Management Of Upper Gastrointestinal Bleeding Research Articles

Cost-effectiveness analysis of high-dose omeprazole infusion before endoscopy for patients with upper-GI bleeding

The use of intravenous (i.v.) proton pump inhibitors (PPI) before an endoscopy in upper-GI bleeding (UGIB) was shown to reduce the need of endoscopic therapy and shorten hospital stay. To investigate whether preemptive use of a PPI in UGIB is a cost-effective strategy. A decision analysis model that represents treatment pathways for patients with UGIB was constructed and structuralized by 30-day outcomes. Direct costs of medical treatment, diagnostic and therapeutic endoscopy, endoscopic re-treatment, surgery, and hospitalization were analyzed. Prince of Wales Hospital, Hong Kong. A total of 631 patients were recruited. Sixty patients (19.1%) in the PPI group and 90 patients (28.4%) in the placebo group required endoscopic hemostasis at index endoscopy. The primary measurements were cost-effectiveness ratios and incremental cost-effectiveness ratios (ICER) to avert endoscopic therapy between PPI and placebo treatment. Sensitivity analyses were conducted by varying the cost of endoscopy, hospitalization, the incidence rate of endoscopic therapy, and the proportion of bleeding peptic ulcers. The overall direct cost per patient was U.S. dollars (USD) $2813 for PPI treatment and USD $2948 for the placebo. A PPI reduced endoscopic therapy by 7.4% and resulted in a lower cost-effectiveness ratio per endoscopic therapy averted (USD $3561) than the placebo (USD $4117). The ICER value was USD -$1843, which indicated that preemptive PPI treatment is more effective and less costly for UGIB. When the proportions of patients with peptic ulcer bleeding were greater than 8.3%, the preemptive PPI treatment remained cost saving. Preemptive use of IV PPI before an endoscopy is a cost-effective strategy in the management of UGIB.

Diagnosis and Management of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is defined as bleeding proximal to ligament of Treitz. Its clinical presentations are hematemesis, melena stool, or even fresh bleeding per rectum. This paper reviews the diagnosis and treatment of upper GI bleeding. Selective literature review. Common causes of upper GI bleeding are peptic ulcer disease, bleeding from gastroesophageal varices, angiodysplasias, and Mallory-Weiss lesions. The most important diagnostic intervention is endoscopy, which allows therapeutic interventions if needed. Peptic ulcer disease is treated endoscopically with injection therapy and endoclips. Acute bleeding from oesophageal varices is treated by banding. Endoscopic treatment is accompanied by medical treatment with proton pump inhibitors for the treatment of peptic ulcer disease, and vasoactive drugs for the treatment of bleeding oesophageal varices. Modern endoscopy affords good localization of the bleeding site and successful treatment for most patients with upper GI bleeding.

Admission risk markers for upper gastrointestinal bleeding: Can urgent endoscopy be avoided?

Admission risk markers for upper gastrointestinal bleeding: Can urgent endoscopy be avoided?

Thyroid Artery Erosion by Esophageal Cancer: Management with Interventional Radiology

Management of upper gastrointestinal bleeding because of erosion of vessels by esophageal cancer may be challenging. We present herein the angiographic images of a 49-year-old patient who was admitted with massive bleeding from a tumor-eroded inferior thyroid artery. Attempts to control the bleeding by means of flexible endoscopy and insertion of a Sengstaken–Blakemore tube had failed. The diagnosis was impressively demonstrated by multislice computed tomography with intravenous contrast in the arterial phase and multiplanar reconstructions (computed tomography angiography) and by digital subtraction angiography. The bleeding was successfully treated with superselective catheterization and coiling of the eroded vessel.

Upper gastrointestinal bleeding

This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care.In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions.This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?

Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern

We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.

A Cerebrovascular Event After Single-Dose Administration of Recombinant Factor VIIa in a Patient with Esophageal Variceal Bleeding

Upper gastrointestinal bleeding (UGIB) is a life-threatening complication of cirrhosis that develops from esophageal varices in almost 70% of patients. The mortality rate from the bleeding episodes is reported to be 30% [1-4]. Standard management of UGIB of cirrhotic patients is vasoactive therapy combined with endoscopic procedures such as endoscopic sclerotherapy and band ligation [5]. Currently, it is reported that recombinant activated fVIIa (Novoseven, NovoNordisc) can correct the prothrombin time in decompensated cirrhotic patients and also can be used safely in Child's B and C cirrhotic patients with UGIB [6-8]. Herein, we describe the first case report in the literature of a cerebrovascular event after the administration of a single dose of fVIIa in a cirrhotic patient with esophageal variceal bleeding.

