Management Of Upper Gastrointestinal Bleeding Research Articles

Upper Gastrointestinal Bleeding at a Public Referal Hospital in Malawi

Background: Upper gastrointestinal bleeding (UGIB) is a medical emergency. Timely and appropriate treatment can be lifesaving. Where medical equipment and supplies are inadequate, management of upper gastrointestinal bleeding is challenging. Methods: A retrospective review of charts of patients who were admitted during the year 2010, with a diagnosis of Upper Gastrointestinal Bleeding (UGIB), was done at Kamuzu Central Hospital, Lilongwe, Malawi. A Rockall score was applied to determine mortality risk. Results: A total number of 187 records (119 men and 68 women, mean age of 40.7 ± 15.3 years) were reviewed. The mortality rate was 23.5%, with a non-significant gender difference. Bleeding oesophageal varices were the most common clinical cause of UGIB (42.8%), with more males (63.1%) than females affected. About 40% of patients had no cause of UGIB indicated in their records. 14 (7.5%) patients had a normal oesophagogastroduodenoscopy (OGD). Oesophageal tumor was present in 2.7% of the subjects as a cause of UGIB. Access to endoscopy, for diagnosis and therapeutic intervention, and surgery (Hassab procedure) was available to less than 50% of the patients. Sixteen patients (9.5%) had surgery after endoscopy due to lack of variceal banding materials. Conclusion: Upper gastrointestinal bleeding is an important and common clinical problem at Kamuzu Central Hospital. Oesophageal varices seem to be the commonest cause of UGIB. Inadequacy of resuscitation materials and perhaps timely diagnostic and therapeutic endoscopic and surgical interventions are important limiting factors to favourable patient outcome. Work towards regular provision and supply of interventional resources regarding UGIB management may improve patient outcome.

Endoscopy After Acute Myocardial Infarction

Upper gastrointestinal bleeding in the setting of acute myocardial infarction (MI) has substantial morbidity and mortality. Several studies have been performed on the safety of esophagogastroduodenoscopy (EGD) after MI; however, these studies vary in definitions and results. We evaluated the safety and effect of EGD in patients with acute MI in a tertiary center. A retrospective, single tertiary-care center study was undertaken of 87 patients who underwent EGD within 30 days of an acute MI between January 2001 and March 2012. Type of MI (ST segment elevation MI [STEMI] and non-ST segment elevation MI [NSTEMI]), peak troponin I, time from MI to EGD, Acute Physiology and Chronic Health Evaluation (APACHE) II score at EGD, cardiac catheterization before EGD, and medical complications within 24 hours of EGD were noted. Medical complications were defined as major complications (death, life-threatening arrhythmias) and minor complications (chest pain, abnormal vital signs, or minor arrhythmias). Eighty-seven patients underwent EGD within 30 days of having an MI. No major complications were observed. Minor complications occurred in 27 of 87 patients (31.0%), including mild hypotension, mild bradycardia, or increased chest pain. Patients with STEMI demonstrated statistically significant quicker endoscopy (P = 0.01) and were more likely to undergo cardiac catheterization in advance of EGD (P < 0.01) than those with NSTEMI. No statistically significant differences were noted for peak troponin I (P = 0.21), APACHE II score at EGD (P = 0.55), or minor complications (P = 0.08) among patients with STEMI versus NSTEMI. Cardiac catheterization before EGD did not seem to affect results. Patients with APACHE II scores >16 experienced more minor complications (P = 0.02). EGD appears relatively safe for the diagnosis and management of upper gastrointestinal bleeding in patients with acute MI.

Experience in the Management of Upper Gastrointestinal Bleeding and Outcomes in Patients Taking Dabigatran Compared with Warfarin: A Retrospective, Comparative Study

Experience in the Management of Upper Gastrointestinal Bleeding and Outcomes in Patients Taking Dabigatran Compared with Warfarin: A Retrospective, Comparative Study

Validation of a live animal model for training in endoscopic hemostasis of upper gastrointestinal bleeding ulcers

