significantly lower incidence rates of upper gastrointestinal bleeding or rebleeding than the PVT group before and after PSM (P Conclusion Liver cirrhosis with PVT increases the risk of upper gastrointestinal bleeding or rebleeding, but it is not an independent risk factor for short-term death in patients with liver cirrhosis. MELD score ≥15 is an independent risk factor for short-term death in patients with liver cirrhosis.

Outcomes of variceal upper gastrointestinal bleeding: A prospective, multicenter, population-based study from West Hungary

Acute variceal gastrointestinal bleeding is associated with significant morbidity and mortality. Our aim was to evaluate the characteristics and prognostic factors in the management of acute upper gastrointestinal bleeding in a large multi-center study from Hungary. This prospective one-year study (between January 1, 2016 and December 31, 2016) involved six community hospitals in Western Hungary. Data collection included demographic characteristics, vital signs at admission, comorbidities, medications, time to hospital admission and endoscopy, laboratory results, endoscopic management, risk assessment using Glasgow-Blatchford Score (GBS), Rockall Score (RS) and the American Society of Anesthesiologists (ASA) Physical Status Score, transfusion requirements, length of hospital stay and mortality. 108 cases (male: 69.4%) of acute variceal gastrointestinal bleeding were registered during the 1-year period. Endoscopic therapeutic intervention was performed in 57.4%. On initial endoscopy, 39.8% of the patients were treated with sclerotherapy and 18.5% had ligation. 76.9% of the patients required blood transfusion. The overall mortality (including in-hospital bleedings) was 24.1%. The GBS predicted transfusions (AUC: 0.793; cut-off: GBS >8 points). The ASA Score was associated with transfusion (OR 7.6 [CI 95% 2.7-21.6]; p<0.001), endoscopic intervention (OR 12.6 [CI 95% 3.4-46.5]; p = 0.033), and showed similar trend with mortality (OR 3.6 [0.8-16.7]; p = 0.095). The increased international normalized ratio (INR) and creatinine levels were associated with mortality (p = 0.001 and p = 0.002). Incidence rates of acute variceal gastrointestinal bleeding in Western Hungary are high. The ASA Score, GBS predicted outcomes and transfusion requirements. The observed high mortality rates, coupled with relatively low rates of endoscopic ligation, warrant optimization of management strategies in acute variceal gastrointestinal bleeding. Orv Hetil. 2021; 162(31): 1252-1259.