Gastrointestinal Complications of Dual Antiplatelet Therapy

Case presentation: A 59-year-old man with a history of hypertension, dyslipidemia, and smoking was hospitalized with acute coronary syndrome requiring emergency percutaneous coronary intervention with 4 drug-eluting stents. His discharge medications included dual antiplatelet therapy with aspirin 325 mg/d and clopidogrel 75 mg/d. Three weeks after discharge, he returned to the Emergency Department with bloody stools and a hematocrit of 23% (previously 36%) and required 3 U of packed red blood cells. Endoscopy showed a bleeding duodenal ulcer with adherent clot (Figure). Endoscopic image of bleeding duodenal ulcer with clot on top. This image was taken in a patient with a history similar to that of our patient. Arrow points to the base of duodenal ulcer with active bleeding. Picture contributed by Sarathchandra Reddy, MD, and Edwin Chun Ouyang, MD, PhD, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Mass. We prescribe dual antiplatelet therapy with aspirin and clopidogrel to prevent and treat cardiovascular, cerebrovascular, and peripheral arterial disease. According to American Heart Association statistics, 700 000 patients had stroke, 13 million had coronary artery disease, and 8 to 12 million suffered from peripheral arterial disease in 2002. Each year, 1.2 million patients in the United States receive dual antiplatelet therapy with aspirin and clopidogrel after percutaneous coronary intervention with drug-eluting stents. The number of patients in the United States who receive dual antiplatelet therapy for various vascular conditions such as coronary artery disease, transient ischemic attack, thrombotic stroke, and peripheral vascular disease probably exceeds several million. The use of aspirin compared with placebo reduces the risk of myocardial infarction, stroke, or death from vascular causes by ≈25%.1 In the Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial, administration of clopidogrel decreased the relative risk of vascular events by 8.7% compared with aspirin.2 The …

Coeliac axis ligation in a case of unmanageable upper gastrointestinal haemorrhage

Upper gastrointestinal haemorrhage (UGH) is a frequent reason for referral in gastroenterologic practice. It consists of bleeding that originates in the upper gastrointestinal tract, between the oesophagus and Treitz's angle. Gastroduodenal peptic ulceration, severe lesions of gastric or duodenal mucosa, and esophageal varicose rupture are the most frequently reported causes of UGH. Clinically, it manifests as rectal bleeding or haematemesis. Regardless of the causal lesion, UGH is differentiated by the degree of haemodynamic instability. Thus, initial management of UGH with haemodynamic instability does not depend on the lesion that produces it but rather on controlling the hypovolaemia in all cases. Subsequent therapeutic measures, which in certain cases are defined in early stages of this picture, depend on the aetiology of the lesion causing the UGH and its treatment. We present a case of unmanageable UGH of unknown aetiology despite multiple diagnostic and therapeutic measures, where final successful treatment required an exceptional surgical intervention – celiac axis ligation.

Management of Acute Bleeding Upper GI Ulcers in the Era of Endoscopic and IV PPI Therapy

Despite advances in therapy, the morbidity and mortality of gastrointestinal bleeding remains high. A review of current practice patterns was undertaken in St Boniface General Hospital, Winnipeg, Manitoba to assess the standard of care provided. To determine whether upper gastrointestinal bleeding (UGIB) attributable to a single acute ulcer is treated appropriately with respect to local therapy, acid suppression and Helicobacter pylori status. A retrospective chart review identified patients with consecutive acute UGIB attributable to a single gastric or duodenal ulcer presenting to a tertiary care centre over a six-month period. The lesions were classified as high- or low-risk based on endoscopic appearance. Local care of the ulcer, acid suppressive therapy and management of H. pylori were determined by reviewing pertinent chart materials. Appropriate care was defined for all three end points a priori using literature-supported standards of care. Fifty-five patients who met study criteria were identified. Twenty-six of 55 (47%) and 29 of 55 (52%) lesions were considered to be low- and high-risk respectively. Of the high-risk lesions, two of 29 received no local therapy, 24 of 29 received adrenaline injection and two had an endoclip placed. Of the 27 patients whose lesions were treated, 16 received thermal coagulation. Twenty-five of 29 (88%) received intravenous proton pump inhibitors. Thirty-three of 55 (55%) patients did not have H. pylori status considered in their management. Weaknesses in the management of UGIB were identified, particularly with respect to addressing the role of H. pylori. Fragmentation and compartmentalization of patient care may be important contributing factors.