The management of upper gastrointestinal bleeding requires training of the endoscopist. We aimed to validate a live animal model of bleeding ulcers for training in endoscopic hemostasis. Bleeding ulcers were created by repeated grasp-and-snare gastric mucosectomies in pigs rendered "bleeders" by preadministration of clopidogrel, aspirin, and unfractionated heparin. The feasibility and reproducibility of the model (proportion of bleeding ulcers, number of ulcers per animal, and time needed to produce a bleeding ulcer) were prospectively evaluated in six animals. Ten endoscopic experts assessed the similarity of this pig model to human bleeding ulcers (four-point Likert scale). The training capabilities of the model for hemostatic techniques (needle injection, bipolar electrocoagulation, and hemoclipping) were evaluated in 46 fellows (four-point Likert scale). A total of 53 gastric ulcers were created in 6 animals (8.8 ± 1.5 ulcers/animal). Successful active ulcer bleeding (Forrest Ib) was achieved in 96.2 % of cases. Bleeding was moderate to abundant in 79 % of cases. Ulcerations consistently reached the submucosal layer. The mean (± SD) time taken to create a bleeding ulcer was 3.8 ± 0.6 minutes. Endoscopic experts assessed the realism of the ulcers and bleeding at 3.2 ± 0.7 and 3.6 ± 0.7 respectively on a four-point Likert scale. The training significantly improved the endoscopic skills of the 46 fellows (P < 0.0001) in all hemostatic techniques. The live porcine model of bleeding ulcers was demonstrated to be realistic, reproducible, feasible, time efficient, and easy to perform. It was favorably assessed as an excellent model for training in endoscopic treatment of bleeding ulcers.

Management of upper gastrointestinal bleeding - Is there a “weekend or night” effect?

Management of upper gastrointestinal bleeding - Is there a “weekend or night” effect?

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

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

Hemospray in the treatment of upper gastrointestinal hemorrhage in patients on antithrombotic therapy

Patients on antithrombotic therapy (ATT) have the highest risk of ongoing bleeding and mortality. Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a novel hemostatic agent for the treatment of upper gastrointestinal bleeding (UGIB). Initial reports on its use appear promising in terms of initial hemostasis and rebleeding rates. It is unknown whether this also pertains to patients on ATT. The aim of the current study therefore was to evaluate the efficacy of Hemospray in the treatment of UGIB in patients taking ATTs. A total of 16 unselected consecutive patients with UGIB who were treated with Hemospray were analyzed (eight taking ATT for various indications and eight not on ATT). Initial hemostasis was achieved after Hemospray application in 5 /8 patients on ATT (63 %) and in all eight patients not on therapy (P = 0.20). Rebleeding rates were similar in both groups. These preliminary data on the use of Hemospray in the management of UGIB are promising in both patients with and without ATT; however, caution should be exercised for its use in patients on ATT with spurting arterial bleeding.

Impact of Trainee Involvement in Management and Outcomes of Upper Gastrointestinal Bleeding

Purpose: Upper gastrointestinal bleeding (UGIB) is common, with an annual incidence of 1 per 1,000 population. Previous studies on trainee involvement in colonoscopies have shown increased adenoma detection rates. The aim of this study was to examine whether fellow participation during management of UGIB affects the outcome when compared to management by an experienced gastroenterologist alone. Methods: This was a retrospective study of 278 cases of UGIB at a tertiary care referral center between August 2010 and July 2011. Demographics, management and outcome details were collected by chart review. Comparison was then made between cases managed by fellows with supervising staff gastroenterologists and the cases managed by a staff gastroenterologist without fellow participation. Results: Fellows were involved in management of 63% of cases, mostly in their 1st year of training. Comparison of demographics, presentation and comorbidities is shown in Table 1. Patients managed by the trainees were more likely to have had hematemesis and low BP but a higher mean hemoglobin. An upper endoscopy was performed in 87% of the cases in the trainee group and 92% of cases in the staff gastroenterologist group. There was no difference in the time to endoscopy from admission, adverse outcomes (mortality and rebleeding), length of hospital stay and cost of hospitalization between the 2 groups. Even though there was no statistically significant difference in the proportions with bleeding stigmata (p=0.3) on upper endoscopy, more patients in the trainee group had endoscopic hemostasis (p=0.02). Increased red blood cell transfusions were noted in the cases managed by the staff gastroenterologist and increased FFP transfusions were noted in trainee-managed cases. These results are summarized in Table 2.Table 1: Comparison of demographics, presentation and comorbidities in cases managed with trainees and without traineesTable 2: Comparison of management and outcomes in cases managed with trainees and without traineesConclusion: Fellow involvement was associated with increased endoscopic hemostasis. This difference is possibly due to endoscopic training involved in the management of those cases; however, no difference was noted in the overall outcome, length of hospital stay or cost of admission.

