Incidence Of Lower Gastrointestinal Bleeding Research Articles

External validation of the SHA2PE score and its comparison to the Oakland score for the prediction of safe discharge in patients with lower gastrointestinal bleeding.

The growing incidence of lower gastrointestinal bleeding (LGIB) is leading to a rise in-hospital admissions even though most LGIB episodes are self-limiting. The Oakland and SHA2PE scores were designed to identify patients best suited to outpatient care. Our aim is explore the validity of the SHA2PE score and compare both of these scores in terms of predictiveness of safe discharge. Retrospective observational study of LGIB patients admitted to a tertiary hospital between June 2014 and June 2019. Safe discharge was defined as the absence of all the following: blood transfusion, haemostatic intervention, re-bleeding, in-hospital death, and re-admission due to LGIB within 28days after discharge. From 595 hospital admissions for LGIB, 398 episodes were included. Fifty-four per cent met safe discharge criteria, with these cases being younger, with a lower score in the Charlson's index and significantly higher haemoglobin concentration upon arrival. The performance of both scores was good, with an AUC for the Oakland score of 0.85 (95% CI 0.82-0.89) and of 0.797 (95% CI 0.75-0.84) for the SHA2PE score. The Oakland score performed better in terms of prediction of safe discharge, with a positive predictive value and specificity of 100% when a cut-off value of ≤ 8 points was used; however, only a minority of patients might benefit from its implementation given its low sensitivity. Almost half of the patients admitted for LGIB met criteria for safe discharge. However, the available indexes only allow for the identification of a small proportion of those patients candidates for outpatient care.

Review article: Advances in the management of lower gastrointestinal bleeding.

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Prophylactic acid suppressants in patients with primary neurologic injury: A systematic review and meta-analysis of randomized controlled trials.

Neurocritical care patients are at risk of stress-induced gastrointestinal ulceration. We performed a systematic review and meta-analysis of stress ulcer prophylaxis (SUP) in critically ill adults admitted with a primary neurologic injury. We included randomized controlled trials (RCTs) comparing SUP with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs) to placebo/no prophylaxis, as well as to each other. The primary outcome was in-ICU gastrointestinal bleeding (GIB). Predefined secondary outcomes were all-cause 30-day mortality, ICU length of stay (LOS), nosocomial pneumonia, and other complications. We identified 14 relevant trials enrolling 1036 neurocritical care patients; 11 trials enrolling 930 patients were included in the meta-analysis. H2RAs resulted in a lower incidence of GIB as compared to placebo or no prophylaxis (Risk ratio [RR] 0.42, 95% CI 0.30-0.58; p < 0.001); PPIs with a lower risk of GIB compared to placebo/no prophylaxis (RR 0.37, 95% CI 0.23-0.59; p < 0.001). No significant difference was observed in GIB comparing PPIs with H2RAs (RR 0.53, 95% CI 0.26-1.06; p = 0.07; I2 = 0%). In neurocritical care patients, the overall high or unclear risk of bias of individual trials, the low event rates, and modest sample sizes preclude strong clinical inferences about the utility of SUP.

Effect of Angiotensin II Antagonism on Gastrointestinal Bleeding in Patients With Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis.

The importance of medical therapy to ameliorate the incidence and impact of left ventricular assistance device-related gastrointestinal bleeding has been highlighted recently with several single-center studies. Electronic databases were searched for studies that compared the incidence of gastrointestinal bleeding for those people on left ventricular assist support with and without angiotensin II inhibition. Angiotensin II inhibition was associated with a lower incidence of gastrointestinal bleeding (pooled RR 0.58, 95% confidence interval (CI): 0.34-0.98; p = 0.04], with a trend toward toward lower incidence with arteriovenous malformation-associated gastrointestinal bleeding (pooled RR 0.50, 95% CI: 0.25-1.03; p = 0.06).

ACEi/ARBs associate with lower incidence of gastrointestinal bleeding in peritoneal dialysis patients.

