Previous History Of Gastrointestinal Bleeding Research Articles

Nonvitamin K Anticoagulants: Risk of Bleeding When Interacting With Other Medications: A Cohort Study From Medicare.

Patients on nonvitamin K antagonist (NVKA) are usually taking other drugs. Potential interaction may increase the gastrointestinal (GI) bleeding risk associated with NVKA. Observational cohort study using Medicare data from 2017 to 2020. Participants receiving a NVKA were included. A concomitant overlapping period while on NVKA was assessed for nonsteroidal anti-inflammatory drugs (NSAIDS), selective serotonin reuptake inhibitors (SSRI), antiplatelets, glucocorticoids, aspirin and proton pump inhibitors (PPI). A logistic regression predicting either any bleeding or GI bleeding was conducted estimating the odds ratio (OR) and 95% confidence interval (CI). A total of 102 531 people on NVKA with mean age 77 years (SD = 9.8) and 55% females (N = 56 671) were included. Previous history of GI bleeding occurred in 2 908 (2.8%) participants, concomitant exposure to PPI occurred in 38 713 (38%), SSRI in 16 487 (16%), clopidogrel in 15 795 (15.4%), NSAIDs in 13 715 (13.4%) and glucocorticoids in 13 715 (13.4%). Risk for any bleeding was shown for clopidogrel (OR: 1.37, 95% CI: 1.30, 1.44), prasugrel/ticagrelor (OR: 1.36, 95% CI: 1.18, 1.58), glucocorticoids (OR: 1.26, 95% CI: 1.19, 1.34), and SSRIs (OR: 1.13, 95% CI: 1.07, 1.19). GI bleeding risk was shown for clopidogrel (OR: 1.44, 95% CI: 1.34, 1.55), prasugrel/ticagrelor (OR: 1.47, 95% CI: 1.20, 1.79), SSRIs (OR: 1.09, 95% CI: 1.01, 1.17) and glucocorticoids (OR: 1.33, 95% CI: 1.23, 1.44). PPI use was correlated with both NSAID (r = 0.07, p ≤ 0.0001) and SSRI use (r = 0.09, p ≤ 0.0001). NVKA concomitantly taken with antiplatelets, glucocorticoids, and SSRIs showed an increased risk for any bleeding and GI bleeding.

Construction of a prediction model for predicting rebleeding in patients with obscure gastrointestinal bleeding after capsule endoscopy

Objective: To explore the risk factors of rebleeding in patients with obscure gastrointestinal bleeding (OGIB) after capsule endoscopy (CE), and construct a model to predict rebleeding. Methods: The data of patients with OGIB who underwent CE in Zhongda Hospital Affiliated to Southeast University from July 2018 to September 2021 were retrospectively analyzed. Follow-up data were obtained via electronic medical records or telephone interviews. Univariate and multivariate Cox regression models were performed to figure out the risk factors of rebleeding in OGIB patients. Then the optimal prediction model was determined and presented as a nomogram. The model was evaluated by C statistic, calibration curve and decision curve analysis. Results: One hundred and thirty patients with OGIB were included, including 64 females and 66 males, aged (55.8±17.2) years (18-87 years), and 39 (30.0%) cases developed rebleeding during follow-up. Univariate and multivariate Cox regression model analysis showed the duration of more than 2 weeks OGIB (HR=3.70, 95%CI: 1.85-7.42, P<0.001), a history of previous gastrointestinal bleeding (HR=5.25, 95%CI: 2.00-13.81, P<0.001), positive CE findings (HR=3.72, 95%CI: 1.66-8.33, P=0.001), and the lowest hemoglobin level before CE<80 g/L (HR=2.00, 95%CI: 1.02-3.84, P=0.044) were risk factors for rebleeding, while specific treatment (HR=0.25, 95%CI: 0.11-0.54, P<0.001) was a protective factor. The corresponding scores of the above five predictive factors were: OGIB duration>2 weeks: 79 points; Previous history of gastrointestinal bleeding: 100 points; The result of CE was positive: 79 points; Specific treatment:-85 points; Minimum hemoglobin before CE<80 g/L: 41 points. The prediction model constructed from the above five variables had good discriminative capability (concordance index=0.798, 95%CI: 0.732-0.865). The calibration curves showed high consistency between nomogram-predicted probabilities and actual observations. The decision curves showed that when the threshold probability was above 0.04, the use of the nomogram to predict rebleeding provided a greater net benefit than the assumption of "all patients rebleeding or no patients rebleeding". Conclusion: The prediction model established in this study has a good ability to predic rebleeding in patients with OGIB after CE examination.

