Need For Endoscopic Intervention Research Articles

Timing of endoscopy in patients with elevated lactate levels and acute upper gastrointestinal bleeding; a retrospective comparative study

Background/Aims While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy. Methods We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB. Results Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p = 0.37), rebleeding (17.2% vs. 15.7%; p = 0.82) and mortality (9.4% vs. 11.4%; p = 0.7) did not differ significantly. Conclusion In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.

Gastrointestinal Bleeding in Children: The Role of Endoscopy and the Sheffield Scoring System in a Resource-Limited Setting.

To document the clinical presentation, endoscopic diagnosis, and Sheffield scores of children with gastrointestinal (GI) bleeding who were referred for endoscopy at the Lagos University Teaching Hospital. The participants who needed endoscopy based on clinical criteria and according to the Sheffield scores were also documented. This study analyzed the records of 111 children with GI bleeding retrospectively from January 2013 to January 2021, while 9 children were recruited prospectively from February 2021 to March 2022. Receiver operating curves and area under the curve were generated to test the ability of the Sheffield scores to predict rebleeds, mortality, and the need for endoscopic intervention for upper GI bleeds. One hundred and twenty participants were recruited. Ninety-one (75.8%) presented with upper GI bleeding (UGIB), while 29 (24.2%) had lower GI bleeding (LGIB). Only 70 (58.3%) (53 UGIB and 17 LGIB) had endoscopy performed. For UGIB, 5 (9.4%) had no source of the bleeding identified at endoscopy, 12 (22.6%) had variceal bleeding, and 36 (67.9%) had nonvariceal bleeding. Colonoscopy revealed juvenile polyps in 5 (29.4%), indeterminate colitis in 5 (29.4%), ulcerative colitis in 4 (23.5%), Crohn's disease in 1 (5.9%), and hemorrhoids in 2 (11.8%) participants, respectively. The Sheffield score was ≥8 in 42 (46.1%) of the participants who presented only with UGIB (hematemesis and melena). The scores were significantly related to the type of bleeds, rebleeds, and deaths (P = 0.00). The clinical and endoscopic findings in this study are similar to those reported previously. The Sheffield scoring was useful in assessing Nigerian children. However, due to limited access and other restraints, endoscopy was not performed on all the study participants even when the scoring system was suggestive. The availability, and therefore, utility of GI endoscopy in this setting are still suboptimal. The need for the provision of adequate equipment and resources and the training of personnel is thus recommended.

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding

BackgroundA considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. ObjectiveThe aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department. MethodsConsecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis. ResultsAlthough 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588–0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103). ConclusionsSyncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

Comparison and validation of the Japanese score and other scoring systems in patients with peptic ulcer bleeding: A retrospective study.

Acute upper gastrointestinal bleeding (UGIB) is one of the most urgent medical conditions, with peptic ulcer bleeding (PUB) accounting for most gastrointestinal bleeding cases. The Japanese scoring system was developed to predict the probability of intervention in patients with UGIB, and it is more effective than other scoring systems, according to several studies. This study aimed to verify whether the Japanese scoring system is better than other scoring systems in predicting the probability of intervention when limited to PUB in patients with UGIB. We enrolled patients who presented with symptoms of UGIB and were diagnosed with peptic ulcers using endoscopy. The performances of the scoring systems in predicting patient outcomes were validated and compared using the receiver-operating characteristic curve analysis. Additionally, we used the chi-square test, Fisher exact test, and the t test to analyze the association between the patients characteristics and clinical outcomes. Of the 1228 patients diagnosed with peptic ulcers, 90.6% underwent endoscopy. rebleeding occurred in 12.5% of the patients, and 2.5% of the patients died within 30 days. The Japanese score was the most effective in predicting the need for endoscopic intervention for PUB. Sex, systolic blood pressure, hematemesis, syncope, blood urea nitrogen level, and the American Society of Anesthesiologists score were predictive factors for the probability of endoscopic intervention in patients with PUB. The Japanese score is an effective predictor of the probability of endoscopic intervention in patients with PUB.