Gastrointestinal bleeding (GIB) is widespread in patients with impaired renal function. Whether angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARBs) potentially take a crucial role in avoiding GIB incidence among peritoneal dialysis (PD) patients is unknown. Overall, 734 PD patients were enrolled after using propensity score matching. Kaplan-Meier analysis and COX regression were used to explore correlation between ACEi/ARBs and GIB. Competitive risk model was aimed to identify whether other events were confounding factors. Forest plot was applied to assess the influence of ACEI/ARBs on GIB incidence in different groups. During 8-year follow-up, 89 (12.13%) cases of GIB were recorded. Kaplan-Meier analysis revealed that the incidence of GIB among patients taking ACEi/ARBs was lower than those subjects who had not (log rank = 6.442, P = 0.011). After adjusted different confounding factors, administration of ACEi/ARBs was associated with lowered GIB incidence (adjusted HR = 0.49, 95% CI 0.32-0.77, P = 0.002). In competitive risk model, considering of other events, the incidence of GIB in two groups was still statistically significant (P = 0.010). Subgroup analysis showed ACEi/ARBs taking impeded GIB in the ≥ 60 age group (HR = 0.52, 95% CI 0.28-0.98, P = 0.040). PD patients who were submitted to ACEi/ARBs inclined to have a lower risk for GIB. In this regard, ACEi/ARBs offered a promising choice to GIB.

Thirty-Year Incidence and Mortality Trends in Upper and Lower Gastrointestinal Bleeding in Finland

Epidemiological data on lower gastrointestinal bleeding (GIB) in the general population are sparse. To describe the incidence, recurrence, mortality, and case fatality rates of major upper GIB and lower GIB in the general population of Finland between 1987 and 2016. This prospective cohort study used data from the 1987 to the 2012 cycles of the National FINRISK Study, a health examination survey that was conducted every 5 years in Finland. Survey participants were adults aged 25 to 74 years who were recruited from a population register by random sampling; those with a history of hospitalization for GIB were excluded. Participants were followed up from survey enrollment to onset of GIB that led to hospitalization, death from any cause, or study end (December 31, 2016). Follow-up was performed through linkage with national electronic health registers. Data were analyzed from February 1, 2019, to January 31, 2020. Incidence, recurrence, mortality, and case fatality rates for all, upper, lower, and unspecified GIB. Outcome measures were stratified by sex and age group. Among the 39 054 participants included in the study, 494 (1.3%) experienced upper GIB (321 men [65.0%]; mean [SD] age, 52.8 [12.1] years) and 645 (1.7%) had lower GIB (371 men [57.5%]; mean [SD] age, 54.0 [11.7] years). The age-standardized incidence rate was 0.94 per 1000 person-years (95% CI, 0.85-1.04) for upper GIB and 1.26 per 1000 person-years (95% CI, 1.15-1.38) for lower GIB; the incidence was higher in men than in women. Between 1987 and 2016 the incidence rate of upper GIB remained mostly stable, ranging from 0.40 to 0.66 per 1000 person-years, whereas constant increases occurred in the incidence of lower GIB until the rate stabilized. The proportion of recurrent GIB events showed an increasing trend from 1987 to 2016. The upper GIB-specific mortality was higher (0.07 per 1000 person-years; 95% CI, 0.04-0.09) than the lower GIB-specific mortality (0.01 per 1000 person-years; 95% CI, 0.001-0.03). Case fatality was high for those with upper GIB (7.0%; 95% CI, 4.7-10.1) compared with those with lower GIB (0.4%; 95% CI, 0.1-1.3). Case fatality remained stable over the years but was higher in men (between 5% and 10%) than women (<2%) with GIB. This study found that the overall incidence rate of upper GIB was lower than the incidence of lower GIB, but the recurrence, mortality, and 28-day case fatality were higher in participants with upper GIB. These data can serve as a reference when putting into context the rates of drug-associated GIB and can inform efforts to improve GIB care and outcome and to prevent rebleeding or death for patients with major GIB.

Trends and Outcomes of Gastrointestinal Bleeding Among Septic Shock Patients of the United States: A 10-Year Analysis of a Nationwide Inpatient Sample.

IntroductionGastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking.MethodsWe queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB.ResultsThe weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) [70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively]. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay [20.56 (0.61) vs. 15.76 (0.13) P < 0.001], higher mortality [54% vs. 45% P < 0.001], and higher admission costs in United States dollar ($) (mean/SEM) [$192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001]. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB [odds ratio: 0.57, P = 0.0008]. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS.ConclusionGIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study.

Background Patients with chronic kidney disease (CKD) with or without hemodialysis were considered to have bleeding tendency and higher risk for gastrointestinal (GI) bleeding. Previous studies had documented that hemodialysis may increase the gastroduodenal ulcer bleeding. Few studies evaluated the relationship between CKD and lower GI bleeding. Materials and Methods. An observational cohort study design was conducted. The end-stage renal disease (ESRD) patients receiving regular hemodialysis (dialysis CKD), CKD patients without dialysis (dialysis-free CKD), and controls were selected from 1 million randomly sampled subjects in the National Health Insurance Research Database of Taiwan. These three group subjects were matched by age, sex, comorbidity, and enrollment time in a 1 : 2 : 2 ratio. The Cox proportional hazard regression models were used to identify the potential risk factors for lower gastrointestinal bleeding. Results Dialysis CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both Conclusion Hemodialysis may have higher risk of lower GI bleeding and angiodysplasia bleeding.

Chronic Lower Gastrointestinal Bleeding: Etiological Profile and Role of Colonoscopy among Children from sub‑Himalayan Ranges of North India

Background: Most patients with chronic lower gastrointestinal (GI) bleeding warrant endoscopic examination of the lower GI tract. This study was done to determine the etiological profile of chronic lower GI bleeding and the role of colonoscopy in its diagnosis, as well as the prognosis among children from sub‑Himalayan ranges of North India. Methods: In this study, we did a retrospective review of the clinical notes of children between 2 and 15 years of age who presented with chronic lower GI bleeding and underwent diagnostic and therapeutic colonoscopy in the Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, from January 2012 to October 2017. Patient demographics, clinical features, and endoscopic and histopathological findings were recorded. Results: Of the total 57 patients reviewed, 22 (38.59%) were female and 35 (61.40%) were male, with a male‑to‑female ratio of 1.62:1.0. The highest incidence of lower GI bleeding was between the ages of 6 and 10 years (43.85%). The presenting symptoms were hematochezia in 50 (87.71%), bloody diarrhea in 5 (8.77%), and positive stool occult blood test in 2 (3.50%) patients. The most common accompanying symptom was constipation in 16 (28.07%), abdominal pain in 14 (24.56%), fever in 5 (8.77%), and weight loss in 5 (8.77%) patients. The most common colonoscopy finding was rectosigmoid polyps (36 cases, 63.15%) followed by internal hemorrhoids (9 cases, 15.78%), rectal ulcers (5 cases, 8.77%), findings suggestive of colitis of left colon (5 cases, 8.77%), and findings suggestive of ileocecal tuberculosis (2 cases, 3.50%). The most common histopathological finding was juvenile colorectal polyps (35 cases, 61.40%) followed by solitary rectal ulcer (5 cases, 8.77%), ulcerative colitis (5 cases, 8.77%), tuberculosis (2 cases, 3.50%), and Peutz–Jegher polyp (1 case, 1.75%). Conclusion: Juvenile colorectal polyps constitute the most common cause of chronic lower GI bleeding in children from sub‑Himalayan ranges of North India followed by hemorrhoids, solitary rectal ulcer, inflammatory bowel disease, and ileocolonic tuberculosis. Colonoscopy remains a useful and safe procedure in children for evaluation of lower GI bleeding both from the diagnostic and therapeutic points of view.

Etiology of gastrointestinal bleeding in patients on dual antiplatelet therapy.