Antiplatelet and anticoagulant therapies in hereditary hemorrhagic telangiectasia: A large French cohort study (RETROPLACOTEL)

BackgroundIt is unclear whether hereditary hemorrhagic telangiectasia (HHT) patients can tolerate antithrombotic therapies (AT) including antiplatelet (AP) and/or anticoagulant (AC) agents. ObjectivesPrimary endpoint was tolerance to AT in HHT. Secondary endpoints were to identify factors associated with major bleeding events (MBE) and premature discontinuation of AT. MethodsRetrospective multicenter study in French national HHT Registry patients exposed to AT. ResultsWe included 126 patients with 180 courses of AT. Median follow-up was 24 [11–52] months. Mean age was 65.6 ± 13.1 years. The first 3 months of AT exposure had an increased risk of hospitalization for hemorrhage (p < 0.001) and transfusions (p < 0.001). MBE (n = 63) occurred more frequently in the first 3 months of AT exposure (p < 0.001). Premature discontinuation of AT occurred in 61 cases. Rate of premature discontinuation was 29 % under both AP and AT therapy but significantly higher under dual AP therapy (n = 4/7, 57 % p = 0.008). Risk factors for MBE were: age ≥ 60 years (HR 2.34 [1.12;4.87], p = 0.023), prior hospitalization in the 3 months before starting AT for hemorrhage (HR 3.59 [1.93;6.66], p < 0.001) or transfusion (HR 3.15 [1.61;6.18], p = 0.001), previous history of gastro-intestinal bleeding (HR 2.71 [1.57;4.65], p < 0.001) or MBE (HR 4.62 [2.68;7.98], p < 0.001). Frequency of MBE did not differ between groups except for a higher risk in the dual AP group (HR 3.92 [1.37;11.22], p = 0.011). ConclusionTolerance of AC or AP therapy was similar in HHT population but not dual AP therapy. We identified risk factors for MBE occurrence or premature discontinuation under AT.

Gastrointestinal bleeding preceding new-onset atrial fibrillation - results from the nationwide FinACAF study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation of Cardiovascular Research Introduction Initiation of oral anticoagulation (OAC) in case of a new-onset atrial fibrillation (AF) requires assessment of bleeding history. Gastrointestinal (GI) bleedings are among the most common bleeding events. Purpose We aimed to assess clinical characteristics and initiation of OAC in patients with new-onset AF and a history of previous GI bleeding. Methods The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. The study population consists of all patients diagnosed with AF between the years 2010-2018 and with laboratory data available. Patients were identified from nationwide primary care and reimbursement registries and hospitalization records. OAC purchases at 90 days from cohort entry were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland. Results 134 242 patients from the initial FinACAF cohort were included in this substudy. Of these, 6543 (4.9%) patients had a history of GI bleeding. Those with GI bleeding were more often male (52.6%), older (mean age 76.6 ± 11.4 vs 72.4 ± 13.1 years), and had more comorbidities. They also had lower blood hemoglobin (mean 124.9 ± 21.3 vs 135.8 ± 18.4 g/l) and higher serum creatinine (mean 99.7 ± 75.8 vs 87.5 ± 52.7 µmol/l) levels than patiens without preceding GI bleeding. Furthermore, initiation of OAC medication was less frequent in the GI bleeding group (46.9% vs 58.6%). Patient characteristics of the study population including age, sex, comorbidities, OAC medication and laboratory findings are shown in Figures 1 and 2. Conclusions Patients with AF and preceding GI bleeding are vulnerable to rebleeding events. This may affect decision-making of clinicians, leading to more infrequent initiation of OAC medications.

A Study of Proton Pump Inhibitors and Other Risk Factors in Warfarin-Associated Gastrointestinal Bleeding.