Pre-hospital use of direct oral anticoagulants agents is associated with a lower risk of major bleeding events in critically ill patients: A single academic center experience

BackgroundThe last decade has witnessed significant advancements in direct oral anticoagulants (DOACs), transforming the landscape of anticoagulation therapy. With the uptrend in DOACs use, critical care physicians are encountering more patients with pre-hospital DOACs prescription. Safety and real world outcomes-related data on DOACs use in critically ill patients are scarce. ObjectiveWe assess the risk of major bleeding (MB) events and patient-centered outcomes with pre-hospital use of direct oral anticoagulant agents (DOACs) compared to warfarin therapy. MethodsObservational study in a single large academic center from January 1st, 2012, through May 4th, 2018. We included adult critically ill patients with warfarin or one of the DOACs, as active medications at the time of hospital admission. The primary outcome was major bleeding (MB), based on the ISTH criteria Results99,481 patients were screened; 558 and 3037 patients were included in the final analysis for the DOAC and warfarin groups, respectively. Multivariable analysis showed that the pre-hospital use of DOACs was associated with lower odds for major bleeding events, GI bleeding, need for endoscopic intervention, hemorrhagic shock, any blood transfusion; but higher odds of intracranial bleeding, as compared to warfarin use. There was no difference in hospital length of stay or ICU-free days. ConclusionsPre-hospital use of DOACs among critically ill patients is associated with lower major bleeding events, GI bleeding, need for endoscopic intervention, and blood transfusion but a higher risk for intracranial bleeding.

AIMS65, Glasgow-Blatchford bleeding score and modified Glasgow-Blatchford bleeding score in predicting outcomes of upper gastrointestinal bleeding: An accuracy and calibration study.

Albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65), Glasgow-Blatchford bleeding score (GBS) and modified GBS (mGBS) are three pre-endoscopy scoring systems used in the risk stratification of upper gastrointestinal bleeding (UGIB). The utility of such scoring systems in a population is estimated by their accuracy and calibration in the population. We aimed at validating and comparing the accuracy of the three scoring systems in predicting clinical outcomes including in-hospital mortality, need for blood transfusion, endoscopic treatment and rebleeding risk. We conducted a single-center, retrospective cohort study on patients with UGIB at a tertiary care center in India over 12 months. Clinical and laboratory data was collected from all patients admitted with UGIB. All patients were risk stratified using AIMS65, GBS and mGBS. The clinical outcome examined were: in-hospital mortality, requirement of blood transfusion, need for endoscopic treatment and rebleeding during hospital stay. The area under receiver-operating curve (AUROC) was calculated to assess the performance and calibration curves (Hosmer-Lemeshow goodness of fit curve) were plotted to examine how accurately the model describes the data of all three scoring systems. Total 260 patients were included in the study, of which 236 (90.8%) were males. As many as 144(55.4%) patients required blood transfusion and 64 (30.8%) required endoscopic treatment. While the incidence of rebleeding was 7.7%, in hospital mortality was 15.4%. Of 208 who underwent endoscopy, the most common causes identified were varices (49%) and gastritis (18.2%), followed by ulcer (11%), Mallory-Weiss tear (8.1%), portal hypertensive gastropathy (6.7%), malignancy (4.8%) and esophageal candidiasis (1.9%). The median AIMS65 score was 1, GBS 7 and mGBS 6. The area under curve (AUROC) for AIMS65, GBS and mGBS was (0.77, 0.73,0.70), (0.75, 0.82,0.83), (0.56, 0.58,0.83), (0.81, 0.94,0.53) for in-hospital mortality, blood transfusion requirement, endoscopic treatmentand rebleeding prediction, respectively. GBS and mGBS are superior to AIMS65 in predicting the requirement of blood transfusion and rebleeding risk, whereas in-hospital mortality was better predicted by AIMS 65. Both scores performed poorly in predicting the need of endoscopic treatment. An AIMS65 of 0,1 and a GBS of ≤ 1 are not associated with significant adverse events. A poor calibration of the scores in our population points to the lack of generalizability of these scoring systems.