Dual antiplatelet therapy (DAPT) is associated with an increased risk of gastrointestinal (GI) bleeding and is thought to cause upper gastrointestinal bleeding (UGIB). However, recent reports indicate that the incidence of lower gastrointestinal bleeding (LGIB) in patients on DAPT may be increasing. We aimed to compare the endoscopic findings and etiology of GI bleeding between patients on DAPT compared with those not on DAPT. This was a retrospective, single-center, case-control study. Cases were 114 consecutive patients admitted with a first episode of GI bleeding while on DAPT who underwent detailed GI evaluation. We chose 114 controls who had GIB but were not on DAPT. There was no significant difference in the incidence of UGIB or LGIB between the two groups (UGIB: 53.5% vs 51.3% and LGIB: 46.5% vs 48.7%, P = 0.10) or within groups (DAPT: 53.5% vs 46.5%, P = 0.30 and controls: 51.3% vs 48.7%, P = 0.80). Although the DAPT group had a lower prevalence of the usual UGIB risk factors, it had a higher likelihood of bleeding from varices or upper GI inflammation [odds ratio (OR) 3.54, 95% confidence interval (CI) 0.14-92.3; OR 13.98, 95% CI 1.40-140.36]. No etiology of bleeding was identified in a higher percentage of patients on DAPT than those who were not (22.8% vs 5.3%). In patients with GI bleeding, the incidences of UGIB and LGIB are similar irrespective of their DAPT use.

Incidence and Predictors of GI Bleeding Among Septic Shock Patients of United States: A 10-Year Analysis of Nationwide Inpatient Population

SESSION TITLE: Sepsis & Septic Shock SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: Gastrointestinal bleeding (GIB) complicating septic shock(SS) presents a therapeutic challenge in the intensive care units. Contemporary large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking. The purpose of this study is to analyze trends, outcomes and risk factors associated with GIB in patients with SS. METHODS: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012 we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria previously validated by recently presented data of the same database (BMC Infectious diseases 2016 10.1186): 1) primary ICD-9 diagnosis of infection associated with sepsis plus vasopressor use, or 2) primary ICD-9 diagnosis of infection associated with sepsis plus a non-primary diagnosis of septic shock, or 3) primary ICD-9 diagnosis of septic shock. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB. Measured outcomes included length-of-stay, mortality and cost of hospitalization. Comorbidities were assessed with a univariate logistic regression to determine associated risk factors for GIB among SS patients. A multivariate analysis was also performed to address any confounders. RESULTS: The weighted sample size from 2003 to 2012 was 119684 admissions for SS. Among them, 6571(5.4%) patients were found to have a GIB. Mean age of the SS population with and without GIB was Age (mean/SEM) {70.85 (0.43) vs. 67.43 (0.13) P<0.001} respectively. The incidence of GIB among black (6.8%) septic patients was higher compared to white (5.3%) or Hispanic (5.9%) P<0.001. No significant difference in the occurrence of GIB between males and females respectively {5.6% vs. 5.7% P=0.653}. Patients with SS and GIB compared to patients with SS and no GIB were found to have longer length of stay {20.56 (0.61) vs. 15.76 (0.13) P<0.001}, higher mortality {54% vs. 45% P<0.001} and higher admission costs (mean/SEM) {192524.89 (7378.20) vs. 142688.55 (1336.65) P<0.001}. Univariate analysis demonstrated that major comorbid conditions associated with an increased incidence of GIB in septic patients included peptic ulcer disease and cirrhosis which both had significant odds ratios {1.56 and 1.709, P=0.016 and 0.046 respectively}. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB {OR: 0.57, P=0.0008}. The cause of sepsis (pneumonia, urinary tract infection or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS. CONCLUSIONS: GIB among SS patients is associated with 9% increase in mortality compared to no GIB, with increased length of stay and cost burden. The risk of GIB in Septic Shock patients is perhaps more related to the baseline patient characteristics and comorbid illness than to the etiology of sepsis. CLINICAL IMPLICATIONS: To the author's knowledge this is the first nationwide extensive study analyzing the association of GIB and SS in US inpatient population. Awareness of the risk factors and association of GIB among SS patients may help to improve the outcomes by institution of agressive prophylactic measures among high risk patients. DISCLOSURE: The following authors have nothing to disclose: Abdul Siddiqui, Faraz Siddiqui, Saqib Abbasi, Tahir Khan, Moiz Ahmed, Sana Alhajri, Shimshon Wiesel, Naureen Narula, Asma Memon, Michel Chalhoub No Product/Research Disclosure Information

Special considerations for therapeutic choice of non-vitamin K antagonist oral anticoagulants for Japanese patients with nonvalvular atrial fibrillation.