BackgroundWarfarin users are at increased risk for gastrointestinal bleeding (GIB). History of GIB, stroke, cardiovascular or chronic kidney disease, age greater than 65 years, and drug interaction with proton pump inhibitors (PPI) have previously been identified as risk factors for GIB in warfarin users. We hypothesized that concomitant use of warfarin and PPI would increase the incidence of GIB relative to warfarin use alone.MethodsWe did a retrospective review of medical records of 626 patients taking warfarin for at least two weeks. Parameters including age, concomitant medication use (non-steroidal anti-inflammatory drugs (NSAID), aspirin, selective serotonin reuptake inhibitors (SSRIs), PPI, and anti-platelet drug), history of GIB, chronic renal failure (CRF), and peptic ulcer disease (PUD) prior to warfarin use were analyzed.ResultsVariables that increase the likelihood of bleeding in warfarin users included aspirin, PPI, history of PUD, history of previous GIB, CRF, and elevated prothrombin time (PT)/international normalized ratio (INR) values. Concomitant antiplatelet use showed a slight increase in GIB but this was not statistically significant (p=0.082). NSAID use and SSRI use were not associated with a higher risk of GIB among warfarin users. Patients who are on PPI and warfarin simultaneously are more likely to be on acetylsalicylic acid (ASA) or have a history of PUD, GIB, or CRF, all of which are associated with increased incidences of GIB.ConclusionsAlthough concomitant use of warfarin and PPI appears to be associated with an increased incidence of GIB, these patients are more likely to have other risk factors that also increase the risk of a GIB outcome. Therefore, the interaction between PPI and warfarin is clinically insignificant.

Retrospective Chart Review of Gastrointestinal Bleeding in Patients with Von Willebrand Disease

Background: Recurrent overt or occult gastrointestinal (GI) bleeding is a serious complication of von Willebrand Disease (VWD) and is the most common cause of hospitalization for patients with VWD. Data from the VWD Prophylaxis Network (VPN) emphasized the importance of prophylaxis in minimizing bleeding episodes in VWD; however, the management of GI bleeding in these patients remains challenging. Despite the availability of von Willebrand factor (VWF) replacement therapy, GI bleeding may be refractory and require the use of multiple treatment approaches. Currently, there are limited published data and no consensus regarding the most effective treatment for GI bleeding in patients with VWD. Aims: To describe the natural history of treatment and management of GI bleeds in patients with VWD, stratified by those patients who have a history of GI bleeding that precedes this chart review versus patients who experienced their first GI bleed within the 5 years of this chart review. Outcomes following the use of VWF replacement products and adjuvant therapy, including recombinant VWF were collected. Methods: This ongoing retrospective, multicenter, observational chart review (abstraction initiated 2019) will include up to 20 patients from 6 US centers with confirmed congenital VWD with ≥1 GI bleed within the last 5 years. Demographics and clinical information, including potential etiology, treatment regimens, will be gathered from patient records on all recorded GI bleeds within the last 5 years. Clinical effectiveness will be defined by treatment response, change in duration of treatment, or time to bleed resolution across treatment cohorts (e.g., prophylaxis vs on-demand; recombinant VWF [rVWF] vs plasma-derived VWF [pdVWF]), at the time of a GI bleed and for any subsequent period of prophylactic treatment to prevent GI bleed recurrence. Data will be analyzed descriptively. Results: To date, data on 37 bleeds in 13 patients with Type 1 (23%), Type 2 (46%) or Type 3 (31%) VWD have been abstracted; 54% were female, mean (±SD) age was 53.9 (22.0) years, 85% had ≥1 recorded GI-specific morbidity, 6 patients (46%) had no history of prior GI bleeding. Three patients (23%) were on regular prophylaxis using pdVWF-factor VIII (FVIII) concentrates at initial GI bleed presentation. All were receiving Humate-P; dose was not recorded for 2 patients and 1 patient received 50 IU/kg. Out of 37 bleeding episodes, 9 (24%) occurred in patients during VWF prophylaxis, of which 7 occurred in 1 patient. Among the 7 patients with a previous history of GI bleeding, 1 was on a prophylactic regimen prior to the initial GI bleeding episode. None of the patients without a history of GI bleeding were on a prophylactic regimen at the initiation of the chart review; 1 patient was receiving prophylaxis at the time the fourth bleed was documented. On-demand treatment for GI bleeding included aminocaproic acid, tranexamic acid, pdVWF-FVIII concentrates, rFVIII, rVWF, corticosteroids, polypectomy, and thalidomide. After resolution of the GI bleeding episode, in 17/37 bleeding events, prophylactic treatment continued (either as part of the final treatment regimen to resolve the bleed and sustained prophylaxis, or after the final treatment regimen purely as prophylaxis). At the conclusion of data collection for the current patients, 4 out of 6 without a GI bleeding history, and 1 out of 7 with a GI bleeding history, were receiving prophylaxis. Conclusions: Data from this retrospective chart review are the first to describe prophylactic regimens prior to and after GI bleeding, in VWD patients with and without a GI bleeding history. More patients with congenital VWD and a history of GI bleeding were treated with prophylaxis following GI bleeds, compared to patients without a history of GI bleeds. These data describe the role of prophylaxis in management of GI bleeding and add to existing data from the VPN describing a modest reduction of GI bleeding in some patients on prophylaxis. These data underscore the continuing unmet need of the successful management of GI bleeding in VWD. Further data will be collected, and additional analyses performed to determine if this trend persists in a larger sample of patients with VWD. Disclosures Roberts: uniQure:Consultancy;Takeda:Consultancy, Research Funding, Speakers Bureau;Pfizer:Consultancy;Novo Nordisk:Consultancy, Speakers Bureau;Sanofi:Consultancy, Speakers Bureau;Octapharma:Consultancy, Speakers Bureau.Escobar:National Hemophilia Foundation:Consultancy, Membership on an entity's Board of Directors or advisory committees;Takeda:Consultancy, Membership on an entity's Board of Directors or advisory committees;Sanofi:Consultancy, Membership on an entity's Board of Directors or advisory committees;Pfizer:Consultancy, Membership on an entity's Board of Directors or advisory committees;Genentech, Inc.:Consultancy, Membership on an entity's Board of Directors or advisory committees;Novo Nordisk:Consultancy, Membership on an entity's Board of Directors or advisory committees.Acharya:Novonordisk, BPL:Membership on an entity's Board of Directors or advisory committees.Hwang:Takeda:Honoraria;Shire:Honoraria.Wang:Bioverativ Inc:Honoraria;CSL Behring:Honoraria;Biomarin:Honoraria;Genentech:Honoraria;Takeda:Honoraria;Bayer:Honoraria.Hale:Takeda Pharmaceutical Company Limited:Current Employment.Oladapo:Takeda:Current Employment, Current equity holder in publicly-traded company.Asghar:HCD Economics:Current Employment.