Urgent endoscopy in elderly patients with non-variceal upper gastrointestinal bleeding.

IntroductionAge of the patient is an important prognostic factor in patients with non-variceal upper gastrointestinal bleeding (UGIB). Despite that fact, current treatment algorithms do not differentiate UGIB management according to the patient's age.AimTo compare treatment outcomes in patients below and above 75 years of age, treated for UGIB with urgent endoscopy.Material and methodsProspective analysis of treatment outcomes in 295 patients with non-variceal UGIB divided into two age groups (group A < 75 years of age, group B > 75 years of age). Urgent endoscopy (up to 3 h since admission) was performed in 292 patients. The groups were compared in regards to the duration of symptoms, previous UGIB, presence of factors predisposing to UGIB (NSAIDs, peptic ulcer disease, liver cirrhosis, and previous gastrointestinal surgery), haemodynamic state and haemoglobin (Hb) levels on admission. We analysed the causes of UGIB, severity of UGIB on the Forrest scale, type of endoscopic bleeding control method, and co-morbidities with use of the Charlson Co-morbidity Index (CCI). Treatment outcomes were assessed in regard of mortality rate, UGIB-recurrence rate, duration of hospital stay, amount of transfused blood products and the requirement of intensive therapy unit (ITU) or other departments’ admissions. Patients were followed until their discharge home.ResultsMortality rate was 6.8% (group A vs. B: 3.5% vs. 18.7%; p = 0.001). Upper gastrointestinal bleeding recurrence was noted in 12.2% of patients (group A vs. B: 12.5% vs. 10.9%; p = 0.73). 2.4% of patients required surgery for UGIB (group A vs. B: 1.7% vs. 4.7%; p = 0.16). Patients in group B required ITU admission more frequently (group A vs. B: 1% vs. 4.7%; p < 0.01). The mean hospital stay (4.3 days) and the mean number of transfused packed red blood cells (PRBCs) (2.35 Units) did not differ between the groups. Patients in group B used NSAIDS much more frequently, more often had hypovolaemic shock and had a higher CCI score.ConclusionsUrgent endoscopy is an important and broadly accepted method of treatment of UGIB. Despite strict adherence to the modern UGIB-treatment algorithms, mortality remains high in the elderly. Thus, these patients need particular attention. The presented study indicates that the standard management might not be sufficient in elderly patients.

Upper gastrointestinal bleeding

Effective management of upper gastrointestinal bleeding (UGIB) relies on the application of clinical risk scores. The validation of risk scores has to date focused mainly on nonvariceal UGIB groups. We aimed to evaluate our clinical and endoscopic management of UGIB, and to validate existing risk scores for a mixed patient population with a high percentage of variceal bleeds. Analysis included UGIB patients presenting consecutively to a tertiary referral university hospital. All patients had been admitted by our emergency department and had undergone upper gastrointestinal endoscopy. Clinical, biochemical and endoscopic data were recorded. Clinical and complete Rockall and Blatchford risk scores were calculated for all patients and statistical analysis was carried out by a multiple logistical regression model. A total of 21% of patients had variceal bleeds. There was considerable heterogeneity between groups with the variceal group having more comorbidities (P=0.003), lower haemoglobin (P=0.003) and lower systolic blood pressure (P=0.013) at presentation. This translated to higher risk scores (P<0.0001) and worse clinical outcomes (rebleeding P=0.004). Only complete Rockall score was predictive of outcome (rebleeding P=0.004, AUC 0.8). Blatchford score did not predict bleeding or mortality. However, no patient with a Blatchford score of 0 had an adverse clinical outcome. Postendoscopic Rockall score can be used as a predictor of outcome for mixed UGIB groups. Although Blatchford score did not predict outcome in our study, at a 0 level it does appear to be a safe triage tool for pre-endoscopic identification of patients with variceal bleeds, even where there is no known history of liver disease.

Diagnosis and management of nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5-10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.

The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery

There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.

Efficacy of fibrin glue in percutaneous transhepatic obliteration for the management of upper gastrointestinal bleeding in patients with portal hypertension

Efficacy of fibrin glue in percutaneous transhepatic obliteration for the management of upper gastrointestinal bleeding in patients with portal hypertension

Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding

Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel's of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.