Nonvalvular atrial fibrillation (AF) is a risk factor for stroke in elderly patients. Although warfarin has been used to prevent AF‐associated stroke for more than 50 years, non–vitamin K antagonist oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban recently have been developed to overcome the disadvantages of warfarin. Based on the results of NOAC clinical trials, Savelieva and Camm made recommendations regarding selection of NOACs in patients with nonvalvular AF. Recent accumulating evidence indicates that NOACs work differently in Asian and non‐Asian individuals. In this review, we discuss the results of the large, randomized, phase 3 international clinical trials on NOACs, the subanalyses of Asians, and a Japanese phase 3 clinical trial of rivaroxaban to discriminate Japanese patient–specific characteristics with regard to their responses to NOACs and make recommendations. Our analysis revealed that rivaroxaban decreased the incidence of gastrointestinal (GI) bleeding compared with warfarin in Japanese patients. The efficacy results showed that rivaroxaban significantly decreased the incidence of ischemic stroke (hazard ratio: 0.40, 95% confidence interval: 0.17‐0.96) compared with warfarin. The lower incidence of GI bleeding and ischemic stroke may be specific to Japanese patients. Based on the present and previous results, the following recommendations regarding the selection of NOACs are added in the Camm chart for Japanese patients: edoxaban for patients with a high risk of bleeding and those with a previous stroke; and rivaroxaban for patients with a high risk of ischemic stroke and a low bleeding risk, and those with previous GI bleeding.

Sa1740 Lower Incidence of Gastrointestinal Bleeding in Apixaban Compared to Warfarin

Sa1740 Lower Incidence of Gastrointestinal Bleeding in Apixaban Compared to Warfarin

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding.

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

Risk of Hospitalized Gastrointestinal Bleeding in Persons Randomized to Diuretic, ACE‐Inhibitor, or Calcium‐Channel Blocker in ALLHAT

Calcium channel blockers (CCBs) are an important class of medication useful in the treatment of hypertension. Several observational studies have suggested an association between CCB therapy and gastrointestinal (GI) hemorrhage. Using administrative databases, the authors re-examined in a post-hoc analysis whether the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants randomized to the CCB amlodipine had a greater risk of hospitalized GI bleeding (a prespecified outcome) compared with those randomized to the diuretic chlorthalidone or the angiotensin-converting enzyme inhibitor lisinopril. Participants randomized to chlorthalidone did not have a reduced risk for GI bleeding hospitalizations compared with participants randomized to amlodipine (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.92-1.28). Those randomized to lisinopril were at increased risk of GI bleeding compared with those randomized to chlorthalidone (HR, 1.16; 95% CI, 1.00-1.36). In a post-hoc comparison, participants assigned to lisinopril therapy had a higher risk of hospitalized GI hemorrhage (HR, 1.27; 95% CI, 1.06-1.51) vs those assigned to amlodipine. In-study use of atenolol prior to first GI hemorrhage was related to a lower incidence of GI bleeding (HR, 0.69; 95% CI, 0.57-0.83). Hypertensive patients on amlodipine do not have an increased risk of GI bleeding hospitalizations compared with those taking either chlorthalidone or lisinopril.

Lower Gastrointestinal Bleeding: Is Urgent Colonoscopy Necessary for All Hematochezia?