S2918 Giant Paraesophageal Hernia and Gastric Volvulus: An Uncommon Etiology of Vomiting and Upper Gastrointestinal Bleeding

INTRODUCTION: Paraesophageal hiatal hernia is a rare type of hiatal hernia, which occurs mostly in the elderly population after the age of 70, and accounts for less than 5% of all hiatal hernias. Here we report a rare case of a large paraesophageal hiatal hernia and gastric volvulus as an uncommon cause of vomiting and upper gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 46-year-old female with a past medical history of anemia and GERD presents with one day history of coffee ground emesis and melena. She has no history of previous gastrointestinal bleeding and denies NSAID use. She has been off PPI agents for one year due to the improvement of acid reflux disease after weight loss of 40 lbs. Etiology of anemia was not found during the previous GI workup including an upper endoscopy completed locally. Upon presentation, her hemoglobin was checked low at 9.3 g/dl from her baseline of 11.0 g/dl. She underwent a repeat upper endoscopy which revealed a large paraesophageal hernia (7 cm) with multiple linear erosions/ulcerations, suggestive of Cameron's lesions. The insufflation of the stomach was abnormal, with a distorted antrum located at an eccentric angle concerning for gastric volvulus. Further workup with computerized tomography (CT) scan of the chest and abdomen showed findings of a large type 3 hiatal hernia with organoaxial volvulus, and no evidence of ischemia or obstruction. She subsequently underwent laparoscopic repair of her paraesophageal hernia and Nissen fundoplication with resolution of anemia after the surgery. DISCUSSION: Paraesophageal hernia with gastric volvulus is a rare entity that can manifest with vomiting due to partial or complete gastric outlet obstruction, and gastrointestinal bleeding due to mucosal ischemia or Cameron's lesions. It is critical for gastroenterologists to recognize paraesophageal hiatal hernias during upper endoscopy evaluation, due to its association with gastric volvulus leading to incarceration and life-threatening strangulation. Emergency surgery is required for acute ischemic gastric volvulus. Otherwise, elective surgery can be offered to symptomatic patients and laparoscopic surgery is the mainstay of treatment approaches.Figure 1.: Giant Paraesophageal hiatal hernia: Retroflexion (A) and forward view (B) revealed giant hiatal hernia with Cameron lesions. C: Chest/abdominal CT confirmed large type 3 paraesophageal hernia with gastric volvulus.