Clinical significance of the noninvasive mucosal inflammation index for assessing the endoscopic activity of Crohn’s disease in children

Introduction. The use of non-invasive methods for examining patients with endoscopic remission can be useful in identifying the need for endoscopic interventions and assessing disease activity over time.&#x0D; Materials and methods. We analyzed two hundred thirty two medical histories of children with Crohn’s disease (CD) who were examined and treated at the National Medical Research Center for Children’s Health. The relationship between the CD simple endoscopic score (SES-CD) and the newly developed mucosal inflammation noninvasive index (MINI) was determined. Similarly, data from 80 children with ulcerative colitis were examined to identify correlations between the ulcerative colitis endoscopic index of severity (UCEIS) and MINI.&#x0D; Results. Among all forms of Crohn’s disease, a direct strong correlation was found between MINI and SES-CD (R = 0.81, &#x0D; p &lt; 0.001). A MINI value &gt; 5 indicated the absence of mucosal healing (SES-CD &gt; 2 points) with a sensitivity of 73% and a specificity of 84%, and a MINI value ≥13 predicted high activity of Crohn’s disease (SES-CD ≥ 16 points) with sensitivity and specificity of 79% and 88%, respectively. The correlation between MINI and UCEIS in patients with ulcerative colitis revealed an average relationship, which requires further modification of the index in accordance with the characteristics of the course of the disease.&#x0D; Conclusion. The newly developed MINI is a simple and intuitive tool for assessing mucosal inflammation in CD children.

Varis dışı üst gastrointestinal kanamada klinik sonuçların tahmininde risk puanlama sistemlerinin karşılaştırılması: prospektif randomize çalışma

Aim: Non-variceal upper gastrointestinal bleeding (UGIB) is a typical gastrointestinal emergency. Detection of high-risk patients is crucial to organize medical care accordingly. This study aims to compare risk assessment scores for their ability to predict prognosis in nonvariceal-UGIB. &#x0D; Material and Method: Adult patients with nonvariceal-UGIB applied to the emergency department were recruited prospectively. Clinical and Complete Rockall score (RS), Glascow-Blatchford score (GBS), AIMS65, and T-Score were compared for endpoints: (1) need for endoscopic treatment, (2) hospitalization, (3) rebleeding, and (4) 30-day mortality.&#x0D; Results: A total of 469 patients were included. While 133 (28.0%) patients were discharged within 24 hours, 336 (72.0%) were hospitalized. The median length of hospital stay was 6.6 (0.0-8.0) days. Endoscopic treatment and transfusion were required in 109 (23.0%) and 255 (54.0%) patients, respectively. Rebleeding was observed in 36 (8.0%) patients. The 30-day mortality rate was 11.0 %. Complete Rockall score was superior among all risk scores regarding the prediction of the need for endoscopic treatment (AUC: 0.707, p

Upfront Laparoscopic Management of Common Bile Duct Stones: What Are the Risk Factors of Failure?

BackgroundTreatment of common bile duct stones (CBDS) includes laparoscopic cholecystectomy (LC) with either laparoscopic common bile duct exploration (LCBDE) or perioperative endoscopic retrograde cholangiopancreatography (ERCP). The main objective of this study was to identify predictive factors for the failure of upfront and exclusive surgical treatment by LCBDE. MethodsThis is a single-center, retrospective study on patients with CBDS and operated for LC between 2007 and 2019. The use of intra- or postoperative endoscopy for CBD clearance within 6 months after surgery was considered as failure of LCBDE. Predictors for the failure of LCBDE were investigated and outcomes were compared. ResultsAmong 222 operated patients, LCBDE was successfully performed in 173 patients (78%) and 49 (22%) required ERCP with sphincterotomy (intraoperative (n=29) or postoperative (n=20)). Independent risk factors for surgical failure were male sex (OR: 2.525 (1.111–5.738); p=0.027), anesthesia induction time ≥ 4 p.m. (OR: 4.858 (1.731–13.631); p=0.003), pediculitis (OR: 4.147 (1.177–14.606); p=0.027), and thin CDB < 4mm (OR: 11.951 (3.562–40.097), p< 0.0001). Age, ASA score, cystic anatomy, presence of cholecystitis, and the surgeon’s experience were not identified as predictors for surgical failure. A general anesthesia number >1 (6% vs. 33%; p < 0.0001), length of initial stay (6 [1–42] vs. 8 [2–27], p=0.012), total length of hospitalization (6 [1–45] vs. 9 [2–27]; p=0.010), and the rate of emergency readmissions (3.5% vs. 12.2%; p=0.027) were significantly higher in the LCBDE failure group. ConclusionsUpfront LCBDE for CBDS was associated with improved outcomes compared to intra-/postoperative ERCP recourse. Male sex, pediculitis, thin CBD, and surgery later than 4 p.m were associated with LCBDE failure and the need for endoscopic treatment. Registration Number and AgencyThe present retrospective study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT04467710).