Upper gastrointestinal bleeding

This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions. Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group. The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.

P0352 RECURRENT GI BLEEDING FROM ???IATROGENIC??? VARIX IN GASTROSTOMY-RESOLUTION BY SURGICAL CLOSURE

Introduction: Gastrointestinal (GI) bleeding from varices is the most significant complication of portal hypertension. Varices occur at the sites where portal and systemic circulation are in close proximity. The natural sites for the development of varices are in the lower esophagus, retroperitoneum, hemorrhoidal venous plexus, and umbilical vein. Varices have also been reported around colostomy and ileostomy sites. We have observed significant bleeding from varices that have developed in the gas-trostomy tract in a patient with portal hypertension. Methods: We report our experience with a patient with history of portal hypertension and repeated admissions at Loma Linda University for the management of upper GI bleeding. The bleeding was found to be from varices in the gastrostomy tract. Results: This is a five-year old female, who initially presented at eight months of age, with history of Jeune’s Syndrome, ventilator dependence, micronodular cirrhosis, portal hypertension, and anemia secondary to recurrent upper GI bleeding. Upper endoscopy revealed non-bleeding esophageal varices and a possible varix in gastrostomy tract. Over the next five months, she required frequent admissions for management of bleeding and required multiple blood transfusions. At thirteen months of age, patient presented with massive upper GI bleeding and a repeat upper endoscopy showed non-bleeding esophageal and gastric varices, and bleeding from a protruding varix from gastrostomy site. Patient was referred to pediatric surgery, and had resection of gastrostomy tract. Since surgical intervention, patient has had no further recurrence of upper GI bleeding in the ensuing four years. Conclusion: A surgical procedure such as gastrostomy can result in the development of portal-systemic collaterals by artificially creating proximity between the portal and systemic venous circulation in patients with portal hypertension. These collaterals could cause significant bleeding, resulting in increased morbidity. Surgical resection of the gastrostomy tract can remove a source of bleeding from varices located around the stoma and potentially reduce the morbidity associated with bleeding in patients with portal hypertension. Non-surgical methods of providing enteral feedings should be considered in patients with portal hypertension and feeding disorder.

A Canadian Clinical Practice Algorithm for the Management of Patients with Non-Variceal Upper Gastrointestinal Bleeding

To use current evidence-based recommendations to provide a user-friendly clinical algorithm for the management of upper gastrointestinal bleeding, adapted to the Canadian environment. A multidisciplinary consensus group of 25 participants representing 11 national societies used a seven-step approach to develop recommendations according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. A small writing subgroup subsequently created the algorithm. Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding secondary to ulcer disease should be tested and treated for Helicobacter pylori infection. This algorithm should facilitate appropriate risk stratification, use of endoscopic therapy and the appropriate utilization of proton-pump inhibition to optimize the care of patients with upper gastrointestinal bleeding. The algorithm should be customized to the resources of individual medical centres. Its application should be studied with appropriate outcomes recorded and validation performed.

Cost analysis of outpatient management versus hospitalization in patients diagnosed of upper gastrointestinal hemorrhage not associated with portal hypertension

Antecedents: In accord with objective criteria, outpatient management of upper gastrointestinal hemorrhage (UG1H) is a safe alternative to hospitalization, so it may save in terms of hospital costs. Aim: To compare the costs between outpatient management vs. hospitalization in patients with UGIH with similar clinical and endoscopic features. Patients and Methods: Two groups of patients with UG1H not associated with portal hypertension, who were prospectively evaluated at Emergency, were included: 150 admitted at hospital (HG) and 150 that were early discharge (OG). At Emergency, all patients were examined by a gastroenterologist: hemodynamic status, clinical history, laboratory tests and shortly endoscopy (before 8 hours in OG). In accord with specific guidelines, patients with any criterion for hospitalization were not included (severe heart failure; recent myocardial or cerebrovascular accident; severe coagulopathy; unsuitable family conditions; severe hemodynamic repercussion; endoscopy stigmata of recent bleeding; impossibility of performing endoscopy), as well as recurrent hemorrhage, surgery or death. Features of both groups were compared: clinical (comorbidy, alcohol/NSAlDs/anticoagulants use, symptoms, hemodypamic status); biological ; endoscopic findings (cause and severity of UGIH), need of blood transfusion and eradication therapy. Cost analysis were obtained by comparison between groups of cost data of Emergency stay, hospital stay, diagnostic procedures, hospital and outpatient therapy and clinic visit on four weeks after discharge. Results: No statistical differences between groups when clinical, hemodynamic, biological variables and transfusion were compared (p>0.05, ChiSquare test). Endoscopy was not performed in 9 patients of HG because negative and no endoscopic findings were detected in 16 of OG. The remaining (141 HG and 134 OG) presented blackish rests or lesion without stigmata. Mean of hospital stay was of 3.05 + 2.13 days in HG, whereas all patients of the OG were discharge at Emergency in <24 hours. Mean costs were of $ 970 + 428 for HG and $ 370 + 71 for OG (p<0.O01, Sntdent-t test). Room costs accounted for difference in total costs. Conclusion: In accord with specific guidelines that depends on clinical and endoscopic criteria, outpatient management of upper gastrointestinal hemorrhage not associated with portal hypertension is safe and produce significant savings in hospital costs