E‐Poster Presentations – A2) Gastric and Duodenal

E‐Poster Presentations – A2) Gastric and Duodenal

Gastrointestinal Bleeding in a Father and Son with Primary Polycythemia Vera

Introduction: Primary Polycythemia Vera (PPV) is a myelodysplastic disorder associated with thrombotic complications. It is associated with an increased risk of gastrointestinal bleeding (GIB) from peptic ulcer disease. We describe a father and son with PPV and JAK 2 mutations, who presented with GIB due to peptic ulcer disease within a one-year interval. Patient 1: A 32-year-old Asian-American male with PPV treated by regular phlebotomy presented with hematemesis and melena and Hgb of 6.6 mg/dL. No previous history of GIB. Following resuscitation, upper endoscopy revealed a duodenal ulcer with a visible vessel. Hemostasis was achieved using epinephrine injection and hemoclips. The patient denied NSAID use and subsequent H.Pylori antibody testing was negative. Patient 2: A 69-yearold Asian-American, the father of patient 1 who also has PPV treated with phlebotomy and has no previous GIB history. He developed hematemesis 11 months after his son's presentation with a drop in Hgb to 7.6 mg/dL. Upper endoscopy revealed two clean based duodenal ulcers. No high risk stigmata was seen and therefore no therapeutic intervention was necessary and he recovered on medical therapy. His Helicobacter pylori antibody was also negative. Discussion: PPV is classified as a myeloproliferative disorder. Patients with PPV are at risk for both thrombotic and hemorrhagic events. GIB related to PPV is not common, but it can be severe. It is associated with the concurrent use of antiinflammatory agents. Additionally, patients with PPV have been found to have a higher incidence of H. pylori infection. Platelet dysfunction is thought to play an important role in the development of GIB. Thrombocytosis leads to the development of Acquired Von Willebrand syndrome (Type 2 AvWD) by increased proteolysis by ADAMTS 13, leading to bleeding episodes. Sluggish microvascular circulation in the GI tract secondary to increased hematocrit has also been implicated in mucosal ischemia leading to breakdown of protective barriers. Increased basophil mediated histamine release has also been proposed as a potential risk factor. Conclusion: PPV is associated with GIB due to PUD due to multiple factors. A possible strategy to mitigate the risk may be to remove other factors that could contribute to the development of PUD. However, our experience suggests that this would not fully eliminate the risk.

Clinical outcomes of nonvariceal upper gastrointestinal bleeding in Kosova

The aim was to determine the sociodemographic and etiologic factors, endoscopic accuracy, treatment efficiency and clinical outcome of patients with nonvariceal upper gastrointestinal system bleeding in Kosova. We retrospectively evaluated patients who had applied to our Gastroenterology Department between January 2006 and December 2010. There were 460 eligible cases with mean age 56.85+16.18 years, while male /female ratio was 2.71/1. The greatest occurrence was at age group of 60-69 years (27.1 %). The most common clinical symptom was melena (62.6%). Comorbid diseases were present in 57, 6% of the patients. The percentage of patients using acetylsalicylic acid and /or other non-steroidal anti-inflammatory drugs was 43.7%. Five point two percent were using anticoagulants. Peptic ulcer was the main cause of bleeding (82.2%) and most of them were Forrest III (41.6%). Endoscopic treatment was performed in 90 patients, primary hemostasis was achieved in 96.7% while rebleeding developed in 10% of these patients. The average length of hospital stay was 9.29+5.58 (1-35) days. Rebleeding was reported in 4.1% of all patients while the overall mortality rate was 5.7%. Age over 60 years, previous history of gastrointestinal bleeding, treatment with anticoagulants, low hemoglobin values at presentation (<7 g/dL), hematemesis, Forrest class, localization of lesion of bleeding, comorbidities, tachycardia, transfusion requirement>2 unit, type of treatment and time of endoscopy were predictors of poor outcome in study present.

Gastrointestinal Bleeding with Dabigatran, a Comparative Study with Warfarin: A Multicenter Experience

The risk of gastrointestinal (GI) bleeding with dabigatran when compared to warfarin has been controversial in the literature. The aim of our study was to assess this risk with the use of dabigatran. We examined the medical records of patients who were started on dabigatran or warfarin from October 2010 to October 2012. The study was conducted in two hospitals. A total of 417 patients were included (208 dabigatran vs. 209 warfarin). GI bleeding occurred in 10 patients (4.8%) in the dabigatran group compared to 21 patients (10.1%) in the warfarin group (p=0.0375). Multivariate analysis showed that patients who were on dabigatran for ≤ 100 days had a higher incidence of GI bleeding than those who were on it for >100 days (p=0.0007). The odds of GI bleeding in patients who were on dabigatran for ≤ 100 days was 8.2 times higher compared to those who were on the drug for >100 days. The incidence of GI bleeding in patients >65 years old was higher than in those <65 years old (p=0.0453, OR=3). History of previous GI bleeding was another risk factor for GI bleeding in the dabigatran group (p=0.036, OR=6.3). The lower GI tract was the most common site for GI bleeding in the dabigatran group (80.0% vs. 38.1%, p=0.014). The risk of GI bleeding was lower with dabigatran. The risk factors for GI bleeding with dabigatran were the first 100 days, age >65 years, and a history of previous GI bleeding.