Lower gastrointestinal bleeding (LGIB) is defined as acute or chronic abnormal blood loss distal to the ligament of Treitz. The incidence of LGIB is only one fifth of that of the upper gastrointestinal tract and is estimated to be 21 to 27 cases per 100,000 adults per year. Acute bleeding is arbitrarily defined as bleeding of <3 days' duration resulting in instability of vital signs, anemia, and/or need for blood transfusion. Chronic bleeding is defined as slow blood loss over a period of several days or longer presenting with symptoms of occult fecal blood, intermittent melena, or scant hematochezia. Bleeding means that the amounts of blood in the feces are too small to be seen but detectable by chemical tests. LGIB is usually chronic and stops spontaneously. Bleeding stop (80%), but male gender and older patients suffer from more severe LGIB. The optimal timing of colonoscopic intervention for LGIB remains uncertain. Urgent colonoscopy may serve to decrease hospital stay. However, urgent colonoscopy is difficult to control, and showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

Acute Lower Gastrointestinal Bleeding

The annual incidence of lower gastrointestinal bleeding (LGIB) is ∼20.5 in 100,000 in the general Western population and results in 1 to 2% of hospital emergencies. When medical management and endoscopic therapy are inadequate in cases of acute LGIB, endovascular intervention can be lifesaving. In these emergent situations it is important for the interventional radiologist to be well versed in the multidisciplinary preangiographic work-up, the angiographic presentations of LGIB, and the endovascular therapeutic options. We describe a case of LGIB managed with endovascular embolization and detail the angiographic techniques used, followed by a detailed discussion of the various treatment approaches to LGIB.

Incidence of spontaneous notifications of adverse reactions with aceclofenac, meloxicam, and rofecoxib during the first year after marketing in the United Kingdom

The objective was to compare the incidence of adverse reactions reported with three nonsteroidal anti-inflammatory drugs with different cyclo-oxygenase (COX)-2 selectivity. All spontaneous adverse reaction notifications in the pharmacovigilance database of the World Health Organisation Collaborating Centre for International Drug Monitoring with aceclofenac, meloxicam, and rofecoxib that were recorded during the first year of marketing were included. The incidence rate (adverse reactions/10(6) defined daily dose) and 95% confidence interval for total adverse reactions was 8.7 (6.1-12.0) for aceclofenac, 24.8 (23.1-26.6) for meloxicam, and 52.6 (49.9-55.4) for rofecoxib. Aceclofenac had a lower incidence of gastrointestinal bleeding, abdominal pain, and arterial hypertension than meloxicam and a lower incidence of gastrointestinal bleeding, abdominal pain, liver toxicity, thromboembolic cardiovascular events, arterial hypertension, and edema than rofecoxib. The incidence of total and gastrointestinal adverse reactions was significantly lower with aceclofenac than with meloxicam or rofecoxib, thus raising doubts about the hypothetical advantage of COX-2 selective inhibitors.

Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage

Gastrointestinal stromal tumor is rare, which arises from the mesenchymal tissues in the gastrointestinal tract, and it is extremely rare in the appendix. Only a few cases have been found in this location to date. Although the annual incidence of lower gastrointestinal bleeding has been increasing, bleeding related to the appendix is quite rare. We herein present a very rare case of gastrointestinal stromal tumor incidentally found by appendiceal hemorrhage.

Chirurgische Therapiekonzepte bei unterer gastrointestinaler Blutung

The estimated incidence of lower gastrointestinal bleeding (LGIB) is 20/100,000 patients per year. Of these cases, 70-80% are minor or stop spontaneously and do not present as emergency hospital admissions. Colonoscopy and angiography detect 80-90% of major LGIB, and subsequent endoscopic intervention or embolisation can control approximately 70%. Emergency surgical intervention is required in haemodynamically unstable patients with persistent bleeding. The surgical treatment of choice is directed to resecting the bleeding bowel segment. Subtotal colectomy is performed in patients with colonic bleeding that can not exactly be localized. Segmental colon resection is often associated with rebleeding and not recommended in this situation. Primary anastomosis can usually be performed; elderly patients in reduced condition, however, are candidates for stoma. In case of persistent or recurrent bleeding and differentiation between intestinal and colonic bleeding fails, loop ileostomy may be performed. If the bleeding appears to originate from somewhere in the small bowel, an additional loop jejunostomy may be performed for specification. The mortality from acute LIGB is approximately 5% but increases with emergency surgery. Risk factors are age, comorbidity, and shock on admission.