Endoscopy for upper gastrointestinal bleeding: how urgent is it?

Early endoscopy has been advocated for the management of upper gastrointestinal bleeding, but the optimal timing for early endoscopy is still uncertain. The aim of this Review is to evaluate the optimal timing of early endoscopy by examining the findings of randomized clinical trials and retrospective cohort studies that used comparable outcome measures and have been reported in the literature. Outcome measurements included recurrent bleeding, surgery, mortality, length of hospital stay, and blood transfusion. Studies were categorized into those in which endoscopy was performed within 2-3 h, 6-8 h, 12 h or 24 h of the patient's presentation to hospital. We conclude that early endoscopy aids risk stratification of patients and reduces the need for hospitalization. However, it may also expose additional cases of active bleeding and hence increase the use of therapeutic endoscopy. No evidence exists that very early endoscopy (within a few hours of presentation) can reduce the risk of rebleeding or improve survival.

Prediction of Need for Urgent Endoscopy and Treatment Outcomes in Upper GI Bleeding Utilizing Risk Scoring Systems

Introduction: Upper gastrointestinal bleeding (UGIB) is a common medical emergency associated with significant morbidity and mortality. Risk assessment scores such as Modified Blatchfold risk score (MBRS) and Rockall risk score (RRS) have been designed to assess the need for urgent endoscopic therapy and to predict treatment outcomes. However, their role in the management of UGIB has not been clearly evaluated. Aims and Methods: The aims of this study were to clarify the feasibility of these risk stratification scoring systems in the management of UGIB.

Risk and management of upper gastrointestinal bleeding associated with prolonged dual-antiplatelet therapy after percutaneous coronary intervention

Prolonged dual-antiplatelet therapy with aspirin and clopidogrel is mandatory after drug-eluting stent implantation because of the potential increased risk of late stent thrombosis. The concern regarding prolonged antiplatelet therapy is the increased risk of bleeding. Gastrointestinal bleeding is the most common site of bleeding and presents a serious threat to patients due to the competing risks of gastrointestinal hemorrhage and stent thrombosis. Currently, there are no guidelines and little evidence on how best to manage these patients who are at high risk of morbidity and mortality from both the bleeding itself and the consequences of achieving optimum hemostasis by interruption of antiplatelet therapy. Managing gastrointestinal bleeding in a patient who has undergone recent percutaneous coronary intervention requires balancing the risk of stent thrombosis against further catastrophic bleeding. Close combined management between gastroenterologist and cardiologist is advocated to optimize patient outcomes.

Weekend Versus Weekday Admission and Mortality From Gastrointestinal Hemorrhage Caused by Peptic Ulcer Disease

Management of upper gastrointestinal bleeding (UGIB) often requires urgent endoscopic intervention; limitations in its availability on weekends might be associated with increased mortality, compared with patients admitted on weekdays. We used the 1993-2005 U.S. Nationwide Inpatient Sample to identify patients hospitalized for UGIB caused by peptic ulceration. Differences in in-hospital mortality between patients admitted on weekends and weekdays were evaluated by using logistic regression models, adjusting for patient and clinical factors including the timing of upper endoscopy. Between 1993 and 2005, there were 237,412 admissions to 3,166 hospitals for peptic ulcer-related UGIB. Compared with patients admitted on a weekday, those admitted on the weekend had an increased risk of death (3.4% vs 3.0%; adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.15), higher rates of surgical intervention (3.4% vs 3.1%; OR, 1.09; 95% CI, 1.03-1.15), prolonged hospital stays, and increased hospital charges (P < .0001 for all comparisons). Patients admitted on the weekend had a longer mean time to endoscopy (2.21 +/- 0.01 vs 2.06 +/- 0.01 days; P < .0001) and were less likely to undergo endoscopy on the day of admission (30% vs 34%; P < .0001). After adjusting for the timing of endoscopy, weekend admission remained an independent predictor of increased mortality (OR, 1.12; 95% CI, 1.05-1.20). Patients admitted to hospital on the weekend for peptic ulcer-related hemorrhage have higher mortality and more frequently undergo surgery. Although wait times for endoscopy are prolonged in patients hospitalized on the weekend, this delay does not appear to mediate the weekend effect for mortality.

Diagnosis and Management of Upper Gastrointestinal Bleeding: In Reply

Diagnosis and Management of Upper Gastrointestinal Bleeding: In Reply