Dieulafoy lesion of the appendix

ttp://dx.doi.org/10.1016/j.dld.2014.04.001 590-8658/© 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All dicitis (Fig. S1, asterisk), the mid and distal appendiceal wall was modified by the presence of a large (2 mm) calibre thick-walled submucosal artery about 10 mm long, corresponding to a Dieulafoy lesion. This calibre-persistent artery originated from the mesoappendix and entered the appendiceal wall directly without previous subdivision (Figs. 1 and S1, arrow). The overlying mucosa at a distance from the inflammatory lesions was intact (Fig. 1, arrowhead) and no previous history of gastrointestinal bleeding was reported, suggesting an incidental non-complicated lesion. Only one similar case associated with lower gastrointestinal bleeding and cured with simple appendectomy has been reported by Japanese authors [1]. Dieulafoy lesion is an uncommon vascular malformation of the gastrointestinal tract characterized by the presence of a thickwalled submucosal artery in an otherwise normal intestinal wall. It can be a cause of massive gastrointestinal bleeding through a small mucosal erosion known as Dieulafoy’s ulcer. It predominates in the stomach but may also exceptionally involve the small bowel, colon and rectum. These cases of appendiceal localizations of a Dieulafoy lesion confirm that this vascular malformation may involve all parts of the gastrointestinal tract and that this peculiar localization may be a diagnostic challenge in cases of massive gastrointestinal tract bleeding. Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.dld.2014.04.001.

Factors Affecting Physician Decision to Utilize Prophylactic Anticoagulation in Hospitalized Cirrhotic Patients

Purpose: To investigate which factors are most likely to influence a physician's decision on whether or not to prophylactically anticoagulate a hospitalized cirrhotic patient to protect against venous thromboembolism (VTE), with a secondary aim to determine associated adverse outcomes, including VTE and bleeding events. Methods: This study is a retrospective cohort study of hospitalized cirrhotic patients at one Veterans Affairs Medical Center between 01/01/2005 and 12/31/2011. Data were collected from electronic medical records, and the primary outcome was whether or not anticoagulation was used. Additional data gathered include: etiology of cirrhosis, age, sex, prothrombin time (PT), platelet count, creatinine, bilirubin, albumin, history of esophageal varices, history of previous gastrointestinal bleeding, previous VTE, and active malignancy. Chi-squared testing and logistical regression was used in the analysis, and a p-value <0.05 was considered significant. VTE outcomes with and without anticoagulation and bleeding complications when given anticoagulation were also collected as part of a secondary aim of the study. Results: One hundred twenty-five patient charts were reviewed. 97.6% of patients were men, and the average age was 60. Overall, 53% of the cirrhotic patients received anticoagulation. In univariate analysis, PT, platelet count, albumin, creatinine, and bilirubin all were significantly related to use of anticoagulation. In multivariate analysis, only PT, platelet count, and albumin were independently significantly related to the use of anticoagulation. Anticoagulation use was more likely the higher the platelet count, and the albumin, and the lower the PT. There were no adverse bleeding complications in any patients. There was one incident of deep vein thrombus in a patient receiving anticoagulation. Conclusion: This study demonstrates that the factors most likely to influence a physician to anticoagulate a cirrhotic patient in the hospital are: PT, platelets, and albumin. This finding may aid in better understanding how to utilize low-dose anticoagulation in hospitalized cirrhotic patients, with the goal to minimize VTE outcomes while concurrently minimizing bleeding complications. Currently, there are no guidelines that help to direct use of prophylactic anticoagulation in cirrhotic patients, despite this being a common management dilemma.