Comparison of Lactate Clearance with Established Risk Assessment Tools in Predicting Outcomes in Acute Upper Gastrointestinal Bleeding

Early risk stratification is mandatory in acute upper gastrointestinal bleeding (AUGIB) to guide optimal treatment. Numerous risk scores were introduced, but lack of practicability led to limited use in daily clinical practice. Lactate clearance is an established risk assessment tool in a variety of diseases, such as trauma and sepsis. Therefore, this study compares the predictive ability of pre-endoscopic lactate clearance and established risk scores in patients with AUGIB at the University Hospital of Cologne. Active bleeding was detected in 27 (25.2%) patients, and hemostatic intervention was performed in 35 (32.7%). In total, 16 patients (15%) experienced rebleeding and 12 (11.2%) died. Initially, lactate levels were elevated in 64 cases (59.8%), and the median lactate clearance was 18.7% (2.7-48.2%). Regarding the need for endoscopic intervention, the predictive ability of Glasgow Blatchford Score, pre-endoscopic Rockall score, initial lactate and lactate clearance did not differ significantly, and their area under the receiver operating characteristic curves were 0.658 (0.560-0.747), 0.572 (0.473-0.667), 0.572 (0.473-0.667) and 0.583 (0.483-0.677), respectively. Similar results were observed in relation to rebleeding and mortality. In conclusion, lactate clearance had comparable predictive ability compared to established risk scores. Further prospective research is necessary to clarify the potential role of lactate clearance as a reliable risk assessment tool in AUGIB.

Endoscopia urgente frente a endoscopia precoz: ¿tiene algún papel la endoscopia urgente en la hemorragia digestiva alta aguda no varicosa?

IntroductionThe main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial. Material and methodsProspective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality. ResultsA total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008). ConclusionUrgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy).

Evaluation of Tofacitinib in Primary Sclerosing Cholangitis and Associated Colitis: A Multicenter, Retrospective Study

Evaluation of Tofacitinib in Primary Sclerosing Cholangitis and Associated Colitis: A Multicenter, Retrospective Study

Chronic pancreatitis: analysis of disease progression factors

Alcohol and tobacco are important risk factors for chronic pancreatitis (CP). To analyze the effect of etiological factors such as tobacco and alcohol and pancreatic enzyme replacement therapy (PERT) in the progression of CP. Patients with a diagnosis of CP were recruited and grouped according to variables such as tobacco, alcohol and PERT. They were followed for 18 months. Subsequently, different variables and analytical parameters involved in the progression of the disease were analyzed. A total of 50 patients diagnosed with CP were included. Of these, 28 patients underwent PERT, 39 were smokers and 33 were alcohol users. Compared with patients without PERT, those with PERT had a higher proportion of diabetes (64 and 32%, respectively), had a higher need for endoscopic treatment (25 and 0%, respectively) and a normal body mass index (71 and 27.3%, respectively. The smokers had higher calcium levels and increased lymphocytosis and leukocytosis. The alcohol consumption group had a higher mean age (p = 0.04) Conclusions: PERT may improve the nutritional status but does not reduce the need for endoscopic or surgical treatment. Smoking and alcohol consumption favored the progression of CP. Also, smoking induced a pro-inflammatory state.

Evaluation of the Sheffield score, clinical characteristics, and the therapeutic approach in children with upper gastrointestinal system bleeding.