Upper gastrointestinal endoscopy: current status.

Esophagogastroduodenoscopy occupies a predominant position in the diagnostic evaluation and therapeutic management of foregut disease. The safety, anatomic refinement, and tissue sampling capabilities offered by endoscopic examination support its use as a premier diagnostic tool. An increasingly diverse and ingenious set of endoscopically delivered tools are available to expand the diagnostic capability, and extend the therapeutic application of esophagogastroduodenoscopy to a wide range of pathology, both benign and neoplastic. Comparative outcome data support the utility of therapeutic esophagogastroduodenoscopy in the management of upper gastrointestinal bleeding and the palliative management of foregut neoplasia. Endoscopically delivered therapies may have an increasing role in the management of gastroesophageal reflux disease in the future, and the development of endoluminal ultrasound has added a whole new dimension to endoscopic diagnostic and, potentially, therapeutic capability. This review highlights the current status of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal pathology.

Management of Upper Gastrointestinal Bleeding due to NSAID Gastropathy that is Unresponsive to Ranitidine

Non steroidal anti-inflammatory drugs (NSAIDS) are now commonly used in clinical practice. On the other hands, this drug could result severe complication such as bleeding and perforation. In such condition, proton pump inhibitor can be used to stop bleeding than H2 antagonists. We reported one cases of upper gastrointestinal bleeding due to NSAID gastropathy that was unresponsive to Ranitidine. The treatment was suitable to proton pump inhibitor that could overcome upper gastrointestinal bleeding.

Evidence-based medicine as it applies to acid suppression in the hospitalized patient.

An evidence-based-medicine approach may be applied to studies in the medical literature to help physicians make sound judgments about efficacy and safety data and to improve clinical decision making. To assess the role of gastric acid suppression in the prevention of stress ulcer bleeding and in the management of upper gastrointestinal bleeding after successful hemostasis of bleeding peptic ulcer disease, the following questions should be addressed: Is it possible to identify risk factors for clinically important bleeding in critically ill patients? Can intravenous acid suppression prevent stress ulcer-related bleeding or prevent rebleeding in peptic ulcers after successful hemostasis? What is the most effective method of acid suppression for these disorders? An evidence-based-medicine review of published trials yields sufficient evidence to support the use of prophylactic acid suppression in critically ill patients with coagulopathy or in those who are receiving prolonged mechanical ventilation. Not enough data have accumulated to prove the superiority of intravenous proton pump inhibitors to intravenous histamine-2-receptor antagonists for prophylaxis of clinically important stress ulcer bleeding. With respect to acute gastrointestinal bleeding, however, two well-conducted trials indicate that an intravenous proton pump inhibitor is significantly more effective than an intravenous histamine-2-receptor antagonist or placebo in reducing the rate of rebleeding after hemostasis in patients with bleeding peptic ulcer. Analysis of the data from both trials shows that only five to six patients would need to receive an intravenous proton pump inhibitor to avoid one episode of rebleeding.

Caregiver out-of-pocket expenses and loss of productivity associated with outpatient management of upper gastrointestinal hemorrhage

Caregiver out-of-pocket expenses and loss of productivity associated with outpatient management of upper gastrointestinal hemorrhage

Outcomes based analysis of a Managed Care VS Group practice model in the management of upper gastrointestinal hemorrhage

Outcomes based analysis of a Managed Care VS Group practice model in the management of upper gastrointestinal hemorrhage

Caregiver out-of-pocket expenses and loss of productivity associated with outpatient management of upper gastrointestinal hemorrhage

Caregiver out-of-pocket expenses and loss of productivity associated with outpatient management of upper gastrointestinal hemorrhage