Incidence and Management of Gastrointestinal Bleeding With Continuous Flow Assist Devices

Continuous flow left ventricular assist devices (CF-LVADs) have emerged as the standard of care for patients in advanced heart failure (HF) requiring long-term mechanical circulatory support. Gastrointestinal (GI) bleeding has been frequently reported within this population. A retrospective analysis of 101 patients implanted with the Heart Mate II from January 2005 to August 2011 was performed to identify incidence, etiology, and management of GI bleeding. Univariate and multivariate regression analysis was conducted to identify related risk factors. A significant incidence of GI bleeding (22.8%) occurred in our predominantly destination therapy (DT) (93%) population. Fifty-seven percent of the patients with bleeding episodes bled from the upper GI (UGI) tract (with 54% bleeding from gastric erosions and 37% from ulcers/angiodysplasias), whereas 35% of patients bled from the lower GI (LGI) tract. Previous history of GI bleeding (odds ratio [OR], 22.7; 95% CI, 2.2-228.6; p=0.008), elevated international normalized ratio (INR) (OR, 3.9; CI, 1.2-12.9; p=0.02), and low platelet count (OR, -0.98; CI, 0.98 -0.99; p=0.001) were independent predictors of GI hemorrhage. Recurrent bleeding was more common in older patients (mean, 70 years; p=0.01). The majority of bleeders (60%) rebled from the same site. Management strategies included temporarily withholding anticoagulation, decreasing the speed of LVADs, and using octreotide. Octreotide did not impact the amount of packed red blood cells used, rebleeding rates, length of hospital stay, or all-cause mortality. Only 1 patient died as a direct consequence of GI bleeding. Multiple factors account for GI bleeding in patients on CF-VADs. A previous history of bleeding increases risk significantly and warrants careful monitoring.

Adherence to routine use of pharmacological prophylaxis of heterotopic ossification after total hip arthroplasty: results from an Italian multicenter, prospective, observational survey

BackgroundIn spite of the proven efficacy of pharmacological prophylaxis of heterotopic ossification following total hip arthroplasty, its routine use is still debated, and no data are available regarding the adherence to its administration in clinical practice.Materials and methodsIn this prospective, observational, multicenter study, 480 consecutive patients operated on for primary total hip arthroplasty during the year 2009 were followed radiographically for 12 months after surgery in order to assess the incidence of periprosthetic heterotopic ossification. Surgeons were free to choose whether to administer pharmacological prophylaxis, and were asked to keep a record of the duration of the prophylaxis (if used) or the reasons for not using it. To facilitate the statistical analysis, all of the participating centers agreed to use only one drug (celecoxib) that had already proven to be effective.Results368 patients were administered celecoxib and 112 patients did not receive any prophylaxis. Reported reasons for not administering celecoxib prophylaxis were the surgeon’s opinion that prophylaxis was not needed on a routine basis (84/112 patients, 75%), previous history of gastrointestinal bleeding (17.8%), and concomitant cardiorenal pathologies (7.1%). The overall incidence of heterotopic ossification in the celecoxib-treated patients was 23% (no cases of Brooker grade 3 or 4 ossifications), compared to 55% in the untreated patients (Brooker grade 3 and 4: 8.9%). Multivariate analysis showed that celecoxib prophylaxis was the single most important variable when predicting the occurrence of heterotopic ossification.ConclusionsThis study confirms the efficacy and tolerability of celecoxib for the prophylaxis of heterotopic ossification after total hip arthroplasty, and shows how the surgeon’s belief that routine prevention is not required still plays an important role in the determination of this complication, together with the fear of possible unwanted side effects.

Evaluation of patients with upper gastrointestinal bleeding in chronic renal failure

Objectives: Incidence of gastrointestinal complications especially gastric bleeding increased in patients with chronic renal failure (CRF). The aim of this study was to comparatively investigate upper gastrointestinal bleeding (UGB) in patients with non-hemodialysis CRF and the patients without CRF. Materials and methods: Seventy-six patients (55 men and 21 women) with and without CRF and UGB was included. The first group who had CRF consisted of 23 patients and the control group 53. All patients were evaluated in the view point of age, gender, smoking status, other illnesses, medicine usage, laboratory parameters, endoscopic evidence and endoscopic intervention (scleroteraphy). Results: Calcium levels of patients with a history of previous UGB was significantly lower compared with those bleeding for the first time (p<0.05). The mean parathormon level was higher in patients with CRF (171.24 ± 141.96 pg/ml) (p<0.05). Serum albumin level was negatively correlated with urea and creatinine (p<0.001), and positively correlated with hemoglobin and hematocrit levels (p=0.003 and p=0.005). The patients undergoing sclerotherapy more frequently needed transfusions (p<0.05). The hospitalization time found to be shortening with increasing hemoglobin, hematocrit, calcium and albumin levels; and lengthens with increased urea and creatinine. Conclusion: The history of previous gastrointestinal bleeding and detection of pathological findings in endoscopy were more frequent in patients with CRF. Gastrointestinal bleeding risk did not reduce using by gastric protection against acetylsalicylic acid and other non-steroidal antiinflammatory drugs. Also, low albumin levels and secondary hiperparathyroidism in these patients may be risky for gastrointestinal bleeding.