Unlike adults, there is no valid and reliable scoring system for upper gastrointestinal system bleeding (UGB) in children. The Sheffield scoring system, which is awaiting confirmation, is the single scoring system which can be predictive for children who require high-risk, endoscopic therapeutic intervention. The aim of this study was to evaluate the efficacy of the Sheffield scoring system, the clinical characteristics of patients, and the treatments applied. Evaluation was made of a total of 86 children with UGB who underwent esophagogastroduodenoscopy and for whom the Sheffield score was calculated. The decision for therapeutic intervention was made according to the clinical status independently of the score. The demographic data of the patients, clinical symptoms and findings, risk factors, and treatments were examined retrospectively. The Sheffield score was calculated as ≤8 in 67.4% of the patients and >8 in 32.6%. Endoscopic hemostatic intervention was applied to 15.1% of the patients. The rate of therapeutic endoscopy was significantly high in the high-score group. In 11 patients with Sheffield score >8, the bleeding was brought under control with octreotide treatment administered before endoscopy and no invasive intervention was applied. The sensitivity and specificity of the Sheffield score were determined to be at a good level in the prediction of the requirement for therapeutic endoscopy and octreotide treatment. The Sheffield score can reliably predict the need for endoscopic treatment with high sensitivity and specificity. In children with a high score, the need for an invasive intervention can be reduced with the administration of vasoactive treatment before esophagogastroduodenoscopy. The Sheffield score can thus be of guidance in the determination of the need for vasoactive treatment.

S689 Utilization of Risk Stratification Scores to Triage Patients With GI Bleed: A Retrospective Cohort Analysis

Introduction: Gastrointestinal (GI) bleeding affects 30-40 per 100,000 hospitalized patients annually. Many of these patients can have severe bleeding with hemodynamic instability and rapid clinical deterioration, often requiring higher levels of care such as intermediate units (IU) or intensive care units (ICU). This study aimed to compare various risk stratification tools with patient outcomes to find which tools can best help providers triage patients most appropriately on admission. Methods: This is a single-center retrospective cohort analysis of patients admitted to IU or ICU with GI bleeding as their primary diagnosis from March, 2015 - March, 2021. Medical records of patients above 18 years of age were reviewed for baseline characteristics, lab values, 30-day mortality, and 90-day readmission. Charlson comorbidity index (CCI), Glasgow-Blatchford Bleeding Score (GBS), AIMS 65, Assessment of Blood Consumption (ABC), quick Sequential Organ Failure Assessment (qSOFA) scores on admission were calculated. Patients were compared according to the level of care. Pearson Chi-square and Mann Whitney U were applied to compare groups. (Figure) Results: Out of 299 patients admitted with GI bleeding, 195 (65.2%) were admitted to IU and 104 (34.8%) to ICU. Baseline characteristics are illustrated in Table. As for treatment, antibiotics (28.8% ICU vs. 10.3% IU; p< 0.01) and PRBC transfusions (median: 3.0 ICU vs. 2.0 IU; p< 0.01) were more frequently utilized in ICU. Outcome variables assessed included need for endoscopic intervention, time to scope, and 90-day readmission rates; no significant difference was seen between groups. Patients admitted to the IU had lower 30-day mortality (p=0.02). Out of the five scores assessed, GBS, AIM-65, and qSOFA were noted to be statistically significant with score being higher in patients admitted to ICU: median (interquartile range (IQR))– GBS: 12 (9, 14.75) vs. 11.00 (8, 13); p< 0.05; AIM-65: 1 (1,2) vs. 1(0,2); p< 0.01, and qSOFA: 0(0,1) vs. 0(0,1); p< 0.01.No significant difference was noted between the median (IQR) CCI and ABC scores between ICU vs. IU: CCI: 5(3,7) vs. IU: 5 (3,7); p >0.05 and ABC: 0 (0,1) vs. IU: 0 (0,1); p >0.05. Conclusion: Our study highlights the utility of scoring tools including GBS, qSOFA, and AIM-65 to assist with triaging GI bleed patients to an appropriate level of care. The scores should be calculated at the time of admission for GI bleed patients and those with elevated scores may benefit from closer monitoring in the ICU. Table 1. - Illustrating the comparison of baseline characteristics, medical history, end organ damage (troponin leak and AKI), 30-day mortality, and 90-day readmission rates, between the patients admitted to intensive care unit and intermediate level of care ICU, n (%) = 104 (34.8%)IU n, (%) = 195 (65.2 p-value Age, mean ± SD (median, IQR) 65.56 ±14.64 (65.50, 55.25-77.00) 68.75±15.71 (71.00, 57.00-80.00) 0.078 GenderMaleFemale 57 (54.8%)47 (45.2%) 113 (57.9%)82 (42.1%) 0.601 RaceCaucasianBlackHispanicOther including data unavailable 69 (66.3%)11 (10.6%)7 (6.7%)17 (16.4%) 126 (64.6%)32 (16.4%)16 (8.2%)21 (10.8%) 0.476 History of HTN 56 (53.8%) 125 (64.1%) 0.155 History of DM 29 (27.9%) 51 (26.2%) 0.747 History of CAD 25 (24%) 78 (40%) 0.006 History of HF 32 (30.8%) 49 (25.1%) 0.296 History of CKD 27 (26%) 53 (27.2%) 0.821 History of Liver disease 23 (22.1%) 35 (17.9%) 0.482 History of DVT/PE 5 (4.8%) 23 (11.9%) 0.047 Personal history of GI tract cancer 10 (9.6%) 24 (12.3%) 0.593 Family history of GI tract cancer 5 (4.8%) 14 (7.2%) 0.625 Use of NSAIDs 17 (16.7%) 23 (12.1%) 0.280 Use of anticoagulants 40 (39.2%) 61 (31.8%) 0.201 Use of antiplatelets 30 (29.4%) 60 (31.1%) 0.766 Use of PPI at home 30 (29.4%) 69 (36.1%) 0.377 Troponin leak 12 (11.5%) 11 (5.6%) 0.172 AKI 48 (46.2%) 46 (23.6%) < 0.001 Antibiotics 30 (28.8%) 20 (10.3%) < 0.001 No. of PRBCs, mean ± SD (median, IQR) 3.29 ±2.64 (3.0, 2-4) 2.13 ±2.61 (2.0, 0-3) < 0.01 Endoscopic intervention 41 (39.4%) 59 (30.3%) 0.110 Time to scope, mean ± SD (median, IQR) 1.35±1.78 (1.0, 0.75-2.00) 1.72±1.46 (1.0, 1-2) 0.051 Alive at 30 days 81 (77.9%) 171 (88.1%) 0.020 90-day readmission due to GI Bleed 17 (16.3%) 41 (21%) 0.330 ICU – Intensive Care Unit; HTN – Hypertension; DM – Diabetes mellitus; CAD – coronary artery disease; HF – Heart Failure; AF – Atrial Fibrillation; CKD – Chronic Kidney Disease; DVT – Deep venous thrombosis; PE – Pulmonary embolism; NSAIDs – Non steroidal anti-inflammatory drugs; PPI – Proton Pump Inhibitors; AKI – Acute Kidney Injury; PRBC – Packed Red Blood Cells.