Massive GI bleeding in a patient with 2 small AVMs in the small intestine: a case report

A 53 year-old Caucasian man with no previous history of gastrointestinal bleeding presented with sudden, massive hematochezia and abdominal pain; his hemoglobin dropped from 12 to 8.3. Colonoscopy revealed coagulated blood in a diverticulum, but bleeding recurred after cautery of the lesion.Repeated upper and lower gastrointestinal (GI) endoscopy, visceral selective angiogram, bleeding scan, and Meckel diverticulum scan did not locate the source of bleeding. Further investigation with capsule endoscopy demonstrated two arteriovenous malformations in the small bowel.Wireless capsule endoscopy is a sensitive and specific test for overt obscure gastrointestinal bleeding. Clinicians need not hesitate to employ this procedure when other diagnostic modalities fail.

Propranolol reduces variceal pressure and wall tension in schistosomiasis presinusoidal portal hypertension

Although prophylaxis with beta-blockers has been shown to decrease variceal pressure and wall tension in cirrhotic patients, this has not been demonstrated in non-cirrhotic portal hypertension caused by Schistosoma mansoni infection. Thirteen patients without history of previous gastrointestinal bleeding were included. All of them had high-risk esophageal varices at endoscopy. An endoscopic gauge and a high-frequency endoscopic ultrasonography miniprobe were used to assess transmural variceal pressure and wall tension before and after achieving beta-blockade with propranolol. Baseline variceal pressure decreased from 13.3 +/- 3.5 to 8.2 +/- 2.0 mmHg (P < 0.0001) and wall tension from 500.2 +/- 279.8 to 274.0 +/- 108.3 mg.mm(-1). The overall effect of propranolol on decreasing variceal pressure and wall tension expressed in percentage change in relation to baseline values was 35.7 +/- 18.4% and 35.9 +/- 26.7%, respectively (P = 0.9993). Propranolol significantly reduced variceal pressure and wall tension in schistosomiasis.

Case 1: A child with gastrointestinal bleeding

A previously healthy seven-year-old boy presented to the emergency room with a two-day history of abdominal pain and bloody stools. His pain was crampy and intermittent, and was isolated to the left side of his abdomen. His parents described bright red blood and passing of clots per rectum, in addition to episodes of melena. The patient had been afebrile, had no sick contacts, no significant travel history and no previous history of gastrointestinal bleeding. His appetite remained good. The family history was unremarkable for coagulopathies, inflammatory bowel disease or polyps. On admission, he was well hydrated, pale but nontoxic. His highest temperature was 38.1°C. He demonstrated an orthostatic heart rate increase from 120 beats/min to 140 beats/min, and a resting blood pressure of 102/42 mmHg. His cardiovascular examination revealed a grade II/VI systolic ejection murmur and normal capillary refill. He had a soft, nondistended abdomen with pain on palpation of the left abdominal quadrants. No peritoneal signs were present. Two days earlier, at the onset of symptoms, the patient’s hemoglobin level was measured at 119 g/L, dropping to 83 g/L the following day. At presentation, his hemoglobin level was 56 g/L. Electrolytes, renal and liver function tests, white blood cell count, international normalized ratio and partial thromboplastin time were all normal. The patient received a fluid bolus and a packed red blood cell transfusion. Stool was sent for culture, electron microscopy, and ova and parasites. An abdominal ultrasound demonstrated no evidence of intussusception. An additional investigation revealed the diagnosis.

Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks

The selective serotonin reuptake inhibitors (SSRIs) are extensively used for the treatment of multiple psychiatric conditions. In vitro and ex vivo data with these agents indicate they may have varying degrees of antiplatelet activity via multiple receptors. Reports of bleeding in patients receiving SSRIs appeared soon after their introduction. A review of the literature suggests SSRI therapy may increase the risk of bleeding especially with concomitant aspirin or nonsteroidal anti-inflammatory agents. Clinicians should exercise caution when prescribing these agents in high risk patients and maintain awareness of the potential contribution of SSRIs to unexplained bleeding episodes.