Upper Gastrointestinal Bleeding: Do Emergency Endoscopic Evaluations Affect Clinical Outcomes?

Objective: We aimed to reveal the effect of time from admission to endoscopy on clinical outcomes such as mortality, rebleeding, and prolonged hospitalization among patients with acute upper gastrointestinal bleeding.Methods: Patients aged ≥18 years with acute upper gastrointestinal bleeding were enrolled in the study. Those who had variceal bleeding during endoscopy, those whose hospital stay was shorter than 24 hours, those who did not undergo endoscopy, and those who underwent endoscopy after 24 hours were excluded from the study. Clinical findings, routine laboratory test results, and imaging findings of the patients were retrospectively reviewed through the hospital’s records system.Results: A total of 252 patients were enrolled in the study. At admission, 30.2% (76) of patients were at clinically high risk of death or rebleeding, 71.8% had melena, and 51.2% had hematemesis. While 72 (28.6%) of the patients had high-risk endoscopic stigmata, 89 (35.3%) had low-risk endoscopic stigmata. The median hospital stay was 6 (1-91) days. In-hospital mortality occurred in 8 (3.2%) cases, rebleeding developed in 16 (6.3%) cases, endoscopic intervention was required in 103 (40.9%) cases, and prolonged hospital stay was required in 43 (17.1%) cases. High-risk endoscopic stigmata were identified in 63 (34.1%) cases in the urgent group and in 9 (13.4%) in the early group (p=0.001). Endoscopic intervention was required in 47.0% cases in the urgent group, while the incidence was 23.9% in the early group (p=0.001).Conclusion: While no significant difference was found between the urgent and early groups in terms of mortality and re-bleeding, the need for endoscopic intervention and the incidence of high-risk endoscopic stigmata were found to be significantly higher in the urgent group.

Validation and Comparison of the Japanese Score and Other Scores in Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Retrospective Study

Background: Various scoring systems have been developed to predict endoscopic intervention, mortality, and rebleeding in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB); however, they have not been sufficiently validated in Korea. Therefore, this study aimed to evaluate the usefulness of several scoring systems in Korea by validating and comparing the Japanese score and other scores in Korean people with NVUGIB. Methods: The medical records of 1,368 patients with NVUGIB were reviewed to collect statistical, clinical, laboratory, and endoscopic data. The Japanese score, ABC score, Glasgow-Blatchford Bleeding Score (GBS), and MAP score were calculated retrospectively at a single research institution. These scores for predicting the need for endoscopic intervention, mortality, and rebleeding were calculated and evaluated using the area under the receiver operating characteristic curve. Results: Of 1,368 patients, 88.5% required endoscopic intervention, 4.1% died within 30 days, and 12.6% experienced rebleeding. The Japanese score was effective for predicting endoscopic intervention, and the ABC score was best for predicting 30-day mortality. Sex, age, hematemesis, blood urea nitrogen, and American Society of Anesthesiologists score were found to be predictors of the need for endoscopic intervention. Conclusion: The Japanese score did not prove useful in Koreans with upper gastrointestinal bleeding. Additional research is needed due to the limitations of a retrospective study conducted in a single research institute.

Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis.

Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis. We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients. Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%. Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.

EARLY PREDICTORS OF OUTCOME IN BLEEDING OESPHAGEAL AND/OR GASTRIC VARICES IN THE EMERGENCY DEPARTMENT

Backgorund and Objective: Acute upper GIT bleeding is a life threatening emergency. Many scoring systems have been developed to evaluate patients with acute UGIB. The purpose of this study was to confirm value of Modified Blatchford scoring system, Full rockall score , AIM65 score &amp;lactate level as a predictor of outcome as regard patient’s mortality, their need for ICU, duration of hospitalization and need for endoscopic intervention in the emergency department. Patients an Methods: This study was performed on 100 patients who presented to the emergency department with acute UGIB in Alexandria main university hospital. All the study scores (GBS, AIMS65, PRS, and FRS) were able to predict the clinical outcomes in the UGIB patients. Results: GBS was the best performing risk score among the four scores for predicting all the clinical outcomes except the prediction of endoscopic intervention. Lactate was a sensitive predictor for ICU admission, hospital stay, rebleeding and mortality during first 48 hrs of admission in patients presenting with UGIB.

Findings and outcomes of emergent endoscopies after cardiovascular surgery.

AimsStudies detailing endoscopic findings and hemostatic interventions for upper gastrointestinal bleeding after cardiovascular surgery are scarce. We conducted this study to determine the frequency and findings of emergent esophagogastroduodenoscopy (EGD) after cardiovascular surgery and the effect of bleeding requiring hemostatic intervention on clinical outcomes.Methods and ResultsWe retrospectively reviewed records of emergent EGD examinations conducted within 30 days after cardiovascular surgery at a tertiary referral center in Japan from April 2011 to March 2020. Of 1625 patients undergoing cardiovascular surgery, 47 underwent emergent EGD. Sources of bleeding were identified in 30 cases, including transesophageal echocardiogram (TEE)‐related injuries (8 patients), gastric ulcers (7 patients), and duodenal ulcers (7 patients). Patients who required endoscopic hemostatic intervention had more TEE‐related injuries (43% vs 3%, P = 0.005), gastric ulcers (35% vs 6%, P = 0.018), or ulcers in the first part of the duodenum (29% vs 0%, P = 0.006) than those who did not. Intraoperative TEE did not increase the need for endoscopic intervention (71% vs 64%, P = 0.435). Intraoperative TEE and the need for endoscopic intervention did not affect length of stay or all‐cause mortality. Only one death was associated with gastrointestinal bleeding.ConclusionDespite the potential severity of bleeding after cardiovascular surgery, most cases can be managed endoscopically with no increase in hospital stay or mortality.